**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to protect the residents' right to be free from were verbal and physical abuse by a resident for 6 of 6 residents (Residents #5, #71, #82, #88, #95, #99) reviewed for abuse, in that: 1.The facility failed to ensure Resident #71 was free abuse when Resident #88 hit Resident #71 on the head on 01/24/25. 2. The facility failed to ensure Resident #71 was free from abuse when Resident #88 had a physical altercation with Resident #71 on 04/05/25. 3. The facility failed to ensure Resident #82, and Resident #99 were free from abuse when Resident #88 had a physical altercation with Resident #82 and Resident #99 on 06/04/25. 4.The facility failed to ensure Resident #5 was free from abuse when Resident #88 entered Resident #5's room and attempted to pull Resident #5 from her wheelchair on 06/22/25. 5.The facility failed to ensure Resident #95 was free from abuse when Resident #88 went up to Resident #95 and attempted to remove her from her wheelchair. Resident #88 shook Resident #95 and then slapped her on the side of her head on 06/28/25. An IJ that occurred in the past was identified. The IJ began on 01/24/25 and removed on 06/28/25. The facility took action to remove the IJ before survey began. While the IJ was removed on 06/28/25, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with a potential for more than minimal harm because all staff had not been trained on abuse/neglect. This failure has the potential to result in serious injury or death as a result of abuse and neglect. 1. Record review of Resident #88's Face Sheet dated 07/24/25 revealed she was a [AGE] year-old female admitted to facility on 10/24/24 with diagnoses of Alzheimer's disease (a progressive disease that destroys the memory and other important mental functions), anxiety disorder, unspecified psychosis (a mental health condition characterized by a loss of contact with reality, often involving symptoms like hallucinations and delusions), and major depressive disorder, recurrent, severe with psychotic symptoms. Record review of Resident #88's quarterly MDS dated [DATE] revealed Resident #88 was usually understood by others and usually was able to understand others. She had a BIMS score of 02 which indicated severe cognitive impairment. Resident had physical behavioral symptoms directed toward others (hitting, kicking, scratching, grabbing), verbal behavioral symptoms directed toward others (screaming at others, cursing at others) and other behavioral symptoms not directed toward others (physical symptoms such as hitting, pacing, rummaging or verbal symptoms like screaming, disruptive sounds). Record review of Resident #88's comprehensive care plan revised on 05/28/25 revealed Resident #88 has been physically aggressive (hitting staff or other resident) r/t dementia: 01/24/25 - Resident became physically aggressive toward another resident The care plan included the following interventions:-When resident becomes agitated: intervene before agitation escalates; guide away from source of distress; engage calmly in conversation; if response is aggressive, staff to walk away calmly and approach later. Record review of Resident #88's Physician's Order Summary for July 2025 revealed orders for: --Gabapentin oral capsule 100 mg, give two capsules by mouth three times a day related to emotional lability, order date 06/09/25.Haldol Decanoate intramuscular solution 50 mg/ml, inject 50 mg intramuscularly monthly starting on the 10th and ending on the 10th every month for agitation, order date 07/06/25 and start date on 07/10/25.Latuda oral tablet 20 mg, give 1 tablet by mouth two times a day related to major depressive disorder, recurrent, severe with psychotic symptoms, order date 06/11/25 and start date 06/12/25.Zyprexa oral tablet 5 mg (Olanzapine), give 5 mg by mouth two times a day related to unspecified psychosis, order date 06/13/14 and start date 06/14/25. Record review of Resident #88's progress notes dated from 06/28/25 to 07/25/25 revealed Resident #88 was put on a continuous one-to-one monitoring until Resident #88 was admitted to a facility in San [NAME]. Record review of Resident #71's Face Sheet dated 07/24/25 indicated she was [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Alzheimer's disease (a progressive disease that destroys memory and other important mental functions.), anemia (a problem in which the blood does not have enough healthy blood cells to carry oxygen to throughout the body), and hypertension (when the blood pressure in the blood vessels is too high). Record review of Resident #71 quarterly MDS dated [DATE] indicated Resident #71 was understood by others, and was able to understand others, did not have any behaviors, and had a BIMS score of 05 which indicated she had moderate cognitive impairment. Record review of facility's Provider Investigation Report dated 01/24/25 revealed Incident date and time: 01/24/25 at 4:00 pm. Nurse Aide saw Resident #88 go hit Resident #71's in the back of the head and pull her hair. Record review of the Provider Action Taken Post Investigation dated 01/24/25: Head to toe assessment performed on 01/24/25 for Resident #71 revealed no other visible injuries noted. Employees were in-serviced on resident-to-resident abuse and resident de-escalation techniques. Social Services did resident safe interviews. Resident behaviors care planned. Staff will keep both residents apart when in close proximity or when doing social activities. Care Plans for both residents updated. Observation of 07/21/25 at 9:32 am revealed Resident #88 in bed on her side with the lights off and a CNA in the room. Resident #88 was still in her pajamas and shoes on. Resident #88 did not respond to greeting and questions regarding incident with Resident #71. In an interview on 07/21/25 9:57 am CNA K said Resident #88 was able to walk and wandered throughout the building, but they had to shadow her to prevent aggressive behaviors toward other residents. If resident was on her own, she would fight with other residents. CNA K said Resident #88 cried a lot and the other residents became impatient with her and then she became aggressive. CNA K said when resident was on her own in her room, she was ok. CNA K said if they gave her colors and pages to color, she would do it. 2. Record review of Incident Report dated 04/05/25 revealed Resident #88 hit Resident #71 on her back and took some coloring pages from her. Resident #88 was separated from Resident #71. Head to toe evaluation of both residents by LVN revealed no injuries to either resident. Record review of Resident #88's care plan was revised on 04/08/25 to include incident on 04/05/25 with aggressive behavior with interventions to monitor for sundowning behavior, continue sertraline100 mg daily (antidepressant), follow up counseling and psych recommendations and monitor behavior. Record review of Psychiatric Progress Note dated 04/24/25 by NP revealed Resident #88 was tearful, confused and wanted to go home to see her mother and father. Patient has many altercations with female residents. The NP last saw Resident #88 on 04/24/25. 3. Record review of Resident #82's Face Sheet dated 07/24/24 revealed Resident #82 was a [AGE] year-old female admitted to facility on 10/24/24 with diagnoses of unspecified dementia (progressive or persistent loss of intellectual functioning), muscle wasting and atrophy, and muscle weakness. Record review of Resident #82's Quarterly MDS dated [DATE] revealed Resident #82 was usually understood by others, and usually understands others, BIMS of 03, and does not have behaviors and was able to ambulate independently. Record review of Resident #82's care plan dated 06/05/25 revealed Resident #82 has a behavior problem (labile moods) r/t dementia. On 06/04/25 Resident had altercation withanother female resident (#88) and grabbed the other female (88) by her shirt and other resident (#88) lost her balance and fell. Interventions included administer medications as ordered, monitor/document for side effects and effectiveness. Explain/reinforce why behaviors are inappropriate and/or unacceptable. Record review of Resident #99's Face Sheet dated 06/10/25 revealed Resident #99 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of muscle wasting and atrophy, anxiety disorder, and major depressive disorder. Record review of facility's Provider Investigation Report revealed Incident Date/Time: 06/04/24 at 7:45 pm. Resident #88 was attempting to grab another female resident (#99) and Resident #82 started yelling at Resident #88 to stop harassing the other resident. Resident #88 then went towards Resident #82. Resident #82 grabbed Resident #88 by her shirt and Resident #88 was not able to keep her balance and fell landing on her right lateral side. Nurse aide ran toward altercation but was not able to stop Resident #88 from falling. Resident #88 suffered a small cut to her right eyebrow, no other visible injuries noted. Resident #88 sent to ER for further evaluation per physician's orders. Record review of Health Status Note dated 06/04/25 at 11:09 pm revealed