**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices reviewed for 1 (Resident #1) of 5 residents reviewed for quality of care. The facility nurses failed to hold Resident #1s health shakes and administered them through a 60ML syringe by mouth while she was not responsive on 3/10/25 at 10:20pm and 3/11/25 at 12:10pm. These failures resulted in an identification of an Immediate Jeopardy (IJ) On 3/12/2025 at 4:35 p.m. While the IJ was removed on 3/14/25, the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that was 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 placed residents who have had a decline or change in condition at risk for aspiration, choking, and death. Findings included: Record review of Resident #1's undated face sheet reflected she was a [AGE] year-old female who was admitted to the facility on [DATE] with diagnosis of Alzheimer Disease (A brain disorder that slowly destroys a person's memory), Dementia (the loss of cognitive function, remembering, thinking, and reasoning), Hypertension (elevated blood pressure), Bradycardia (a slow heart rate). Record review of Resident #1's Significant change in status MDS dated [DATE] reflected she Had a BIMS score of 00 indicating she had severe cognitive impaired. Resident #1 required substantial/maximal assistance indicating the helper does more than half the effort or the helper lifts or holds trunk or limbs and provides more than half the effort for ADL care showering, upper and lower body dressing, and toileting hygiene. The MDS reflected Resident #1 required set up or clean up assistance with eating and was receiving hospice services. Record review of Resident #1's care plan dated 02/06/2025 reflected a significant/Un-expected weight loss due to decline in overall health and decline in oral intake. Goal: Will receive adequate nutrition and fluid intake and weight will stabilize through the next review. Interventions included Provide supplements as ordered. Provide/offer hydration throughout the day. Serve diet as ordered and offer substitution if intake less than 50%. Record review of Resident #1s progress notes dated 3/10/25 at 10:20pm reflected Resident was able to consume 180ml of Ensure (health shake) via syringe. No signs or symptoms of chocking noted. Head of bed up right. No signs and symptoms of pain or distress noted. Resident Family Member notified of residents' intake of Ensure. Call light within reach. Care needs met. Signed by LVN C. Record review of Resident #1s' Physician orders for March 2025 reflected an order for a fortified diet, mechanical soft ground meats dated 01/02/2025 and health shakes or equivalent three times a day dated 02/23/2025. The physicians' orders also reflected that Resident #1 was admitted to Hospice services on 01/20/2025. Resident #1 had an order for a stat (without delay) chest x-ray to rule our aspiration dated 03/11/2025. Record review of Resident #1s Chest X ray ordered for Resident #1 on 3/11/25 at 5:59pm reflected there was no aspiration seen. In an observation completed on 3/11/25 at 11:00am Resident #1was fidgeting with her fingers in the air, unresponsive to verbal stimuli. The head of her bead was elevated 45 degrees, she had her mouth open, and head leaned back looking upward to the ceiling. There was a bottle of health shake with a straw in it next to a 60cc syringe in a clear package on the bedside table. In a second observation and interview of Resident #1 and CNA A on 3/11/25 at 12:10 when Resident #1 appeared in the same position. At 12:13pm CNA A entered the room as this surveyor was inquiring about Resident #1s lunch tray. CNA A stated Resident #1 was too weak to eat. She stated the Resident #1 had not been offered a food tray. CNA A was putting on gloves and drawing up a 60cc syringe full of health shake. As CNA A was talking with the surveyor, she then proceeded over to the Resident #1 and placed the syringe in the resident's mouth. This surveyor asked CNA A to stop at that time. CNA A Stated she worked with agency and today was her first day in the facility. She stated there was an orientation on the agency app prior to taking a shift at the facility, she did not know if feeding was part of that orientation. CNA A Stated Resident #1 did not have the strength to eat and that she was told in report (employee to employee review of residents' conditions) this morning by the night nurse to feed and give fluids to Resident #1 with the syringe so she would not be dehydrated. CNA A stated she had given Resident #1 two full 60 cc syringes of health shake this morning. She stated she had not been instructed by the building DON or ADON to feed or give fluids to a resident with a syringe. In an interview on 3/11/25 at 12:20pm the DON stated Resident #1 had been unresponsive for about 2-3 days. The DON stated it was not normal practice to feed or give fluids to residents with a syringe. She stated The Family Member was insistent with hospice that it could be done. The DON stated the CNAs have not been trained to feed or give fluids using a syringe unless the hospice nurse instructed them to do so. She stated Resident #1 could get aspiration pneumonia (an infection that is the results of food or fluids going into the lungs instead of the stomach). The DON stated feeding residents with a syringe is not facility protocol. She stated the 60cc syringe came from Hospice. In an interview on 3/11/25 at 1:02pm LVN B stated she had worked at the facility for 3 days and she was the charge nurse for Resident #1. She stated she was aware Resident #1 was on hospice for a cardiac condition and Resident #1 had a hip injury that was nonoperational. She stated Resident #1s family was upset she was not eating, and she had talked to the family about reasons including end of life. She stated she also explained to the family that she could aspirate (a condition where the fluid goes into the lung) if she was not swallowing. LVN B stated at no time did CNA A report that the night nurse had instructed her to feed or give fluids to Resident #1 with a syringe. She stated it also was not passed along in their nursing report from the night nurse. She stated the Resident #1 was unresponsive this morning. LVN B stated feeding or giving fluids through a syringe to a resident who was not responsive could lead to the resident aspirating. LVN B stated she did an assessment on Resident #1, and her lungs were clear (free from abnormal sounds of respirations). LVN B stated a Chest x ray was ordered by the physician, and the facility was waiting on that to be completed. Attempted to contact LVN C who works night shift (6pm -6am) on 3/10/25 on 3/11/25 at 1:42 pm with no answer. In an interview with a Family Member of Resident #1 on 3/11/25 at 2:51 stated when she had mentioned giving Resident #1 fluids through a syringe, she was not talking about a large syringe full of fluids. She stated she was asking for the staff to give her drips out of a small syringe. She stated something to keep Resident #1's mouth moist. She stated she did not ask for them to force feed her. She stated she just wanted Resident #1s mouth moist, not as dry; she wanted her to have oral care, swab her mouth out, not force feed her though a syringe. In an interview on 3/11/25 at 3:00 pm with The Medical Director and Primary Care Physician for Resident #1 stated it was not recommend feeding or give fluids by mouth a resident with a syringe. He stated he was over the Resident#1s hospice company as well and he had called hospice, and they had no recommendations for feeding or giving fluids through a syringe either. He stated if a person were to squirt a bunch of thin liquids at one time into Resident#1s mouth she would aspirate, causing choking, and pneumonia. He stated the resident was not eating. He stated he did listen to Resident #1s lungs, and they sounded clear and did not see any harm from the resident receiving the thin liquids per the syringe. He stated he did instruct the nursing staff not to feed or give fluids to her through the syringe. He stated he ordered routine oral care to be completed to ensure the residents mouth was moist. In an interview on 3/11/25 at 3:46 pm RN D Resident #1's hospice nurse stated hospice did not recommend feeding or giving fluids to Resident #1 with a syringe. He stated The Family Member had called him and was upset that the facility would not feed Resident #1 with a syringe. He stated he educated the family on risk of feeding and giving fluids with a syringe. He stated that he instructed the family that hospice would not feed or give fluids to Resident #1 with a syringe. He stated there was never an order to do that. The Family Member stated the night nurse told her that she got her to take a half of a bottle of health shake and she did not elaborate how she got her to take the fluid. He stated he had instructed the family on the death and dying process and that it was a traumatic event such as a hip fracture that causing the resident to further decline and that not having an appetite and not eating was part of that decline. He stated the resident has not been responsive the last 3-4 days. In an interview with the DON and ADM on 3/12/25 at 3:09 when the DON stated there was never any formal training to feed or give residents any fluids through a syringe because it was not the facility practice to do so. She stated here was never any order for food or fluids to be given through a syringe because that it not the facility practice. The DON stated agency staff were aware of the Residents#1s plan or care through verbal report. She stated the agency staff were also given a point click care password so they could access the plan or care and be aware of resident's needs. The DON stated there was a book with specific instructions at the nurses' station on how to navigate point click care and facility policy and procedures provided to agency staff. She stated they encourage agency staff to ask questions if needed. Record review of facility policy titled Competency