Resident #88 returned from the ER with swelling to right eye and light purple discoloration due to fall. Dermabond was applied to laceration for closure. CT was negative. Resident will be on neuro checks due to fall. Bed at lowest position with call light within reach. Record review of facility's Provider Investigation Report revealed Incident Date/Time:06/07/25 at 8:29 am. Resident #88 was in the dining room and attempted to assist Resident #5 in the wheelchair. Resident #5 said she did not want the assistance. Resident #88 became aggressive and pulled Resident #5's hair. The residents were separated and both Residents were taken to their rooms. Both Residents were assessed by LVN N. After the altercation Resident #88 was taken to the nurse's station for the remainder of the shift.Investigation Summary: After investigation it was determined Resident #82 attempted to stop Resident #88 from harassing another resident and Resident #88 lunged at Resident #82. Resident #82 grabbed Resident #88 by the shirt and Resident #88 lost her balance. The NP, family and the police were notified of the incident. Provider action taken post-investigation: Performed resident interviews and Follow-up with the psych NP as needed. In an interview on 07/21/25 at 12:54 pm Resident #82 said she did not fight with anyone, and she did not recall any incidents when another Resident tried to hit her. Resident #82 said she kept to herself and participated in her own activities. In an interview on 07/22/25 at 4:28 pm CNA J said she was walking toward the nurse's station when she saw Resident #82 pull Resident 88's shirt and push her toward the floor. CNA said Resident #88 must have done something to Resident #82 because Resident #82 did not usually fight. CNA J said the CNA in front of her ran toward Resident #88 and then asked her to get the nurse. CNA J said she went to look for the nurse, but he was providing care to a resident, and he asked CNA J to get the nurse from the back hall. CNA J said she went to get LVN N and then LVN N went and attended to Resident #88. Observation on 07/23/25 at 12:55 pm revealed Resident #88 was walking up A [NAME] Wing. CNA S was holding Resident #88's hand as they ambulated through the hallway. 07/23/25 1:25 pm CNA S said he had been on a one to one with Resident #88 since 07/22/25 through 07/25/25. CNA S said Resident #88 was on a one-to-one monitoring for the 2-10 shift. CNA S said he went everywhere Resident #88 went. CNA S said if Resident #88 became aggressive with another resident, he would intervene and if necessary, would get between the two residents so she would not hit the other resident. He would redirect Resident #88 toward another direction and keep walking with her. 4. Record review of Resident #5 Face Sheet dated 06/10/25 revealed Resident #5 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of hemiplegia (weakness to one side of the body) and hemiparesis (weakness to one side of the body), muscle wasting and atrophy, and unspecified dementia. Record review of Resident #5's quarterly MDS dated [DATE] revealed Resident #5 was sometimes understood by others, usually understood others, had a BIMS of 08 indicating she had moderate cognitive impairment and did not have any behaviors and required substantial/maximal assistance with her ADLs. Record review of facility's Provider Investigation Report dated 06/22/25 revealed Incident date and time: 06/22/25 at 7:20 pm. Nurse Aide saw Resident #88 go into Resident #5's room. Nurse Aide followed her into the room. Nurse Aide saw that Resident #88 was attempting to get Resident #5 out of her wheelchair while she was in it. Resident #5 shoved/pushed Resident #88 with her right hand (arm in splint) causing Resident #88 to re-open her wound to her right eyebrow. Nurse Aide immediately separated residents. Head to toe assessments performed by LVN R for both residents. Resident #88 re-opened wound to right eyebrow, no other visible injuries noted. Notified MD/RP/Administrator. Reported to police. Self-report to HHSC.Resident #88 had Latuda (aggression) increased on 06/12/25 to BID and Zyprexa (antipsychotic) 5mg BID on 06/14/25. Provider Action Taken Post-investigation: 06/22/25 Charge nurse placed her WOW in front of resident's room throughout the rest of shift and 10-6 shift. 5.Record review of Resident #95's Face Sheet dated 07/24/25 revealed Resident #95 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of unspecified dementia, muscle wasting and atrophy, muscle weakness, and Parkinson's Disease (a progressive neurodegenerative disorder that primarily affects movement). Record review of Resident #95's quarterly MDS dated [DATE] revealed Resident #95 is usually understood by others, usually able to understand others, has a BIMS of 00 meaning she has severe cognitive impairment and does not have any behaviors. Record review of Resident #95's comprehensive care plan dated 07/29/20 revealed Resident #95 requires staff assistance with ADLs due to diagnosis of Parkinson's at risk for decline in ADL function. Record review of Resident #95's progress note dated 06/28/25 at 10:50 am revealed late entry: Resident A came up to resident during service, shook this resident, and slapped resident on the side of the head. Resident A was immediately stopped and separated was sent to her room. Record review of facility's Provider Investigation Report revealed Resident #88 came up to Resident #95 who was sitting in her wheelchair during service, shook resident and slapped resident on the side of her head. Resident #88 was immediately stopped and separated, went back to her room with nurse.Head to toe assessment performed by nurse (Resident #95).Provider Response:Resident (#88) was placed on a one-to-one, family came to stay with her for 1-2 hours. Labs ordered UA to rule out UTI, and CBC, CMP to rule out any infection. Reported it to police with case number 25-16894. Started abuse and neglect in-service. Resident continues on psych services with medication adjustments.Provider Action Taken Post-investigationStarted looking for other facility placement for resident. Given 30-day notice. Safety survey done, continue with 1 to 1 monitoring. Record review of Resident#88's electronic medical record dated 06/28/25 through 07/25/25 revealed Resident #88 was on a one-to-one monitoring all three shifts. A CNA is with Resident #88 at all times. Observation on 07/21/25 at 9:07 am revealed Resident #95 was in her room sitting in her wheelchair. Resident #95 had tremors in her head and hands. Resident #95 was talking to herself. Surveyor attempted to interview Resident #95, but she has garbled speech and was difficult to understand. In an interview on 07/22/25 at 3:25 pm Resident #60 said she was in the dining room when she saw Resident #88 approach Resident #95. Resident #88 was yelling at Resident #95 and then she shook Resident #95. Resident #60 said then she saw Resident #88 slap Resident #95 on the face. Resident #60 said the staff intervened and took Resident #88 to her room. Resident #60 said the police were called and interviewed her, but nothing was done because the police said Resident #88 had dementia. In an interview on 07/22/25 at 5:28 pm CNA L said Resident #88 would walk around the facility. CNA L said Resident #88 was currently on a one-to-one because she was in an altercation with another resident. Resident #88 slapped another resident and was put on a one to one. Before being on a one-to-one Resident #88 would wander into different rooms and they would have to redirect her before she got upset and started a fight with a resident. They have in-services on ANE every month. CNA L said if she witnessed any person abusing a resident she would intervene and then make sure resident was safe. CNA said she would report it to her supervisor. The Abuse Coordinator was the Administrator.In an interview on 07/22/25 at 5:41 pm LVN E said he worked PRN for 2 or 3 months. LVN said he was familiar with Resident #88. LVN said Resident #88 needed a lot of redirections. LVN E said if someone got in her way, she became upset. If it was a person in a wheelchair, Resident #88 would try to push them around because she thought she was helping them. LVN E said they tried to verbally deescalate the situation and redirect Resident #88. Usually if they offered food, drink, or candy it would help redirect Resident #88 from the situation. LVN E said they also had her at the nurse's station with the nurse. Resident would stay a while then would get up again. Resident #88 was currently on a one to one in her room. Resident was allowed to come out and walk around the facility with the sitter following Resident #88. LVN E said they have in-services on abuse/neglect monthly. In an interview on 07/23/25 at 5:00 pm, the Psychiatric NP said she had not seen Resident #88 since April. The NP said she did not know that Resident #88 was on more than one antipsychotic. Surveyor asked NP what the behavioral plan for Resident #88 was and she said they had to rule out medical issues, see if something physiologically was causing the behaviors. The NP said