Evaluation dated 04/2024 and revised 01/2025 reflected: It is the policy of this facility to evaluate each employee to assure they meet appropriate competencies and skills for performing their job. An Immediate Jeopardy was identified on 3/12/2025 at 4:35 p.m. and an IJ template was provided to the ADM and DON. The following Plan of Removal submitted by the facility was accepted on 03/13/2025 at 10:28 a.m. PLAN OF REMOVAL Problem: The facility failed to ensure that all nursing staff possess the competencies and skill sets necessary to provide nursing and related services to meet the residents' needs safely and in a manner that promotes each resident's rights, physical, mental, and psychological well-being. An audit was completed by nurse management to ensure no other residents were at risk. Resident #1 had a chest x-ray completed on 3/11/25 that showed no aspiration. Resident # 1 was assessed by the DON & the facility medical director. Resident #1 remains in the facility in stable condition. Immediate action: 11. As soon as the DON was made aware of the situation on 3/11/25 she immediately removed the syringe from the resident's room. 12. CNA #1 was given a one-on-one education by ADON on 3/11/25 that a resident should never be syringe fed. Our investigation revealed that an overnight nurse instructed the CNA to administer the resident ensure through a syringe. A telephone call was placed to the night nurse & a message left for her to call the facility. The night nurse had not returned our phone call. A message was left that she could not return to the facility until she spoke with the DON. 13. DON started In-servicing facility & agency licensed nurses & CNAS on 3/11/25 at 1300 that residents were never to fed via a syringe. All 6-2 & 2-10 nursing staff on duty were educated. In-services for facility licensed nurses & CNAS will be completed on 3/13/25. Any agency staff that has not previously been in-serviced will be required to complete the in-services prior to starting their shift. 14. DON/ADON started In-servicing on 3/12/25 with agency staff to ensure they were educated on where to find the residents plan of care. 15. DON/ADON started In-servicing on 3/12/25 with all CNAs both facility & agency on the importance of not attempting to feed a resident that is unresponsive. Any new facility or agency CNA will be provided the education prior to working. 16. The agency binder was reviewed to ensure that agency staff know where to look to review the residents plan of care. Interventions 17. Any new agency staff will be in-serviced by nurse management on how to find the residents plan of care prior to starting their shift. The education started on 3/12/25 & will be ongoing when new facility or agency staff are scheduled. 18. Shift Key will download the process of where to find the residents plan of care prior to accepting a shift. The ADON will be responsible for the communication to Shift Key. 19. Nurse management will review the residents' care plan to ensure that it reflects the resident's needs. The care plan review will be completed by 3/14/25. 20. When a resident experiences a change of condition the care plan will be updated to reflect the resident's current needs. The DON/ADON/ Unit Manager will be responsible for updating resident care plan when a change of condition is identified. Ongoing Projected completion 3/13/25 for facility nursing staff. Care Plan review will be completed by 3/14/25. Any staff member who was not present during initial in-servicing/training will not be allowed to assume their duties until in-service was completed. The DON/ADON/WC NURSE will complete Ongoing In-service/or weekend nurse supervisor, until all staff, weekend, prn, and agency staff in completed. Monitoring 5. Nurse management will question random CNAs 3 X's a week to ensure they understand Resident #1s plan of care. Nurse management will perform random questions 3 X's a week for 6 weeks. 6. Staff will complete a questionnaire related to providing care that reflects the resident's needs. 7. On 3/13/25 The DON/designee began a questionnaire to validate the effectiveness of the training. The questionnaire is conducted with facility staff. Immediate re-education will be completed by the DON/designee if any staff is unable to answer appropriately to the questions on the questionnaire. Staff will not be allowed to work until after completion of the questionnaire. Projected completion 3/14/25. 8. On 3/12/25 An impromptu QAPI meeting was conducted with the facility's Medical Director to notify of the potential for non-compliance and the action plan implemented for approval. 3/13/25 Surveyor Monitoring included the following: 10. Observation completed on 3/13/25 at 12:50PM reflected there was no longer a syringe for feeding In Resident #1s room. 11. Record review of Momentum Skilled Services 1:1 in service dated 3/11/25 signed by CNA#1 reflected that CNA A was given a one-on-one education by The ADON that read a resident should never be syringe fed. 12. Record review of Inservice dated 03/11/25 and 03/12/25 provided to licensed nurses and certified nurse aides reflected they had been educated by The DON that no residents would be fed or given fluids orally with a syringe for any reason. 13. Record review of facility in-service provided to agency staff working within the building dated 3/12/25 reflected that the residents plan of care was in the EMR (electronic medical record) under the [NAME] tab (a tab that contains certain needs for residents that staff may review). If they were to have any questions after reading the residents plan of care they must find their charge nurse for clarification. 14. Record review of facility in-service dated 03/12/25 provided to all certified nursing assistance both agency and facility staff reflected staff members must never attempt to feed or give fluids to a resident that was unresponsive. If they had a resident that was unresponsive, they must find the charge nurse for clarification. 15. The DON reviewed the agency binder to ensure the agency staff would be able to locate the residents plan of care to provide services. 16. Interviewed 22 nursing staff (CNA D, E,F,G,H,I,J,K,L,M,N,O,P,Q and LVN R,S,T,U,V,W,X) from all shifts and they stated they had been educated on not syringe feeding residents. They stated they had been educated on not attempting to feed unresponsive residents. They stated the risk for resident would be aspiration or choking. They stated they had been educated on where and how to locate a resident's plan of care to provide and meet the resident's needs. The agency staff were able to locate the facility binder with their expectations and EMR directions to provide services and care to residents. They stated if a plan of care did not seem accurate for a resident they would go to their charge nurse for clarification. They stated even if a nurse told them to do something that was out of their scope, they would report it to the ADON or DON for further clarification. The agency staff stated they were instructed prior to their shift to review the blue binder at the nurses' station. They stated within the binder there was current in-services for staff, policy and procedures for pain and falls, abuse, and neglect, also directions on how to navigate the electronic medical record to see the residents current plan of care. The binder also included current in-services for staff. Included in in-services within the blue binder were: no resident will be fed by syringe, Staff members must never attempt to feed a resident that is unresponsive, and where the plan of care is located within the EMR. 17. In an interview with The ADON on 3/13/25 at 2:46PM- The ADON stated the facility had posted an automatic notification that must be acknowledged to review in-services prior to the start of agency staffs shift instructing staff they must sign in at the nurses' station and all agency staff must read and abide by the blue binder located at the nurse's station. Within the blue binder was found an emergency phone list, items to report immediately, sign in sheets, facility management contacts. The binder also included current in-services for staff. Included in in-services within the blue binder were: no resident will be fed by syringe, Staff members must never attempt to feed a resident that is unresponsive, and where the plan of care is located within the EMR. Record review of shift key logs reflected the notification of in-services prior to coming on shift had been signed and acknowledged by 6 agency staff working 3/13/25. 18. Record review of a Care Plan Audit on 3/14/25 completed by the DON was 100% completed. The DON stated there were no further negative findings within the Care plan audit for all residents. She stated the care plans were accurate for Residents to reflects the resident's needs. 10. Signed QAPI minutes reviewed for 3/12/25 and reflected a meeting was held that included the facilities ADM, DON, ADON, MDS, and Medical Director The ADM and DON were informed the Immediate Jeopardy was removed on 03/14/2025 at 11:53 a.m. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy and a scope of Isolated 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 observation, interview, and record review, the facility failed to assure that all nursing staff possess the competencies and skill sets necessary to provide nursing and related services to meet the residents' needs safely and in a manner that promotes each resident's rights, physical, mental, and psychosocial well-being for 1 (Resident #1) of 5 residents reviewed. The facility nurses failed to hold Resident #1's health shakes and administered them through a 60 ML syringe by mouth while she was not responsive on 3/10/25 at 10:20pm and 3/11/25 at 12:10pm. These failures resulted in an identification of an Immediate Jeopardy (IJ) On 3/12/2025 at 4:35 p.m. While the IJ was removed on 3/14/25, the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that was 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 placed residents who have had a decline or change in condition at risk for aspiration, choking, and death. Findings included: Record review of Resident #1's undated face sheet reflected she was a [AGE] year-old female who was admitted to the facility on [DATE] with diagnosis of Alzheimer Disease (A brain disorder that slowly destroys a person's memory), Dementia (the loss of cognitive function, remembering, thinking, and reasoning), Hypertension (elevated blood pressure), Bradycardia (a slow heart rate). Record review of Resident #1's Significant change in status MDS dated [DATE] reflected she Had a BIMS score of 00 indicating she had severe cognitive impaired. Resident #1 required substantial/maximal assistance indicating the helper does more than half the effort or the helper lifts or holds trunk or limbs and provides more than half the effort for ADL care showering, upper and lower body dressing, and toileting hygiene. The MDS reflected Resident #1 required set up or clean up assistance with eating and was receiving hospice services. Record review of Resident #1's care plan dated 02/06/2025 reflected a significant/Un-expected weight loss due to decline in overall health and decline in oral intake. Goal: Will receive adequate nutrition and fluid intake and weight will stabilize through the next review. Interventions included Provide supplements as ordered. Provide/offer hydration throughout the day. Serve diet as ordered and offer substitution if intake less than 50%. Record review of Resident #1's progress notes dated 3/10/25 at 10:20pm reflected Resident was able to consume 180 ml of Ensure (health shake) via syringe. No signs or symptoms of chocking noted. Head of bed up right. No signs and symptoms of pain or distress noted. Resident Family Member notified of residents' intake of Ensure. Call light within reach. Care needs met. Signed by LVN C. Record review of Resident #1's Physician orders for March 2025 reflected an order for a fortified diet, mechanical soft ground meats dated 01/02/2025 and health shakes or equivalent three times a day dated 02/23/2025. The physicians' orders also reflected that Resident #1 was admitted to Hospice services on 01/20/2025. Resident #1 had an order for a stat (without delay) chest x-ray to rule our aspiration dated 03/11/2025. Record review of Resident #1's Chest X ray ordered for Resident #1 on 3/11/25 at 5:59pm reflected there was no aspiration seen. In an observation completed on 3/11/25 at 11:00am Resident #1 was fidgeting with her fingers in the air, unresponsive to verbal stimuli. The head of her bead was elevated 45 degrees, she had her mouth open, and head leaned back looking upward to the ceiling. There was a bottle of health shake with a straw in it next to a 60 cc syringe in a clear package on the bedside table. In a second observation and interview of Resident #1 and CNA A on 3/11/25 at 12:10 when Resident #1 appeared in the same position. At 12:13pm CNA A entered the room as this surveyor was inquiring about Resident #1's lunch tray. CNA A stated Resident #1 was too weak to eat. She stated the Resident #1 had not been offered a food tray. CNA A was putting on gloves and drawing up a 60 cc syringe full of health shake. As CNA A was talking with the surveyor, she then proceeded over to the Resident #1 and placed the syringe in the resident's mouth. This surveyor asked CNA A to stop at that time. CNA A Stated she worked with agency and today was her first day in the facility. She stated there was an orientation on the agency app prior to taking a shift at the facility, she did not know if feeding was part of that orientation. CNA A Stated Resident #1 did not have the strength to eat and that she was told in report (employee to employee review of residents' conditions) this morning by the night nurse to feed and give fluids to Resident #1 with the syringe so she would not be dehydrated. CNA A stated she had given Resident #1 two full 60 cc syringes of health shake this morning. She stated she had not been instructed by the building DON or ADON to feed or give fluids to a resident with a syringe. In an interview on 3/11/25 at 12:20pm the DON stated Resident #1 had been unresponsive for about 2-3 days. The DON stated it was not normal practice to feed or give fluids to residents with a syringe. She stated The Family Member was insistent with hospice that it could be done. The DON stated the CNAs have not been trained to feed or give fluids using a syringe unless the hospice nurse instructed them to do so. She stated Resident #1 could get aspiration pneumonia (an infection that is the results of food or fluids going into the lungs instead of the stomach). The DON stated feeding residents with a syringe is not facility protocol. She stated the 60 cc syringe came from Hospice. In an interview on 3/11/25 at 1:02pm LVN B stated she had worked at the facility for 3 days and she was the charge nurse for Resident #1. She stated she was aware Resident #1 was on hospice for a cardiac condition and Resident #1 had a hip injury that was nonoperational. She stated Resident #1's family was upset she was not eating, and she had talked to the family about reasons including end of life. She stated she also explained to the family that she could aspirate (a condition where the fluid goes into the lung) if she was not swallowing. LVN B stated at no time did CNA A report that the night nurse had instructed her to feed or give fluids to Resident #1 with a syringe. She stated it also was not passed along in their nursing report from the night nurse. She stated the Resident #1 was unresponsive this morning. LVN B stated feeding or giving fluids through a syringe to a resident who was not responsive could lead to the resident aspirating. LVN B stated she did an assessment on Resident #1, and her lungs were clear (free from abnormal sounds of respirations). LVN B stated a Chest x ray was ordered by the physician, and the facility was waiting on that to be completed. Attempted to contact LVN C who works night shift (6pm -6am) on 3/10/25 on 3/11/25 at 1:42pm with no answer. In an interview with a Family Member of Resident #1 on 3/11/25 at 2:51pm stated when she had mentioned giving Resident #1 fluids through a syringe, she was not talking about a large syringe full of fluids. She stated she was asking for the staff to give her drips out of a small syringe. She stated something to keep Resident #1's mouth moist. She stated she did not ask for them to force feed her. She stated she just wanted Resident #1's mouth moist, not as dry; she wanted her to have oral care, swab her mouth out, not force feed her though a syringe. In an interview on 3/11/25 at 3:00pm with The Medical Director and Primary Care Physician for Resident #1 stated it was not recommend feeding or give fluids by mouth a resident with a syringe. He stated he was over the Resident#1's hospice company as well and he had called hospice, and they had no recommendations for feeding or giving fluids through a syringe either. He stated if a person were to squirt a bunch of thin liquids at one time into Resident#1's mouth she would aspirate, causing choking, and pneumonia. He stated the resident was not eating. He stated he did listen to Resident #1's lungs, and they sounded clear and did not see any harm from the resident receiving the thin liquids per the syringe. He stated he did instruct the nursing staff not to feed or give fluids to her through the syringe. He stated he ordered routine oral care to be completed to ensure the residents mouth was moist. In an interview on 3/11/25 at 3:46pm RN D Resident #1's hospice nurse stated hospice did not recommend feeding or giving fluids to Resident #1 with a syringe. He stated The Family Member had called him and was upset that the facility would not feed Resident #1 with a syringe. He stated he educated the family on risk of feeding and giving fluids with a syringe. He stated that he instructed the family that hospice would not feed or give fluids to Resident #1 with a syringe. He stated there was never an order to do that. The Family Member stated the night nurse told her that she got her to take a half of a bottle of health shake and she did not elaborate how she got her to take the fluid. He stated he had instructed the family on the death and dying process and that it was a traumatic event such as a hip fracture that causing the resident to further decline and that not having an appetite and not eating was part of that decline. He stated the resident has not been responsive the last 3-4 days. In an interview with the DON and ADM on 3/12/25 at 3:09pm when the DON stated there was never any formal training to feed or give residents any fluids through a syringe because it was not the facility practice to do so. She stated here was never any order for food or fluids to be given through a syringe because that it not the facility practice. The DON stated agency staff were aware of the Residents#1's plan or care through verbal report. She stated the agency staff were also given a point click care password so they could access the plan or care and be aware of resident's needs. The DON stated there was a book with specific instructions at the nurses' station on how to navigate point click care and facility policy and procedures provided to agency staff. She stated they encourage agency staff to ask questions if needed. Record review of facility policy titled Competency Evaluation dated 04/2024 and revised 01/2025 reflected: It is the policy of this facility to evaluate each employee to assure they meet appropriate competencies and skills for performing their job. An Immediate Jeopardy was identified on 3/12/2025 at 4:35pm and an IJ template was provided to the ADM and DON. The following Plan of Removal submitted by the facility was accepted on 03/13/2025 at 10:28am PLAN OF REMOVAL Problem: The facility failed to ensure that all nursing staff possess the competencies and skill sets necessary to provide nursing and related services to meet the residents' needs safely and in a manner that promotes each resident's rights, physical, mental, and psychological well-being. An audit was completed by nurse management to ensure no other residents were at risk. Resident #1 had a chest x-ray completed on 3/11/25 that showed no aspiration. Resident # 1 was assessed by the DON & the facility medical director. Resident #1 remains in the facility in stable condition. Immediate action: 1. As soon as the DON was made aware of the situation on 3/11/25 she immediately removed the syringe from the resident's room. 2. CNA #1 was given a one-on-one education by ADON on 3/11/25 that a resident should never be syringe fed. Our investigation revealed that an overnight nurse instructed the CNA to administer the resident ensure through a syringe. A telephone call was placed to the night nurse & a message left for her to call the facility. The night nurse had not returned our phone call. A message was left that she could not return to the facility until she spoke with the DON. 3. DON started In-servicing facility & agency licensed nurses & CNAS on 3/11/25 at 1:00pm that residents were never to fed via a syringe. All 6-2 & 2-10 nursing staff on duty were educated. In-services for facility licensed nurses & CNAS will be completed on 3/13/25. Any agency staff that has not previously been in-serviced will be required to complete the in-services prior to starting their shift. 4. DON/ADON started In-servicing on 3/12/25 with agency staff to ensure they were educated on where to find the residents plan of care. 5. DON/ADON started In-servicing on 3/12/25 with all CNAs both facility & agency on the importance of not attempting to feed a resident that is unresponsive. Any new facility or agency CNA will be provided the education prior to working. 6. The agency binder was reviewed to ensure that agency staff know where to look to review the residents plan of care. Interventions 7. Any new agency staff will be in-serviced by nurse management on how to find the residents plan of care prior to starting their shift. The education started on 3/12/25 & will be ongoing when new facility or agency staff are scheduled. 8. Shift Key will download the process of where to find the residents plan of care prior to accepting a shift. The ADON will be responsible for the communication to Shift Key. 9. Nurse management will review the residents' care plan to ensure that it reflects the resident's needs. The care plan review will be completed by 3/14/25. 10. When a resident experiences a change of condition the care plan will be updated to reflect the resident's current needs. The DON/ADON/ Unit Manager will be responsible for updating resident care plan when a change of condition is identified. Ongoing Projected completion 3/13/25 for facility nursing staff. Care Plan review will be completed by 3/14/25. Any staff member who was not present during initial in-servicing/training will not be allowed to assume their duties until in-service was completed. The DON/ADON/WC NURSE will complete Ongoing In-service/or weekend nurse supervisor, until all staff, weekend, prn, and agency staff in completed. Monitoring 1. Nurse management will question random CNAs 3 X's a week to ensure they understand Resident #1s plan of care. Nurse management will perform random questions 3 X's a week for 6 weeks. 2. Staff will complete a questionnaire related to providing care that reflects the resident's needs. 3. On 3/13/25 The DON/designee began a questionnaire to validate the effectiveness of the training. The questionnaire is conducted with facility staff. Immediate re-education will be completed by the DON/designee if any staff is unable to answer appropriately to the questions on the questionnaire. Staff will not be allowed to work until after completion of the questionnaire. Projected completion 3/14/25. 4. On 3/12/25 An impromptu QAPI meeting was conducted with the facility's Medical Director to notify of the potential for non-compliance and the action plan implemented for approval. 3/13/25 Surveyor Monitoring included the following: 1. Observation completed on 3/13/25 at 12:50pm reflected there was no longer a syringe for feeding In Resident #1's room. 2. Record review of Momentum Skilled Services 1:1 in service dated 3/11/25 signed by CNA#1 reflected that CNA A was given a one-on-one education by The ADON that read a resident should never be syringe fed. 3. Record review of Inservice dated 03/11/25 and 03/12/25 provided to licensed nurses and certified nurse aides reflected they had been educated by The DON that no residents would be fed or given fluids orally with a syringe for any reason. 4. Record review of facility in-service provided to agency staff working within the building dated 3/12/25 reflected that the residents plan of care was in the EMR (electronic medical record) under the [NAME] tab (a tab that contains certain needs for residents that staff may review). If they were to have any questions after reading the residents plan of care they must find their charge nurse for clarification. 5. Record review of facility in-service dated 03/12/25 provided to all certified nursing assistance both agency and facility staff reflected staff members must never attempt to feed or give fluids to a resident that was unresponsive. If they had a resident that was unresponsive, they must find the charge nurse for clarification. 6. The DON reviewed the agency binder to ensure the agency staff would be able to locate the residents plan of care to provide services. 7. Interviewed 22 nursing staff (CNA D, E,F,G,H,I,J,K,L,M,N,O,P,Q and LVN R,S,T,U,V,W,X) from all shifts and they stated they had been educated on not syringe feeding residents. They stated they had been educated on not attempting to feed unresponsive residents. They stated the risk for resident would be aspiration or choking. They stated they had been educated on where and how to locate a resident's plan of care to provide and meet the resident's needs. The agency staff were able to locate the facility binder with their expectations and EMR directions to provide services and care to residents. They stated if a plan of care did not seem accurate for a resident they would go to their charge nurse for clarification. They stated even if a nurse told them to do something that was out of their scope, they would report it to the ADON or DON for further clarification. The agency staff stated they were instructed prior to their shift to review the blue binder at the nurses' station. They stated within the binder there was current in-services for staff, policy and procedures for pain and falls, abuse, and neglect, also directions on how to navigate the electronic medical record to see the residents current plan of care. The binder also included current in-services for staff. Included in in-services within the blue binder were: no resident will be fed by syringe, Staff members must never attempt to feed a resident that is unresponsive, and where the plan of care is located within the EMR. 8. In an interview with The ADON on 3/13/25 at 2:46pm- The ADON stated the facility had posted an automatic notification that must be acknowledged to review in-services prior to the start of agency staffs shift instructing staff they must sign in at the nurses' station and all agency staff must read and abide by the blue binder located at the nurse's station. Within the blue binder was found an emergency phone list, items to report immediately, sign in sheets, facility management contacts. The binder also included current in-services for staff. Included in in-services within the blue binder were: no resident will be fed by syringe, Staff members must never attempt to feed a resident that is unresponsive, and where the plan of care is located within the EMR. Record review of shift key logs reflected the notification of in-services prior to coming on shift had been signed and acknowledged by 6 agency staff working 3/13/25. 9. Record review of a Care Plan Audit on 3/14/25 completed by the DON was 100% completed. The DON stated there were no further negative findings within the Care plan audit for all residents. She stated the care plans were accurate for Residents to reflects the resident's needs. 10. Signed QAPI minutes reviewed for 3/12/25 and reflected a meeting was held that included the facilities ADM, DON, ADON, MDS, and Medical Director The ADM and DON were informed the Immediate Jeopardy was removed on 03/14/2025 at 11:53am The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy and a scope of Isolated 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 interview and record review, the facility failed to ensure residents had the right to be free from abuse for one (Resident #1) of five residents reviewed for abuse. The facility failed to protect Resident #1 from physical abuse when CNA A was slapped by Resident #1 across the face and CNA A slapped Resident #1 back across their face on 1/5/2025. An Immediate Jeopardy (IJ) was identified on 01/22/2025. The IJ template was provided to the facility on [DATE] at 5:43 PM. While the IJ was removed on 01/23/2025, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because all staff had not been trained on abuse/neglect. This failure placed residents at risk of abuse, trauma, and/or psychosocial harm. Findings included: Review of Resident #1's Quarterly MDS dated [DATE] revealed a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including traumatic bran dysfunction (an injury to the brain caused by external mechanical force), dementia (a group of symptoms affecting memory, thinking, and social abilities), senile degeneration of brain (progressive deterioration of brain tissue and function that occurs beyond what's considered normal aging), and age-related physical debility. Resident #1 had a BIMS score of 00 indicating severe cognitive impairment. Review of Resident #1's care plan, dated last reviewed 