then they could prescribe medications at a medium dose and see how the resident was doing on them. Then they needed to see if the resident's family was supportive of resident taking the medications. The NP said the resident could benefit with psychological counseling.In an interview on 07/24/25 at 4:40 pm the Administrator said his responsibility was to know what was going on in the facility. The Administrator said they had morning meetings, and, in the afternoon, they had stand down meetings. They discussed any concerns regarding resident care or grievances from families. The Administrator said they educated staff on the need to report any and all abuse. They tell staff that they needed to report abuse and if they did not report it then they were just as guilty as the person abusing a resident. They would investigate all incidents and reported any incident that could be considered abuse, neglect, or misappropriation. The Administrator said Resident #88 had been getting aggressive more often and that was the reason they had provided a 30-day discharge notice to the family. Resident #88 has been seen by a psychiatric NP and was put on a one-to-one monitoring since 06/28/25. Record review of Resident #88's 30-day notice of discharge revealed the Notice of Involuntary Transfer or Discharge and Opportunity for Appeal was provided to Resident #88's Responsible Party on 07/07/25. The notice indicated the reason for the notice was This discharge, or transfer is necessary for your welfare because your needs can not be met in this facility, as documented in your clinical record by your physician. 42C.F.R.S483.15(C)(1)(A); 40 Tex. Admin. Code 19.502(b)(1).In an interview on 07/07/25 at 8:56 am LVN A has been employed about three months. LVN A said her responsibilities were to make sure the residents were safe, and their needs were met. LVN A said she would report to the physician any change of condition to the residents and make sure the labs were done and results sent to physician. LVN A said she also supervises the CNAs to make sure they were treating residents kindly and interacting with them gently. They have in-services on abuse/neglect frequently and there was a resident on the other side of the hall that has behaviors and would fight with other residents. They would have an in-service on abuse/neglect after each incident. They had an in-service on abuse/neglect last week. The abuse Coordinator was the Administrator. LVN A said if a resident hit another resident that was considered abuse. LVN A said the residents needed to be separated and assessed for injuries. Then she would document and would report any change in condition to the RP, physician, DON and the Administrator. LVN A said an aggressive resident needs to be monitored frequently. LVN A said she would contact the physician, and they might give orders for an antipsychotic medication, call the RP to inform of the incident and request consent before administering the medication.In an interview on 07/25/25 at 9:56 am CNA M said her responsibilities were to attend to the resident's needs. Whatever the resident needs she would attend to them. CNA M said they would check on a resident with aggressive behavior or wandering into other resident room often. CNA M said they would offer snacks or give Resident #88 activities to do. CNA M said Resident #88 liked to push the residents in the wheelchairs but when resident would refuse the help Resident #88 would get mad. CNA M said they would redirect her by telling her Let's go to the dining room for coffee or let's go do an activity then the resident would go with her. Resident #88 liked coloring, and they would provide coloring pages and crayons. Resident #88 would be taken to the Activity room, and she would sit there to color pages. The nurses also kept her at the nurse's station with them. CNA M said the types of abuse were physical verbal, sexual and when a resident asked them to be showered, or for water and the staff ignored the resident then that was neglect. CNA M said if she saw a resident being abused, she would separate the resident from that person and then she would report it to her supervisor. The Administrator was the Abuse Coordinator. CNA M said she would report the abuse right away. In an interview on 07/25/25 at 10:12 am the SW said Resident #88 needed redirection by distracting resident to do something else. The SW said she would take Resident #88 to her office and gave her a pen, notebook, and a snack. Resident #88 would finish eating the cookie and she would want to get up and leave. The SW said she tried to get resident to write in a notebook, but she would only write for a few seconds and then would get up and walk away. The SW said it was constant redirections. SW said Resident #88 had a short attention span of a few seconds. Resident #88 had difficulty focusing on a task and following directions. Directions had to be broken down in small steps. The SW said the family did attend the care plan meeting via phone and lately in the facility. The last care plan meeting was at the facility. The daughter came in with the Ombudsman. The SW said the daughter was informed of the incidents Resident #88 had with other residents. The family was fine with whatever medications the doctor prescribed. The facility asked that the family to come more often to stay with resident, but they did not come very often. The SW said the DON made a power point in-service on dementia. It addressed the medical and personal effects of dementia and the different types of behaviors. The SW said Resident #88 was sent to the hospital on [DATE] to be cleared medically and then sent to the behavioral center to be stabilized. Resident #88 would then be sent to a long-term care facility in San [NAME] with a memory unit. In an interview on 07/25/25 at 10:54 am the DON said when a resident was identified with behaviors, they would monitor the resident by keeping her close to a nurse or with the DON in her office. They encouraged the resident to be taken to activities and for the family to visit her. The DON said they would ask resident if she wanted to go color. Redirection was used for the resident to do tasks or activities that she liked doing. Maybe make a bed, fold clothes, or color pages. The DON said they needed to be able to find the triggers that sets Resident #88 off. DON said she asked the daughter, but the daughter said Resident #88 did not have any triggers. DON said the daughter was not able to help them find what caused the resident's aggression. She would do an in-service on whatever the incident was about. If it was abuse/neglect or misappropriation she would train staff on it. The DON said she had conducted a presentation earlier this year on dementia and behaviors. The DON said they did train on abuse/neglect monthly and whenever there was an incident. The DON said Resident #88 was discharged to the hospital to clear her medically before she was sent to the Behavioral Center. Record review of her Immediate Discharge Notice dated 07/24/25 with Effective Date of Discharge 07/24/25 and the reason was for the health and safety of resident or others and the location was to a local hospital. Based on observation, interview, and record review, the facility failed to protect the residents' right to be free from were verbal and physical abuse by a resident for 6 of 6 residents (Residents #5, #71, #82, #88, #95, #99) reviewed for abuse, in that: 1.The facility failed to ensure Resident #71 was free abuse when Resident #88 hit Resident #71 on the head on 01/24/25. 2. The facility failed to ensure Resident #71 was free from abuse when Resident #88 had a physical altercation with Resident #71 on 04/05/25. 3. The facility failed to ensure Resident #82, and Resident #99 were free from abuse when Resident #88 had a physical altercation with Resident #82 and Resident #99 on 06/04/25. 4.The facility failed to ensure Resident #5 was free from abuse when Resident #88 entered Resident #5's room and attempted to pull Resident #5 from her wheelchair on 06/22/25. 