01/12/2025, reflected she had impaired cognitive function and impaired thought processes with interventions to cue, reorient, and supervise as needed, and to not correct her if she gets confused to reality. Review of a witness statement, dated 1/5/2025 and documented by CNA B, reflected the following: I witnessed [Resident #1] coming up to [CNA A] and hit her in the face [CNA A] slapped [Resident #1] on the left cheek and [Resident #1] sat by her afterwards. I went to the restroom afterwards came back got the administrators number called then went to inform the nurse. I did ask 2 coworkers on what to do I've never experienced situation before. Review of a written statement dated 1/5/25 and documented by CNA A, reflected the following: I was sitting on the brown table when [Resident #1] walked up to me and started talking to me from there she slapped me in my face from there I did reach and pushed her back with my hand in her face. Just to make myself clear I did not slap the resident on the face I put my heel of my hand on her left cheek and pushed her back. When I realized I may contact with her I apologized to the resident. Review of a video footage provided by the facility with a date/time stamp of 01/05/2025 11:51 am reflected CNA A seated on a bench/table with Resident #1 to her right-side adjusting items on the bench/table. Resident #1 then walked to the front of CNA A and the two appeared to be in conversation. Resident #1 could be seen moving both of her arms while talking and then raised her right arm and slapped CNA A across the right side of her face. CNA A was then seen raising her right arm all the way up and slapping Resident #1 back across the left side of her face and Resident #1 can be seen being turned about 45-degrees due to the slap. After that, Resident #1 and CNA A can be seen in conversation again, and Resident #1 turns to walk to her left when CNA A grabbed the back of Resident #1's shirt and pulled toward her, making Resident #1 fall into a seated position to the right side of CNA A on the bench/table. Review of CNA A's time stamp card dated 01/05 revealed she clocked in at 06:02 AM and clocked out at 10:04 PM, working a total of 16.03 hours. During a phone interview on 01/22/2025 at 12:37 PM with RN A she stated that she was the charge nurse during the morning of 01/05/2025 and that CNA A did not tell her that she had slapped Resident #1 back. It was not until after CNA B contacted the ADM and then went to speak with RN A that she was notified that CNA A had slapped the resident. She stated that after she was informed by CNA B, she immediately went to go assess Resident #1, who exhibited no signs of trauma, and had no redness or signs of bruising. During a phone interview on 01/22/2025 at 12:47 PM with CNA B, she revealed from her phone log that she called the ADM on 01/05/2025 at 2:17 PM to notify him of the alleged abuse of Resident #1 by CNA A that happened earlier that day at 11:51 AM. CNA B was instructed by the ADM to then go and write a statement of the events that occurred as well as to inform the charge nurse. During a phone interview on 01/22/2025 at 1:00 PM with the ADM (who is the abuse coordinator), when asked why CNA A was allowed to finish her shift, he stated that at that point in time and after getting [CNA A's] statement it was unclear whether [the alleged abuse] was incidental or intentional, he had no concern about other residents being harmed at that time. CNA A had spoken with the charge nurse and there was no concern. CNA A was moved out of the MC unit and allowed to finish the remainder of her shift working another hall of the facility. CNA A was terminated the next day. Review of the facility's Abuse, Neglect and Exploitation policy dated last revised 01/08/2023 reflected the following: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Physical Abuse includes, but is not limited to hitting, slapping, punching, biting, and kicking. It also includes controlling behavior through corporal punishment. Protection of Resident The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Investigation of Alleged Abuse, Neglect and Exploitation 12. Any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete. The IDON, ADON, and ADM were notified on 01/22/2025 at 5:43 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 01/23/2025 at 5:15 PM: PLAN OF REMOVAL Name of facility: [name of facility] Date: 1/22/25 F 600 - Problem: The facility failed to keep the residents free from abuse. Resident #1 Was immediately assessed by the nurse without noted injuries and remains in the facility in stable condition. Immediate action: 1. On 1/22/25 The facility IDON/ADON/Designee immediately initiated skin assessments to ensure no s/s of physical injuries were present in all residents currently residing at the facility- no issues noted. Completed 1/23/25 2. On 1/22/25 The facility Adm/IDON/Designee initiated Life safety rounds with interviewable residents, interviews revealed no negative outcomes. Non-interviewable residents' responsible parties will also be interviewed. Any issues identified will be addressed immediately. Completed 1/23/25 3. On 1/22/25 The VPO conducted a 1:1 in-service with the facility administrator on the company abuse and neglect policy focusing on immediately suspending employees pending allegations of abuse and neglect. This included returned verbalized understanding of the process. This was documented on a signed in-service sheet. Any reportable incidents will also be reported to the corporate VP of Operation and or VP of Clinical to ensure an appropriate investigation, interventions and follow-up takes place. Any issues identified with this process will be addressed through further education and or disciplinary action. Interventions 4. On 1/22/25 The Adm initiated an in-service with the facility management staff on expectations to assure residents safety, abuse and neglect policy and reporting incidents immediately, this includes removing/suspending any staff members involved with any allegations or suspicion of abuse. Comprehension was verified by successfully completing a questionnaire on the subject, Completed 1/23/25 5. On 1/22/25 The facility Adm/IDON/Designee initiated an in-service with the staff on the corporate compliance hot line to report unusual events. Comprehension was verified by successfully completing a questionnaire on the subject, Completed 1/23/25 On 1/22/25 The facility Adm/DON/Designee initiated in-service with the facility staff on Abuse and Neglect focusing on ensuring residents safety and immediately reporting suspected abuse or neglect to the abuse prevention coordinator and or the corporate compliance hot line. The Abuse prevention coordinator contact information is posted throughout the facility. The abuse prevention coordinator will suspend, investigate, rule out, or report any allegation of abuse and neglect within the allotted time frame. Completed 1/23/25. Ongoing Projected completion 1/23/25. Any staff member not present during initial in-servicing/training will not be allowed to assume their duties until in-service. Ongoing In-service will be completed by IDON/ADON/WC NURSE/or weekend nurse supervisor, until all staff, weekend, PRN, and agency staff in completed. Monitoring 1. The facility IDT conduct residents Angel Rounds at least 5xweek to ensure residents do not have unknown safety concerns. Any concerns will be documented on the rounding sheet then turned to the administrator/Designee for immediately follow up. VP of Ops and/or Regional Nurse will provide additional oversight to ensure steps are completed. On going 1/22/25. 2. On 1/22/23 The DON/designee began a questionnaire to validate the effectiveness of the training. The questionnaire is conducted with facility staff. Immediate re-education will be completed by the DNS/designee if any staff is unable to answer appropriately to the questions on the questionnaire. Staff will not be allowed to work until after completion of the questionnaire. Projected completion 1/23/25. 3. On 1/22/25 An impromptu QAPI meeting was conducted with the facility's Medical Director to notify of the potential for non-compliance and the action plan implemented for approval. Plan approved on 1/22/25. 4. Any reportable incidents will also be reported to the corporate VP of Operation and or VP of Clinical to ensure an appropriate investigation, interventions and follow-up takes place. Any issues identified with this process will be addressed through further education and or disciplinary action 1/22/25. The surveyor monitored the POR on 01/23/2025 as followed: During interviews on 01/23/2025 from 4:30pm -5:20pm 3 CNA's, 1 LVN, and 1 MA (from all 3 shifts) all stated they were in-serviced before starting their shift on 01/23/2025 and then given questionnaires to complete to verify their knowledge. All were able to state that their abuse coordinator was the ADM, if he were not available, they were to notify the ADON, IDON, or charge nurse. They were all able to give examples of physical, verbal, and emotional abuse. All expressed the importance of reporting abuse the first time they see or hear it. All know where the corporate compliance hotline number is posted and know when to contact if needed. During interviews on 01/23/2025 from 3:55pm-4:20pm with 3 alert and oriented residents revealed they had recently had communication with management regarding their satisfaction with living at the facility and that they have no concerns about their safety, the staff that provide their daily care, or the management at the facility. Interview with the ADM on 1/23/2025 at 5:10pm, he stated he was in-serviced one-on-one with the VPO regarding the timeliness of reporting alleged abuse to HHSC (within 2 hours of the alleged abuse), keeping residents safe, prevention of abuse, and that he was to notify the VPO anytime an allegation was made of ANE. The ADM stated that all employees will be in-serviced before the start of their next shift. The ADM also stated that CNA A was terminated on 1/6/2025. Review of skin assessments dated 1/22/2025-1/23/2025 of all residents revealed no new skin issues/concerns. Review of one-on-one in-service dated 1/22/2025 titled Health and Human Services Reportable Guidelines presented by the VPO to the ADM revealed he went over review of the facility abuse, neglect, and exploitation policy. Included a review of policy section III. Prevention of abuse, neglect, and exploitation, and section VI. Investigation of alleged abuse, neglect and exploitation and section VII. Protection of resident. Review of in-service dated 1/22/2025 titled 'Abuse and Neglect policy: prevention and reporting' was provided by the ADM to department managers. Review of in-service dated 1/22/2025 titled 'Abuse and Neglect policy: It is our policy to ensure resident safety and immediately report suspected abuse or neglect to the abuse coordinator', and listed the ADM's telephone number, was provided to direct care staff. Review of in-service dated 1/22/2025 titled 'Company Compliance Program' revealed information on the company's compliance hotline for employees to contact and was provided to direct care staff. Review of in-service titled 'Angel/Ambassador Rounds Policy' with the policy attached was provided to Angel Round staff members. Review of 'Responsible Party Contact Log' dated week of 1/20/2025 revealed 48 residents' responsible parties were contacted and notes were written regarding complaints/praises/remarks. No notes made regarding suspected abuse/neglect. Review of Safe Surveys dated week of 1/20/2025-1/24/2025 revealed no residents expressing concerns regarding their safety or abusive staff. Review of multiple employee Abuse/Neglect and Compliance Questionnaire's dated between 1/22/2025-1/23/2025 revealed staff answered questions based on the in-services provided. Review of QAPI meeting notes dated 1/22/2025 revealed an email from the MD stating his agreement to their path moving forward. The ADM was informed the IJ was removed on 01/23/2025 at 5:15 PM. The facility remained out of compliance at a severity level of no actual harm and a scope of isolated 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 interview and record review, the facility failed to implement their written policies and procedures regarding investigating abuse for one (Resident #1) of five residents reviewed for abuse and neglect. The facility failed to ensure CNA A was suspended/terminated or removed from working with all residents after she slapped a resident in the memory care unit, potentially causing additional abuse and/or emotional distress. An Immediate Jeopardy (IJ) was identified on 01/22/2025. The IJ template was provided to the facility on [DATE] at 5:43 PM. While the IJ was removed on 01/23/2025, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because all staff had not been trained on abuse/neglect. This failure placed residents at risk of abuse, trauma, and psychosocial harm. Findings included: Review of Resident #1's Quarterly MDS dated [DATE] revealed a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including traumatic bran dysfunction (an injury to the brain caused by external mechanical force), dementia (a group of symptoms affecting memory, thinking, and social abilities), senile degeneration of brain (progressive deterioration of brain tissue and function that occurs beyond what's considered normal aging), and age-related physical debility. Review of Resident #1's care plan, dated last reviewed 01/12/2025, reflected she had impaired cognitive function and impaired thought processes with interventions to cue, reorient, and supervise as needed, and to not correct her if she gets confused to reality. Review of a witness statement, dated 1/5/2025 and documented by CNA B, reflected the following: I witnessed [Resident #1] coming up to [CNA A] and hit her in the face [CNA A] slapped [Resident #1] on the left cheek and [Resident #1] sat by her afterwards. I went to the restroom afterwards came back got the administrators number called then went to inform the nurse. I did ask 2 coworkers on what to do I've never experienced situation before. Review of written statement dated 1/5/25 and documented by CNA A, reflected the following: I was sitting on the brown table when [Resident #1] walked up to me and started talking to me from there she slapped me in my face from there I did reach and pushed her back with my hand in her face. Just to make myself clear I did not slap the resident on the face I put my heel of my hand on her left cheek and pushed her back. When I realized I may contact with her I apologized to the resident. Review of video footage provided by the facility with a date/time stamp of 01/05/2025 11:51 am reflected CNA A seated on a bench/table with Resident #1 to her right-side adjusting items on the bench/table. Resident #1 then walked to the front of CNA A and the two appeared to be in conversation. Resident #1 could be seen moving both of her arms while talking and then raised her right arm and slapped CNA A across the right side of her face. CNA A is then seen raising her right arm all the way up and slapping Resident #1 back across the left side of her face and Resident #1 can be seen being turned about 45-degrees due to the slap. After that, Resident #1 and CNA A can be seen in conversation again, and Resident #1 turns to walk to her left when CNA A grabbed the back of Resident #1's shirt and pulled toward her, making Resident #1 fall into a seated position to the right side of CNA A on the bench/table. Review of CNA A's time stamp card dated 01/05 revealed she clocked in at 06:02 AM and clocked out at 10:04 PM, working a total of 16.03 hours. During a phone interview on 01/22/2025 at 12:37 PM with RN A she stated that she was the charge nurse during the morning of 01/05/2025 and that CNA A did not tell her that she had slapped Resident #1 back. It was not until after CNA B contacted the ADM and then went to speak with RN A that she was notified that CNA A had slapped the resident. She stated that after she was informed by CNA B, she immediately went to go assess Resident #1. During a phone interview on 01/22/2025 at 12:47 PM with CNA B, she revealed from her phone log that she called the ADM on 01/05/2025 at 2:17 PM to notify him of the alleged abuse of Resident #1 by CNA A that happened earlier that day at 11:51 AM. CNA B was instructed by the ADM to then go and write a statement of the events that occurred as well as to inform the charge nurse. During a phone interview on 01/22/2024 at 1:00 PM with the ADM, when asked why CNA A was allowed to finish her shift, he stated that at that point in time and after getting [CNA A's] statement it was unclear whether [the alleged abuse] was incidental or intentional, he had no concern about other residents being harmed at that time. CNA A had spoken with the charge nurse and there was no concern. CNA A was moved out of the MC unit and allowed to finish the remainder of her shift working another hall of the facility. CNA A was terminated the next day. During a phone interview on 01/22/2025 at 1:41 PM with the NP she stated that she expected facilities to immediately suspend an employee who had abused a resident and report it to HHSC. She stated that you can never tell if it could happen again. If the perpetrator were to stay working with the resident it could get worse for the resident. Review of the facility's Abuse, Neglect and Exploitation policy dated last revised 01/08/2023 reflected the following: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Physical Abuse includes, but is not limited to hitting, slapping, punching, biting, and kicking. It also includes controlling behavior through corporal punishment. Protection of Resident The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Investigation of Alleged Abuse, Neglect and Exploitation 12. Any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete. The IDON, ADON, and ADM were notified on 01/22/2025 at 5:43 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 01/23/2025 at 5:15 PM: PLAN OF REMOVAL Name of facility: [name of facility] Date: 1/22/25 F 607 -Problem: The facility failed to implement written policies and procedures to investigate allegations of abuse Resident #1 Was immediately assessed by the nurse without noted injuries. Remains in the facility in stable condition. Immediate action: 1. On 1/22/25 The facility IDON/ADON/Designee immediately initiated skin assessments to ensure no s/s of physical injuries were present in all residents currently residing at the facility- no issues noted. Completed 1/23/25 2. On 1/22/25 The facility Adm/IDON/Designee initiated Life safety rounds with interviewable residents, Interviews revealed no new negative events. Completed 1/23/25. 