5.The facility failed to ensure Resident #95 was free from abuse when Resident #88 went up to Resident #95 and attempted to remove her from her wheelchair. Resident #88 shook Resident #95 and then slapped her on the side of her head on 06/28/25. An IJ that occurred in the past was identified. The IJ began on 01/24/25 and removed on 06/28/25. The facility took action to remove the IJ before survey began. While the IJ was removed on 06/28/25, the facility remained out of compliance at a scope of K and a severity level of no actual harm with a potential for more than minimal harm because all staff had not been trained on abuse/neglect. This failure has the potential to result in serious injury or death as a result of abuse and neglect. The findings were: 1. Record review of Resident #88's Face Sheet dated 07/24/25 revealed she was a [AGE] year-old female admitted to facility on 10/24/24 with diagnoses of Alzheimer's disease (a progressive disease that destroys the memory and other important mental functions), anxiety disorder, unspecified psychosis (a mental health condition characterized by a loss of contact with reality, often involving symptoms like hallucinations and delusions), and major depressive disorder, recurrent, severe with psychotic symptoms. Record review of Resident #88's quarterly MDS dated [DATE] revealed Resident #88 was usually understood by others and usually was able to understand others. She had a BIMS score of 02 which indicated severe cognitive impairment. Resident had physical behavioral symptoms directed toward others (hitting, kicking, scratching, grabbing), verbal behavioral symptoms directed toward others (screaming at others, cursing at others) and other behavioral symptoms not directed toward others (physical symptoms such as hitting, pacing, rummaging or verbal symptoms like screaming, disruptive sounds). Record review of Resident #88's comprehensive care plan revised on 05/28/25 revealed Resident #88 has been physically aggressive (hitting staff or other resident) r/t dementia: 01/24/25 - Resident became physically aggressive toward another resident The care plan included the following interventions:-When resident becomes agitated: intervene before agitation escalates; guide away from source of distress; engage calmly in conversation; if response is aggressive, staff to walk away calmly and approach later. Record review of Resident #88's Physician's Order Summary for July 2025 revealed orders for: --Gabapentin oral capsule 100 mg, give two capsules by mouth three times a day related to emotional lability, order date 06/09/25.Haldol Decanoate intramuscular solution 50 mg/ml, inject 50 mg intramuscularly monthly starting on the 10th and ending on the 10th every month for agitation, order date 07/06/25 and start date on 07/10/25.Latuda oral tablet 20 mg, give 1 tablet by mouth two times a day related to major depressive disorder, recurrent, severe with psychotic symptoms, order date 06/11/25 and start date 06/12/25.Zyprexa oral tablet 5 mg (Olanzapine), give 5 mg by mouth two times a day related to unspecified psychosis, order date 06/13/14 and start date 06/14/25. Record review of Resident #88's progress notes dated from 06/28/25 to 07/25/25 revealed Resident #88 was put on a continuous one-to-one monitoring until Resident #88 was admitted to a facility in San [NAME]. Record review of Resident #71's Face Sheet dated 07/24/25 indicated she was [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Alzheimer's disease (a progressive disease that destroys memory and other important mental functions.), anemia (a problem in which the blood does not have enough healthy blood cells to carry oxygen to throughout the body), and hypertension (when the blood pressure in the blood vessels is too high). Record review of Resident #71 quarterly MDS dated [DATE] indicated Resident #71 was understood by others, and was able to understand others, did not have any behaviors, and had a BIMS score of 05 which indicated she had moderate cognitive impairment. Record review of facility's Provider Investigation Report dated 01/24/25 revealed Incident date and time: 01/24/25 at 4:00 pm. Nurse Aide saw Resident #88 go hit Resident #71's in the back of the head and pull her hair. Record review of the Provider Action Taken Post Investigation dated 01/24/25: Head to toe assessment performed on 01/24/25 for Resident #71 revealed no other visible injuries noted. Employees were in-serviced on resident-to-resident abuse and resident de-escalation techniques. Social Services did resident safe interviews. Resident behaviors care planned. Staff will keep both residents apart when in close proximity or when doing social activities. Care Plans for both residents updated. Observation of 07/21/25 at 9:32 am revealed Resident #88 in bed on her side with the lights off and a CNA in the room. Resident #88 was still in her pajamas and shoes on. Resident #88 did not respond to greeting and questions regarding incident with Resident #71. In an interview on 07/21/25 9:57 am CNA K said Resident #88 was able to walk and wandered throughout the building, but they had to shadow her to prevent aggressive behaviors toward other residents. If resident was on her own, she would fight with other residents. CNA K said Resident #88 cried a lot and the other residents became impatient with her and then she became aggressive. CNA K said when resident was on her own in her room, she was ok. CNA K said if they gave her colors and pages to color, she would do it. 2. Record review of Incident Report dated 04/05/25 revealed Resident #88 hit Resident #71 on her back and took some coloring pages from her. Resident #88 was separated from Resident #71. Head to toe evaluation of both residents by LVN revealed no injuries to either resident. Record review of Resident #88's care plan was revised on 04/08/25 to include incident on 04/05/25 with aggressive behavior with interventions to monitor for sundowning behavior, continue sertraline100 mg daily (antidepressant), follow up counseling and psych recom

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible and each resident received adequate supervision to prevent accidents for 1 of 2 residents (Resident #1 ) reviewed for accidents and supervision, in that: 1. The facility failed to ensure Resident #1 received supervision to prevent Resident #1 from eloping from the facility undetected on 04/29/2023. The non-compliance for Resident #1 was identified as Past Non-Compliance. The Immediate Jeopardy (IJ) began on 04/29/2023 and ended on 05/01/2023. The facility corrected the non-compliance before the investigation began. This failure could place the residents with exit seeking behaviors and repeated falls at risk for injury or death. The findings were: Record review of Resident #1's face sheet dated 04/24/2023 revealed the resident was a [AGE] year-old male with an admission date of 04/29/2023 and a discharge date of 04/30/2023. The resident's diagnoses included Alzheimer's disease, and dementia. Record review of Resident #1's entry MDS assessment dated [DATE] reflected only section A (identification information) was completed. Record review of Resident #1's initial assessment dated conducted by nursing staff on 04/29/2023 reflected he required limited assistance with bed mobility, and with transfer. For mobility, he required limited assistance with walk in room/self-performance. For mobility walk in corridor, activity did not occur. Record review of Resident #1's incident report dated 04/29/2023 completed by LVN A at 11:40 p.m. reflected: Incident Description: New admission unknown type of behavior. [Resident #1] was seen walking back and forth in B wing north, resident was calm and relax in no distress, no signs of exit seeking. Immediate action: Started checking each room, closet, restrooms, called ADON informed him of situation went outside the building and started searching for resident. All Managers alerted to report to facility. Area searched, 911 notified, police department arrived and provided canine support, family here. Patient found adjacent to facility in church property. Patient taken to hospital for evaluation. Record review of Resident #1's hospital records dated 04/30/2023 reflected [AGE] year-old male with worsening dementia and mood disorder who comes here brought because he actually walked out of the skilled unit he was discharged too yesterday [04/29/2023]. Apparently he spent the night outside of the nursing home. The patient apparently found on the grass where he apparently slept all night. He appears to be definitely much more lethargic then yesterday when he left. He appeared to be shivering a lot and having some dry cough. He was unable to provide history. He was brought here for evaluation after being found. Hospital notes also revealed family refused to allow Resident #1 go back to facility. Hospital records were only from the emergency department, they did not reveal any treatment received or if resident was admitted . Record review of a police report dated 04/30/2023 reflected the police were dispatched to the facility at 1:01 a.m. in reference to a missing person. At approximately 11:00 p.m. to 11:20 p.m., a resident identified as Resident #1 had left the facility. Resident #1 was last seen wearing a black sweater and blue jeans and he suffered from Alzheimer's and dementia. On Sunday April 30, 2023, at 7:47 a.m., the police officer was searching the back parking lot of a local church located next to the facility. The report reflected when I noticed an elderly male subject trapped behind a chain link fence. I then made contact with the male subject and noticed that it was [Resident #1] who had been reported missing. I then had one of the officers cut the chain to the gate and we were able to get [Resident #1] out. An interview on 04/23/2024 at 9:45 a.m., the SW said Resident #1 had been admitted to the facility the evening of 04/29/2023 (Friday) from a local hospital. She said the only assessment done on that day was the initial screening by chare nurse. The SW said the facility did not know if Resident #1 had any exit seeking behaviors at the time