3. On 1/22/25 The VPO conducted a 1:1 in-service with the facility administrator on the company abuse and neglect policy focusing on immediately suspending employees pending allegations of abuse and neglect. This included returned verbalized understanding of the process. This was documented on a signed in-service sheet. Any reportable incidents will also be reported to the corporate VP of Operation and or VP of Clinical to ensure an appropriate investigation, interventions and follow-up takes place. Any issues identified with this process will be addressed through further education and or disciplinary action. Interventions On 1/22/25 The Adm initiated an in-service with the facility management staff on expectations to assure residents safety, abuse and neglect policy and reporting incidents immediately, this includes removing/suspending any staff members involved with any allegations or suspicion of abuse. Any staff member not present during initial in-servicing/training will not be allowed to assume their duties until in-service. Ongoing In-service will be completed by IDON/ADON/WC NURSE/or weekend nurse supervisor, until all staff, weekend, prn, and agency staff in completed. Comprehension was verified by successfully completing a questionnaire on the subject. Completed 1/23/25 4. On 1/22/25 The facility Adm/IDON/Designee initiated an in-service with the staff on the corporate compliance hot line to report unusual events. Comprehension was verified by successfully completing a questionnaire on the subject. Completed 1/23/25 5. On 1/22/25 The facility Adm/DON/Designee initiated in-service with the facility staff on Abuse and Neglect focusing on ensuring residents safety and immediately reporting suspected abuse or neglect to the abuse prevention coordinator and or the corporate compliance hot line. The Abuse prevention coordinator contact information is posted throughout the facility. The abuse prevention coordinator will suspend, investigate, rule out, or report any allegation of abuse and neglect within the allotted time frame. Comprehension was verified by successfully completing a questionnaire on the subject, Completed 1/23/25. Ongoing Projected completion 1/23/25. Any staff member not present during initial in-servicing/training will not be allowed to assume their duties until in-service. Ongoing In-service will be completed by IDON/ADON/WC NURSE/or weekend nurse supervisor, until all staff, weekend, prn, and agency staff in completed. Monitoring 1. The facility IDT conduct residents Angel Rounds at least 5xweek to ensure residents do not have unknown safety concerns. Any concerns will be reported to the Adm/Designee immediately for proper follow up. VP of Ops and/or Regional Nurse will provide additional oversight to ensure steps are completed. On going 1/22/25. 2. On 1/22/23 The DON/designee began a questionnaire to validate the effectiveness of the training. The questionnaire is conducted with facility staff. Immediate re-education will be completed by the DNS/designee if any staff is unable to answer appropriately to the questions on the questionnaire. Staff will not be allowed to work until after completion of the questionnaire. Projected completion 1/23/25. 3. On 1/22/25 An impromptu QAPI meeting was conducted with the facility's Medical Director to notify of the potential for non-compliance and the action plan implemented for approval. Plan approved on 1/22/25. The surveyor monitored the POR on 01/23/2025 as followed: During interviews on 01/23/2025 from 3:55pm-4:20pm with 3 alert and oriented residents revealed they had recently had communication with management regarding their satisfaction with living at the facility and that they have no concerns about their safety, the staff that provide their daily care, or the management at the facility. During interviews on 01/23/2025 from 4:30pm -5:20pm 3 CNA's, 1 LVN, and 1 CMA (from all 3 shifts) all stated they were in-serviced before starting their shift on 01/23/2025 and then given questionnaires to complete to verify their knowledge. All were able to state that their abuse coordinator was the ADM, if he were not available, they were to notify the ADON, IDON, or charge nurse. They were all able to give examples of physical, verbal, and emotional abuse. All expressed the importance of reporting abuse the first time they see or hear it. All know where the corporate compliance hotline number is posted and know when to contact if needed. Interview with the ADM on 1/23/2025 at 5:10pm, he stated he was in-serviced one-on-one with the VPO regarding the timeliness of reporting alleged abuse to HHSC (within 2 hours of the alleged abuse), keeping residents safe, prevention of abuse, and that he is to notify the VPO anytime an allegation is made of ANE. The ADM stated that all employees will be in-serviced before the start of their next shift. The ADM also stated that CNA A was terminated on 1/6/2025. Review of skin assessments dated 1/22/2025-1/23/2025 of all residents revealed no new skin issues/concerns. Review of one-on-one in-service dated 1/22/2025 titled Health and Human Services Reportable Guidelines presented by the VPO to the ADM revealed he went over review of the facility abuse, neglect, and exploitation policy. Included a review of policy section III. Prevention of abuse, neglect, and exploitation, and section VI. Investigation of alleged abuse, neglect and exploitation and section VII. Protection of resident. Review of in-service dated 1/22/2025 titled 'Abuse and Neglect policy: prevention and reporting' was provided by the ADM to department managers. Review of in-service dated 1/22/2025 titled 'Abuse and Neglect policy: It is our policy to ensure resident safety and immediately report suspected abuse or neglect to the abuse coordinator', and listed the ADM's telephone number, was provided to direct care staff. Review of in-service dated 1/22/2025 titled 'Company Compliance Program' revealed information on the company's compliance hotline for employees to contact and was provided to direct care staff. Review of in-service titled 'Angel/Ambassador Rounds Policy' with the policy attached was provided to Angel Round staff members. Review of 'Responsible Party Contact Log' dated week of 1/20/2025 revealed 48 residents' responsible parties were contacted and notes were written regarding complaints/praises/remarks. No notes made regarding suspected abuse/neglect. Review of Safe Surveys dated week of 1/20/2025-1/24/2025 revealed no residents expressing concerns regarding their safety or abusive staff. Review of multiple employee Abuse/Neglect and Compliance Questionnaire's dated between 1/22/2025-1/23/2025 revealed staff answered questions based on the in-services provided. Review of QAPI meeting notes dated 1/22/2025 revealed an email from the MD stating his agreement to their path moving forward. The ADM was informed the IJ was removed on 01/23/2025 at 5:15 PM. The facility remained out of compliance at a severity level of no actual harm and a scope of isolated 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 interview and record review, the facility failed to, in response to allegations of abuse, prevent further potential abuse for one (Resident #1) of five residents reviewed for abuse and neglect while the investigation of alleged abuse was in progress. The facility failed to ensure CNA A was suspended/terminated or removed from working with all residents while the investigation of alleged abuse was ongoing. CNA A was moved to another wing to continue the remainder of her shift working with other residents for approximately 10 additional hours on the day she slapped a resident in the memory care unit. An Immediate Jeopardy (IJ) was identified on 01/22/2025. The IJ template was provided to the facility on [DATE] at 5:43 PM. While the IJ was removed on 01/23/2025, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because all staff had not been trained on abuse/neglect. This failure placed residents at risk of abuse, trauma, and/or psychosocial harm. Findings included: Review of Resident #1's Quarterly MDS dated [DATE] revealed a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including traumatic bran dysfunction (an injury to the brain caused by external mechanical force), dementia (a group of symptoms affecting memory, thinking, and social abilities), senile degeneration of brain (progressive deterioration of brain tissue and function that occurs beyond what's considered normal aging), and age-related physical debility. Resident #1 had a BIMS score of 00 indicating severe cognitive impairment. Review of Resident #1's care plan, dated last reviewed 01/12/2025, reflected she had impaired cognitive function and impaired thought processes with interventions to cue, reorient, and supervise as needed, and to not correct her if she gets confused to reality. Review of a witness statement, dated 1/5/2025 and documented by CNA B, reflected the following: I witnessed [Resident #1] coming up to [CNA A] and hit her in the face [CNA A] slapped [Resident #1] on the left cheek and [Resident #1] sat by her afterwards. I went to the restroom afterwards came back got the administrators number called then went to inform the nurse. I did ask 2 coworkers on what to do I've never experienced situation before. Review of written statement dated 1/5/25 and documented by CNA A, reflected the following: I was sitting on the brown table when [Resident #1] walked up to me and started talking to me from there she slapped me in my face from there I did reach and pushed her back with my hand in her face. Just to make myself clear I did not slap the resident on the face I put my heel of my hand on her left cheek and pushed her back. When I realized I may contact with her I apologized to the resident. Review of video footage provided by the facility with a date/time stamp of 01/05/2025 11:51 am reflected CNA A seated on a bench/table with Resident #1 to her right-side adjusting items on the bench/table. Resident #1 then walked to the front of CNA A and the two appeared to be in conversation. Resident #1 could be seen moving both of her arms while talking and then raised her right arm and slapped CNA A across the right side of her face. CNA A is then seen raising her right hand all the way up and slapping Resident #1 back across the left side of her face and Resident #1 can be seen being turned about 45-degrees due to the slap. After that Resident #1 and CNA A can be seen in conversation again, and Resident #1 turns to walk to her left when CNA A grabbed the back of Resident #1's shirt and pulled toward her, making Resident #1 fall into a seated position to the right side of CNA A on the bench/table. Review of CNA A's time stamp card dated 01/05 revealed she clocked in at 06:02 AM and clocked out at 10:04 PM, working a total of 16.03 hours. During a phone interview on 01/22/2025 at 12:37 PM with RN A she stated that she was the charge nurse during the morning of 01/05/2025 and that CNA A did not tell her that she had slapped Resident #1 back. It was not until after CNA B contacted the ADM and then went to speak with RN A that she was notified that CNA A had slapped the resident. She