he was admitted . She said she received a text at about 3:30 a.m. on 04/30/2023 from the facility's Administrator who requested for her to report to the facility to assist with the search for Resident #1. The SW said she did not see the text message until 04/30/2023 at 5:00 a.m. and at that time called the Administrator who told her she was not needed anymore. The SW said Resident #1 was found in the back yard of a church next to the facility on [DATE] (not sure of the time). An interview on 04/24/23 at 10:21 a.m., the Administrator said he was not able to comment on Resident #1's elopement because he was not employed at the facility at the time. He referred the surveyor to the facility's Regional Director of Operations who he said was more familiar with the incident. In an interview on 04/24/2024 at 10:15 a.m., the Regional Director of Operations said Resident #1 was admitted (did not give date) without a warning that he was an exit seeker. She said Resident #1 was found in the backyard of a church next to the facility the next day. She stated Resident #1 had spent the night outside. She said Resident #1 had not sustain any injuries but was taken to hospital to be evaluated. She said the facility investigated the incident and determined Resident #1 must have exited the building by a side exit door that led to the patio because it was the only door that did not have an alarm. She said that staff and resident used door to go out to the patio. She said what might have happened was one of the residents messed with the door and did not close it right allowing Resident #1 to exit the building. She said they removed the dead bolt and installed magnetic lock/keypad on 05/01/23. An observation/interview on 04/24/2024 at 3:00 pm, the Maintenance Director said after Resident #1's elopement the side door lock was changed. He said the dead bolt was removed and replaced with a keypad, and a code alert was installed. He said if a resident with a wander guard would try to open the side door an alarm would go off and lock the door. The Maintenance Director took a wander guard and attempted to exit the facility's doors and an alarm was activated and doors locked. LVN A said Resident #1 was admitted on the evening (not sure what time) of 04/29/2023 and eloped before 11:00 p.m., on the same day. LVN A said CNA B advised him between 10:45 p.m. and 11:00 p.m. that while she was doing her rounds, she noticed Resident #1 was not in his room. He said he had immediately activated the facility's elopement code (code silver) and the search ensued. LVN A said he advised the CNA's to search every room in the facility while he and other male staff searched outside the building. LVN A said he also called his ADON to let him know Resident #1 was missing and the local police department to report Resident #1 as a missing person. He said he also notified Resident #1's RP. LVN A said at some point all department heads were also called to report to the facility to assist in the search for Resident #1. LVN A said the facility's staff, Resident #1's family, and police department search all night for him city wide. He said his shift ended at 6:00 a.m. and by that time Resident #1 had still not been found. LVN A said he was told by other staff members; Resident #1 was found in the backyard of a church next to the facility. LVN A said all staff were in-serviced on the topic of elopement the next day. An interview on 04/24/2024 at 3:54 pm, CNA B said when she clocked in at 10:00 pm on 04/29/2023, she was given the report by the outgoing CNA that Resident #1 did not walk and that his bed needed to be kept at the lowest position. CNA B said she started doing her rounds and when she got to his room (around 11:00 p.m.) she noticed Resident #1 was not there. CNA B said she started looking for him and also informed LVN A. She said another CNA (did not remember name) told her she had seen a man that she did not recognize walking towards the kitchen. CNA B said she headed towards the kitchen but did not see anybody. She said the facility's staff searched all night but were not able to locate Resident #1 until the next day. CNA B said all staff were in-serviced on their elopement procedures on 04/30/2023. CNA B said the in-service covered what to do when a resident went missing, who they need to notify, and the code used over the intercom to alert all staff a resident is missing. Record review of facility's Elopements policy revised on December 2007 reflected: Policy Statement: Staff shall investigate and report all cases of missing residents. Policy Interpretation: 1 Staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the Charge Nurse or Director of Nursing. 4. If an employee discovers that a resident is missing from the facility, he/she shall: a. Determine if the resident is out on an authorized leave or pass; b. If the resident was not authorized to leave, initiate a search of the building(s) and premises; c. If the resident is not located, notify the Administrator and the Director of Nursing Services, the resident's legal representative (sponsor), the Attending Physician, law enforcement officials, and (as necessary) volunteer agencies (i.e., Emergency Management, Rescue Squads, etc.); d. Provide search teams with resident identification information; and e. Initiate an extensive search of the surrounds area. Record review of facility in-services revealed the following in-services were conducted with staff from all three shifts after the incident: Topic: 04/30/2023 Elopement-staff shall promptly report any resident who tried to leave premises or is suspected of leaving to the charge nurse. Topic: 04/30/2023 and 05/01/2023: all new admissions with diagnosis of dementia will need a wander guard for 72 hours. Topic: 04/30/2023 and 05/01/2023: Nurse's and CNA's are to do a walking round at start and at the end of their shifts. Record review of facility's purchase order dated 05/01/2023 reflected: The only door without an alarm was replaced with a magnetic lock with power supply, an all-weather keypad, and a 24V supply with back-up battery port. Record review of facility's elopement binder reflected all 11 residents who were at risk of wandering had a current face sheet and demographic information in binder. An observation on 04/25/2024 at 11:00 a.m., the surveyor accompanied the DON who verified all 11 residents who were at risk of wandering had their wander guard on. An observation on 04/25/2024 at 3:30 p.m., revealed the Maintenance Director tested all exit doors and ensured the alarm was activated if a resident with a wander guard tried to exit. An interview on 04/24/24 CNA T, B, C, U, V, and G said they had been in-serviced said they had been in serviced on the topics of facility policy and procedure related to identifying residents with exit seeking tendencies, redirecting, and the facility's code used for elopements. They said she was aware of the elopement binder kept in the nurse's station and knew all residents listed on the binder had a wander guard. An interview on 04/23/24 LVN W, X, Y, J, S and ADON E said they had been in-serviced said they had been in serviced on the topics of facility policy and procedure related to identifying residents with exit seeking tendencies, redirecting, and the facility's code used for elopements. They said she was aware of the elopement binder kept in the nurse's station and knew all residents listed on the binder had a wander guard. An interview on 04/25/24 DON said she had been in-serviced said she had been in serviced on the topics of facility policy and procedure related to identifying residents with exit seeking tendencies, redirecting, and the facility's code used for elopements. She said she was aware of the elopement binder kept in the nurse's station and knew all residents listed on the binder had a wander guard. Policy Statement All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Policy Interpretation and Implementation Reporting Allegations to the Administrator and Authorities 3. Immediately is defined as: a. within two hours of an allegation involving abuses or result in serious bodily injury; or b. within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. Record review of Resident #4's 01/10/24 at 01:00 pm Health Status Note written by LVN N reflected, Note Text: Received call from MD at ER O (Emergency Room) to report resident had CT of Head done. CT clear. Resident will be admitted with Dx: bradycardia. Called RP to inform.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to consult with the resident's physician when there was a significant change in the resident's physical, mental or psychological status for 1 of 3 residents (Resident #1) reviewed for notification of change of condition. The facility failed to notify the resident's physician when Resident #1 was noticed with discoloration to her outer lower leg on 11/29/2023. On 12/19/2023 at 3:40 p.m., an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 12/21/2023, the facility remained out of compliance at a severity level of actual harm and a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure could affect residents with injuries by placing them at risk of delayed medical treatment, hospitalization, and decline in condition. Findings included: Record review of Resident #1's face sheet dated 12/13/2023 reflected she was a [AGE] year-old female who was admitted on [DATE]. Relevant diagnosis were right ankle contracture, muscle wasting and atrophy, muscle weakness, lack of coordination, speech and language deficits, vascular dementia, and Alzheimer's disease. Record review of Resident #1's quarterly MDS dated [DATE] reflected her: Hearing was moderate difficulty Speech clarity was unclear Sometimes understood/understand Vision was moderately impaired BIMS score of 00 (severly impaired) Functional limitation in range of motion: Upper extremity was impaired on one side; Lower extremity was impaired on both sides. Required substantial/maximal assistance with shower/bathe, upper body dressing, lower body dressing, and putting on/off footwear. Dependent for roll left and right, sit to lying, chair/bet-to-chair transfer and tub/shower transfer. Record review of Resident #1's comprehensive care plan reflected she was a 2 person assist with transfer and mobility. In a hospital observation on 12/13/2023 at 12:45 p.m. Resident #1 was lying in bed, eyes closed and was receiving a breathing treatment. She had a urinary catheter and was on intravenous therapy. In an interview on 12/13/2023 at 12:55 p.m., hospital RN AA said Resident #1 had been admitted with a diagnosis of a closed left ankle fracture. She said Resident #1 was ready to be discharged they were just waiting for the paperwork to be completed. In a hospital interview on 12/13/2023 at 1:00 p.m., Resident #1 whispered she was in pain and complained her left foot was hurting. She kept repeating she was in pain and then closed her eyes. She was not able to answer any questions related to the discoloration to her outer lower left leg. In an interview on 12/14/2023 at 8:45 a.m., the NP said she had been Resident #1's NP since before she was admitted to the nursing facility. She said she was notified on 12/09/2023, Resident #1 had swelling and discoloration to her left ankle. She said she also received a picture, LVN F had taken of Resident #1's ankle. The NP said from looking at the picture she was sent, Resident #1's ankle did not look deformed but had swelling and was discolored. She said she gave orders for x-rays and when the results came back as acute distal tibial and fibular fractures with no significant displacement to the left ankle, she gave an order for Resident #1 to be sent to the hospital for further evaluation. The NP said she asked LVN F how Resident #1 had sustained the injury and was told they did not know how it had happened. The NP said she was not surprised of the fracture Resident #1 sustained given her frailty and any wrong movement might have caused a fracture. She said, with that being said, she still needs to be handled with care. the NP said that 12/09/2023 was the first time she was notified of Resident #1's discoloration. In an interview on 12/14/2023 at 5:00 p.m., LVN B said she was the wound care nurse. She said she provided wound care to Resident #1 on a daily basis. She said she did not noticed any discoloration or swelling to Resident #1's outer left leg or ankle. She said Resident #1 had a stage IV pressure ulcer to the coccyx area that required daily care. She said when she would first arrive at Resident #1's room, she would reposition her to her left side (side Resident #1 preferred) and lower the flat sheet to down to Resident #1's knees and started with the wound care. She said she never noticed any discoloration and/or swelling to Resident #1's outer lower leg or ankle. LVN B said Resident #1 would show signs of pain whenever she was performing wound care. LVN B said she would not remove Resident #1's heel protector during wound care to the coccyx area. LVN B said she would also do weekly skin assessments and never noticed any discoloration or swelling to Resident #1's out left leg or ankle. In an interview on 12/14/2023 at 5:18 p.m., CNA H said she saw Resident #1 one time while in the covid hall. She said on 11/29/2023 she remembered LVN B telling RN A that Resident #1 had a yellowing bruise to the top of her left ankle and above the heel protector boot. She said RN A and her went over to Resident #1's room where RN A uncovered her, assessed her, and said oh yes, she has a little bruising but did not remove the heel protector. She said Resident #1 was not complaining of pain during that time. CNA H said RN A give Resident #1 pain medication and that was all she did. In an interview on 12/14/2023 at 5:30 p.m., RN A said on 11/29/2023 was assigned to the Covid unit because she had just returned to work due to having Covid herself. She said on 11/29/2023 she was advised by LVN B that while doing wound care she noticed, Resident #1 had a light to medium discoloration to her outer left leg. RN A said she went over to Resident #1's room, assessed her. She described the discoloration as being yellowish in color. She said Resident #1 was wearing a heel protector on her left ankle. She said when she touched Resident #1's lower leg she was very sensitive. She said she thought her sensitivity was due to Resident #1 being Covid positive. RN A said Resident # 1 was crying and had facial grimacing so she decided to give her pain medication and monitor her as that was all I could do. RN A said she was not sure why she did not remove Resident #1's heel protector to assess her ankle. RN A said she documented her finding on PCC under MAR or progress notes. She said she did not inform the incoming nurse because she took it for granted the incoming nurse would read her notes. RN A said that was the first and only day she worked in the covid unit and had contact with Resident #1. In an interview on 12/18/2023 at 2:18 p.m., the DON said since Resident #1 was always in pain due to her stage IV coccyx pressure ulcer the nursing staff might have confused Resident #1's fractured ankle pain to her stage IV coccyx pressure ulcer pain. The DON said there were no negative outcome on Resident #1's delay to assess, notify the NP, and document on progress notes of discoloration which was first noticed on 11/29/2023 and later identified as an acute distal tibial and fibular fractures to the left ankle on 12/09/2023 because she was being assessed for pain and given pain medication when needed. She said that was all they could do since Resident #1 did not require surgery. In an interview on 12/18/2023 at 4:00 p.m., the Administrator said the information he collected during his investigation was conflicting in regards to Resident #1's discoloration to her lower left leg. He said RN A told him LVN B advised her that while she was doing wound care, she noticed the discoloration, but LVN B denied ever telling RN A. The Administrator said RN A told him she failed to document her findings, notify NP, and notify in-coming nurse. He said he was not able to say if Resident #1 suffered any negative effects because that was a clinical question. Record review of facility's policy on Change in a Resident's Condition or Status revised on February 2021 reflected: Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.) Policy Interpretation and Implementation 1. The nurse will notify the resident's attending physician or physician on call when there has been a (an): Accident or incident involving resident Discovery of injuries of an unknown source Significant change in the resident's physical/emotional/mental condition This was determined to be an Immediate Jeopardy (IJ) on 12/19/2023 at 3:40 p.m. The Administrator was notified. The Administrator was provided with the IJ template on 12/19/2023 at 3:40 p.m. The following Plan of Removal submitted by the facility was accepted on 12/21/2023 at 4:00 p.m. Immediate action taken On 12/19/2023 the Charge Nurse who failed to notify the physician of the discoloration was terminated. By 12/19/2023 all residents have updated pain assessments completed by the DON, the ADON, the MDS, and the Treatment Nurse. By 12/19/2023 all residents have updated skin observations documents by the DON, the ADON, the MDS, and the Treatment Nurse. By 12/19/2023 all direct care staff have been in-serviced by the DON, the ADON, the MDS, and Treatment Nurse on immediate notification of any skin observation, new onset of pain, and/or change of condition. 1. The nurse will notify the resident's attending physician or physician on call when there has been a (an): Accident or incident involving resident Discovery of injuries of an unknown source Significant change in the resident's physical/emotional/mental condition 2. A significant change of condition is a major decline or improvement in the resident's status that: Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting) Impacts more than one areas of the residents health status Requires interdisciplinary review and/or revision to the care plan 3. Prior to notifying the physician or health care provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by Interact SBAR communication form. Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the residence medical/ mental condition or status. As of 12/19/2023 the DON, the ADON, the MDS, and the Treatment Nurse educated CNA's on notifying the Charge Nurse regarding any new skin issue identified. The CNA will verbally inform Charge Nurse, and Nurses will document skin issue in Point Click Care and CNA's will document new skin issues or injuries in Point Click Care. Monitoring/Supervision As of 12/19/2023 the DON and the ADON review 24-hour report for documentation and pain/skin assessment daily during the morning clinical meetings. DON and ADON will review Point Click Care documentation during morning clinical meeting. As of 12/19/2023 the DON, the ADON, or the MDS will assess all nonverbal bedridden patients twice a week for a month to verify compliance and then monthly x 3 months. Any new direct care employee will be educated on immediate notification of any new skin observation, new onset of pain, and/or change of condition prior to working with residents. All the above-mentioned education/in-services should serve to resolve questions regarding steps taken during a change of condition. In addition to procedures for monitoring and initiating interventions to ensure residents safety. Verification: started on 12/20/2023 at 2:30 p.m. and included: The following observations, record reviews and interviews were conducted to ensure CNA's and licensed staff's understanding of in-service training received by 12/19/2023. Observations on 12/20/2023 and 12/21/2023 of 3 skin assessment conducted by RN I and LVN J. Record review of all direct care staff In-Serviced Sign In Sheet for the topic of: Notification of changes in condition and new skin issues conducted by the DON/ADON reflected 1of 2 RN's (1 is the DON), 19 of 20 LVN's (1 was out of the country), 23 of 23 CNA's and 6 of 6 Med Aides were in-serviced from all shifts. Interviews on 12/20/2023 and12/21/2023 with the following CNA's C, D, E, G, H, K, L, M, N, O, and P. All stated they were in-serviced on immediate notification of any new skin observations, new onset of pain and/or change of conditions. All understood they were to notify their charge nurse in case they observed any new skin condition and document their findings in PCC. Interviews on 12/20/2023 and 12/21/2023 with the following LVN's/RN F, I, J, Q, R, S, T, U, V, W, X, Y and Z. All stated they were in-serviced on immediate notification of any new skin observations, new onset of pain and/or change of conditions. All understood if a CNA informed them a resident has a new skin observation, new onset of pain and/or change of condition they are to do a head-to-toe assessment, notify their physician, document in PCC, and carry out any new orders. They were to also do a 24-hour report and verbally notify the in-coming nurse to any new discoveries. They also needed to complete an SBAR assessment. The Administrator was informed the Immediate Jeopardy was removed on 12/21/2023 at 4:00 p.m. The facility remained out of compliance at the severity of actual harm with a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on 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 for one (Resident #1) of three residents reviewed for quality of care, in that: The facility failed to ensure Resident #1 was accurately assessed after being discovered with abnormal discoloration to her lower outer left leg on 11/29/2023. Between 11/29/2023 to 12/08/2023, Resident #1 was observed crying and with facial grimacing. Resident #1 was diagnosed with a left ankle fracture. On 12/19/2023 at 3:40 p.m., an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 12/21/2023, the facility remained out of compliance at a severity level of actual harm and a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure could place residents at risk of experiencing unmanaged pain, a decreased quality of life and hospitalization. Findings included: Record review of Resident #1's face sheet dated 12/13/2023 reflected she was a [AGE] year-old female who was admitted on [DATE]. Relevant diagnosis were right ankle contracture, muscle wasting and atrophy, muscle weakness, lack of coordination, speech and language deficits, vascular dementia, and Alzheimer's disease. Record review of Resident #1's quarterly MDS assessment dated [DATE] reflected her: Hearing was moderate difficulty Speech clarity was unclear Sometimes understood/understand Vision was moderately impaired BIMS score of 00 (severely impaired) Functional limitation in range of motion: Upper extremity; lower extremity was impaired on both sides. Required substantial/maximal assistance with shower/bathe, upper body dressing, lower body dressing, and putting on/off footwear. Dependent for roll left and right, sit to lying, chair/bet-to-chair transfer and tub/shower transfer. Record review of Resident #1's comprehensive care plan reflected she was a 2 person assist with transfer and mobility. Record review of Resident #1's bathing history reflected she was bathed/showered a total of 10 times between 11/29/2023 and 12/08/2023. Record review of Resident #1's skin assessments history reflected there was one done on 12/05/2023 that only addressed her sacral wound. Record review dated 12/09/2023 of Mobile X-Rays on Demand results reflected, Resident #1 had 3 views of left ankle x-rays completed with findings of an acute distal tibial and fibular fractures with no significant displacement to the left ankle. Record review of Resident #1's progress notes from 11/29/2023 to 12/08/2023 did not reflect any documentation on the discoloration first noticed on 11/29/2023 to her outer lower left leg. In a telephone interview on 12/12/2023 at 5:35 p.m., RN BB (complainant) said he was the charge nurse at the ER department where Resident #1 was seen. He said Resident #1 was transferred from nursing facility to be evaluated for a diagnosis of a fractured left ankle. He said he was concerned because Resident #1 was a bedridden resident and unable to say what had happened due to her history of Alzheimer's. He said when he called the nursing facility (he did not get the name of staff who he spoke with) he was told Resident #1 had been crying for 2 weeks and they had no record as to how she had sustained the injury to her left ankle. The Complainant said Resident #1 was admitted to hospital due to an ankle fracture and elevated blood pressure. He said he was not able to describe how Resident #1's ankle looked like or the exact time she was seen at the ER department because he was at home and did not have access to her medical records. He said Resident #1 was seen at the ER department between 6 am-2 pm shift. In an interview on 12/13/2023 at 11:41 a.m., CNA C stated Resident #1 was a bedridden resident and required total assistance with all ADL's. CNA C said Resident #1 as only able to answer yes and no questions. She said on 12/09/2023 she had been assigned to shower residents. She said Resident #1 arrived at the shower room sitting on a shower chair. She said she did not remember if Resident #1 was wearing a heel protector when she first arrived. She said was transferred by CNA's D and E. She said when she started showering Resident #1, she noticed she was whining and had facial grimacing and when she got to her feet, she stated she noticed discoloration to her lower outer left leg and ankle. She said she asked Resident #1 if she was in pain and Resident #1 nodded yes and started to cry. She said as soon as CNA's D and E took Resident #1 back to her room, she went and notified her charge nurse, LVN F of her findings. She said LVN F and herself immediately went over to Resident #1's room where LVN F assessed her. CNA C said about 2 hours later she went back to Resident #1's room to reposition and feed her. She said asked Resident #1 if she was in pain and she nodded yes. CNA C said she went to tell LVN F Resident #1 was still in pain. LVN F told her she had already given her pain medication, called the NP and x-rays had been ordered. In an observation at the hospital on [DATE] at 12:45 p.m. revealed Resident #1 was lying in bed; eyes closed and was receiving a breathing treatment. She had a urinary catheter and was on intravenous therapy. In an interview on 12/13/2023 at 12:55 p.m., hospital RN AA said Resident #1 had been admitted with the diagnosis of a closed left ankle fracture. She said Resident #1 was ready to be discharged they were just waiting for the paperwork to be completed. In an interview at the hospital on [DATE] at 1:00 p.m., Resident #1 whispered she was in pain and complained her left foot was hurting. She kept repeating she was in pain and then closed her eyes. She was not able to answer any questions related to the discoloration of her outer lower left leg. In an interview on 12/13/2023 at 2:35 p.m., CNA E said Resident #1 was a bedridden resident. She said on 12/09/2023 she and her partner CNA D had transferred Resident #1 from her bed to the shower chair. She said Resident #1 was a 2 person assist and required total assistance. She