stated that after she was informed by CNA B she immediately went to go assess Resident #1. During a phone interview on 01/22/2025 at 12:47 PM with CNA B, she revealed from her phone log that she called the ADM on 01/05/2025 at 2:17 PM to notify him of the alleged abuse of Resident #1 by CNA A that happened earlier that day at 11:51 AM. CNA B was instructed by the ADM to then go and write a statement of the events that occurred as well as to inform the charge nurse. During a phone interview on 01/22/2025 at 1:00 PM with the ADM, when asked why CNA A was allowed to finish her shift he stated that at that point in time and after getting [CNA A's] statement it was unclear whether [the alleged abuse] was incidental or intentional, he had no concern about other residents being harmed at that time. CNA A had spoken with the charge nurse and there was no concern. CNA A was moved out of the MC unit and allowed to finish the remainder of her shift working another hall of the facility. CNA A was terminated the next day. During a phone interview on 01/22/2025 at 1:41 PM with the NP she stated that she expected facilities to immediately suspend an employee who had abused a resident and report it to HHSC. She stated that you can never tell if it could happen again. If the perpetrator were to stay working with the resident it could get worse for the resident. Review of the facility's Abuse, Neglect and Exploitation policy dated last revised 01/08/2023 reflected the following: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Physical Abuse includes, but is not limited to hitting, slapping, punching, biting, and kicking. It also includes controlling behavior through corporal punishment. Protection of Resident The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Investigation of Alleged Abuse, Neglect and Exploitation 12. Any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete. The DON, ADON, and ADM were notified on 01/22/2025 at 5:43 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 01/23/2025 at 5:15 PM: PLAN OF REMOVAL Name of facility: [name of facility] Date: 1/22/25 F 610 -Problem: The facility failed to prevent further potential abuse while the investigation was in progress. Resident #1 Was immediately assessed by the nurse without noted injuries Remains in the facility in stable condition. Immediate action: 1. On 1/22/25 The facility IDON/ADON/Designee immediately initiated skin assessments to ensure no s/s of physical injuries were present in all residents currently residing at the facility- no issues noted. Completed 1/23/25 2. On 1/22/25 The facility Adm/IDON/Designee initiated Life safety rounds with interviewable residents, Interviews revealed no new negative events. Completed 1/23/25. 3. On 1/22/25 The VPO conducted a 1:1 in-service with the facility administrator on the company abuse and neglect policy focusing on immediately suspending employees pending allegations of abuse and neglect. This included returned verbalized understanding of the process. This was documented on a signed in-service sheet. Any reportable incidents will also be reported to the corporate VP of Operation and or VP of Clinical to ensure an appropriate investigation, interventions and follow-up takes place. Any issues identified with this process will be addressed through further education and or disciplinary action. Interventions 4. On 1/22/25 The Adm initiated an in-service with the facility management staff on expectations to assure residents safety, abuse and neglect policy and reporting incidents immediately, this includes removing/suspending any staff members involved with any allegations or suspicion of abuse. Comprehension was verified by successfully completing a questionnaire on the subject Completed 1/23/25 5. On 1/22/25 The facility Adm/IDON/Designee initiated an in-service with the staff on the corporate compliance hot line to report unusual events. Comprehension was verified by successfully completing a questionnaire on the subject Completed 1/23/25. 6. On 1/22/25 The facility Adm/DON/Designee initiated in-service with the facility staff on Abuse and Neglect focusing on ensuring residents safety and immediately reporting suspected abuse or neglect to the abuse prevention coordinator and or the corporate compliance hot line. The Abuse prevention coordinator contact information is posted throughout the facility. The abuse prevention coordinator will suspend, investigate, rule out, or report any allegation of abuse and neglect within the allotted time frame. Comprehension was verified by successfully completing a questionnaire on the subject Completed 1/23/25. Ongoing Projected completion 1/23/25. Any staff member not present during initial in-servicing/training will not be allowed to assume their duties until in-service. Ongoing In-service will be completed by IDON/ADON/WC NURSE/or weekend nurse supervisor, until all staff, weekend, prn, and agency staff in completed. Monitoring 1. The facility IDT conduct residents Angel Rounds at least 5xweek to ensure residents do not have unknown safety concerns. Any concerns will be reported to the Adm/Designee immediately for proper follow up. VP of Ops and/or Regional Nurse will provide additional oversight to ensure steps are completed On going 1/22/25. 2. On 1/22/23 The DON/designee began a questionnaire to validate the effectiveness of the training. The questionnaire is conducted with facility staff. Immediate re-education will be completed by the DNS/designee if any staff is unable to answer appropriately to the questions on the questionnaire. Staff will not be allowed to work until after completion of the questionnaire. Projected completion 1/23/25. 3. On 1/22/25 An impromptu QAPI meeting was conducted with the facility's Medical Director to notify of the potential for non-compliance and the action plan implemented for approval. Plan approved on 1/22/25. The surveyor monitored the POR on 01/23/2025 as followed: During interviews on 01/23/2025 from 4:30pm -5:20pm 3 CNA's, 1 LVN, and 1 CMA (from all 3 shifts) all stated they were in-serviced before starting their shift on 01/23/2025 and then given questionnaire's to complete to verify their knowledge. All were able to state that their abuse coordinator was the ADM, if he were not available, they were to notify the ADON, IDON, or charge nurse. They were all able to give examples of physical, verbal, and emotional abuse. All expressed the importance of reporting abuse the first time they see or hear it. All know where the corporate compliance hotline number is posted and know when to contact if needed. During interviews on 01/23/2024 from 3:55pm-4:20pm with 3 alert and oriented residents revealed they had recently had communication with management regarding their satisfaction with living at the facility and that they have no concerns about their safety, the staff that provide their daily care, or the management at the facility. During interviews on 01/23/2025 from 4:30pm -5:20pm 3 CNA's, 1 LVN, and 1 CMA (from all 3 shifts) all stated they were in-serviced before starting their shift on 01/23/2025 and then given questionnaires to complete to verify their knowledge. All were able to state that their abuse coordinator was the ADM, if he were not available, they were to notify the ADON, IDON, or charge nurse. They were all able to give examples of physical, verbal, and emotional abuse. All expressed the importance of reporting abuse the first time they see or hear it. All know where the corporate compliance hotline number is posted and know when to contact if needed. Interview with the ADM on 1/23/2025 at 5:10pm, he stated he was in-serviced one-on-one with the VPO regarding the timeliness of reporting alleged abuse to HHSC (within 2 hours of the alleged abuse), keeping residents safe, prevention of abuse, and that he is to notify the VPO anytime an allegation is made of ANE. The ADM stated that all employees will be in-serviced before the start of their next shift. Review of skin assessments dated 1/22/2025-1/23/2025 of all residents revealed no new skin issues/concerns. Review of one-on-one in-service dated 1/22/2025 titled Health and Human Services Reportable Guidelines presented by the VPO to the ADM revealed he went over review of the facility abuse, neglect, and exploitation policy. Included a review of policy section III. Prevention of abuse, neglect, and exploitation, and section VI. Investigation of alleged abuse, neglect and exploitation and section VII. Protection of resident. Review of in-service dated 1/22/2025 titled 'Abuse and Neglect policy: prevention and reporting' was provided by the ADM to department managers. Review of in-service dated 1/22/2025 titled 'Abuse and Neglect policy: It is our policy to ensure resident safety and immediately report suspected abuse or neglect to the abuse coordinator', and listed the ADM's telephone number, was provided to direct care staff. Review of in-service dated 1/22/2025 titled 'Company Compliance Program' revealed information on the company's compliance hotline for employees to contact and was provided to direct care staff. Review of in-service titled 'Angel/Ambassador Rounds Policy' with the policy attached was provided to Angel Round staff members. Review of 'Responsible Party Contact Log' dated week of 1/20/2025 revealed 48 residents' responsible parties were contacted and notes were written regarding complaints/praises/remarks. No notes made regarding suspected abuse/neglect. Review of multiple employee Abuse/Neglect and Compliance Questionnaire's dated between 1/22/2025-1/23/2025 revealed staff answered questions based on the in-services provided. Review of QAPI meeting notes dated 1/22/2025 revealed an email from the MD stating his agreement to their path moving forward. The ADM was informed the IJ was removed on 01/23/2025 at 5:15 PM. The facility remained out of compliance at a severity level of no actual harm and a scope of isolated that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.