said with the assistance of a gait belt, she, and her partner each put one hand under her shoulder and the other hand under Resident #1's knees and transferred her in a sitting position to the shower chair. CNA E said at no time did Resident #1's feet touch the floor and denied seeing any discoloration to Resident #1's lower outer left leg. She said she did not remember if Resident #1 had a heel protector on her left foot. In a telephone interview on 12/13/2023 at 2:45 p.m., CNA D said Resident #1 was bedridden resident. She said on 12/09/2023 she and her partner CNA E had transferred Resident #1 from her bed to the shower chair with the assistance of a gait belt. She said she and her partner each put one hand under her shoulder and other hand under Resident #1's knees and transferred her in a sitting position to the shower chair. CNA D said Resident #1 did not complain of pain nor cried during the transfer. She said she did not notice any discoloration to Resident #1's left outer foot or ankle. She said she did not remember if Resident #1 was wearing a heel protector at the time of transfer. She stated if she did, it would be CNA's C responsibility to remove it prior to starting the shower. In an interview on 12/13/2023 at 3:51 p.m., CNA G said Resident #1 was bedridden resident and required total assistance with all ADL's. She said she cared for Resident #1 while she was in the COVID unit from November 28, 2023, to December 8, 2023. She said she would sponge bathe Resident #1 because she had pneumonia and was too weak to be transferred to the shower room. She said she did not notice any discoloration to Resident #1's left outer leg. She said Resident #1 wore a heel protector on her left foot the whole time she was in the covid unit. CNA G said Resident #1 never complained of pain or showed any physical signs she was in pain. She said Resident #1 had a pressure ulcer in her coccyx area and was receiving daily wound care. CNA G said as far as she remembered, Resident #1 did not sustain any injury while in the covid unit. In an interview on 12/14/2023 at 8:45 a.m., the NP said she had been Resident #1's NP since before she was admitted to the nursing facility. She said she was notified on 12/09/2023, Resident #1 had swelling and discoloration to her left ankle. She said she also received a picture, LVN F had taken of Resident #1's ankle. The NP said from looking at the picture she was sent, Resident #1's ankle did not look deformed but was swollen and discolored. She said she gave orders for x-rays and when the results came back as acute distal tibial and fibular fractures with no significant displacement to the left ankle, she gave an order for Resident #1 to be sent to the hospital for further evaluation. The NP said she asked LVN F how Resident #1 had sustained the injury and was told they did not know how it had happened. The NP said she was not surprised with the fracture Resident #1 sustained given her frailty and any wrong movement might have caused a fracture. She said, with that being said, she still needs to be handled with care. The NP said that 12/09/2023 was the first time she was notified of Resident #1's discoloration. In an interview on 12/14/2023 at 9:00 a.m., LVN F said on 12/09/2023 she was advised by CNA C that Resident #1 had discomfort to her left ankle. She said she immediately went to Resident #1's room where she did a head-to-toe assessment and compared both her right and left ankle. She said her left ankle/outer left leg looked swollen and had discoloration. LVN F said based on the color of Resident #1's discoloration (bluish, greenish, and yellowish) on outer lower leg and ankle the injury looked days old. She said Resident #1 would complain of pain when her left ankle was moved. LVN F said she gave Resident #1 pain medication and called the NP. She said she also sent the NP a picture of Resident #1's lower left foot and ankle. LVN F said the NP ordered x-rays and to advise of results. LVN F said mobile x-rays were called to the facility and the results showed Resident #1's ankle was fracture. She said when she relayed the results to the NP, she was ordered to send Resident #1 to the ER for further evaluation. LVF said she did not know how Resident #1 sustained the fracture to her left ankle. LVN F claimed Resident #1 was not showered or transferred out of her bed on 12/09/2023. LVN said she followed facility's protocol and documented her findings on Resident #1's medical record (PCC) under progress notes, 24-hour report, SBAR and incident log. In an interview on 12/14/2023 at 5:00 p.m., LVN B said she was the wound care nurse. She said she would provide wound care to Resident #1 on a daily basis. She said she never noticed any discoloration or swelling to Resident #1's outer left leg or ankle. She said Resident #1 had a stage IV pressure ulcer to the coccyx area that required daily care. She said when she would first arrive at Resident #1's room, she would reposition her to her left side (side Resident #1 preferred) and lower the flat sheet to down to Resident #1's knees and started with the wound care. She said she never noticed any discoloration and/or swelling to Resident #1's outer lower leg or ankle. LVN B said Resident #1 would show signs of pain whenever she was performing wound care. LVN B said she would not remove Resident #1's heel protector during wound care to the coccyx area. LVN B said she would also do weekly skin assessments and never noticed any discoloration or swelling to Resident #1's out left leg or ankle. In an interview on 12/14/2023 at 5:18 p.m., CNA H said she saw Resident #1 one time while in the covid hall. She said on 11/29/2023 she remembered LVN B telling RN A that Resident #1 had a yellowing bruise to the top of her left ankle and above the heel protector boot. She said RN A and her went over to Resident #1's room where RN A uncovered her, assessed her, and said oh yes, she has a little bruising but did not remove the heel protector. She said Resident #1 was not complaining of pain during that time. CNA H said RN A gave Resident #1 pain medication and that was all she did. In an interview on 12/14/2023 at 5:30 p.m., RN A said on 11/29/2023 she was assigned to the COVID unit because she had just returned to work due to having Covid herself. She said on 11/29/2023 she was advised by LVN B that while doing wound care she noticed, Resident #1 had a light to medium discoloration to her outer left leg. RN A said she went over to Resident #1's room, assessed her. She described the discoloration as being yellowish in color. She said Resident #1 was wearing a heel protector on her left ankle. She said when she touched Resident #1's lower leg she was very sensitive. She said she thought her sensitivity was due to Resident #1 being Covid positive. RN A said Resident # 1 was crying and had facial grimacing so she decided to give her pain medication and monitor her as that was all I could do. RN A said she was not sure why she did not remove Resident #1's heel protector to assess her ankle. RN A said she documented her finding on PCC under MAR or progress notes. She said, she did not inform the incoming nurse because she took it for granted the incoming nurse would read her notes. RN A said that was the first and only day she worked on the COVID unit and had contact with Resident #1. In an interview on 12/18/2023 at 2:18 p.m., the DON said since Resident #1 was always in pain due to her stage IV coccyx pressure ulcer the nursing staff might have confused Resident #1's fractured ankle pain with her stage IV coccyx pressure ulcer pain. The DON said there were no negative effects on Resident #1's delay to assess, notify the NP, and document on the progress notes the discoloration of her ankle, which was first noticed on 11/29/2023 and later identified on an x-ray as an acute distal tibial and fibular fractures to the left ankle on 12/09/2023. The DON stated there were no negative outcomes because she was being assessed for pain and given pain medication when needed. She said that was all they could do since Resident #1 did not require surgery. In an interview on 12/18/2023 at 2:45 p.m., the NP said she did not order a heel protector for Resident #1 as it was considered part of the basic care the facility would provide. She said she was glad Resident #1 had been wearing one. In an interview on 12/18/2023 at 4:00 p.m., the Administrator said the information he collected during his investigation was conflicting in regard to Resident #1's discoloration. He said RN A told him LVN B advised her that while she was doing wound care, she noticed the discoloration, but LVN B denied ever telling RN A. The Administrator said RN A told him she failed to document her findings, notify the NP, and notify the in-coming nurse. He said he was not able to say if Resident #1 suffered any negative effects because that was a clinical question. Record review of facility's policy on Change in a Resident's Condition or Status revised on February 2021 reflected: Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.) Policy Interpretation and Implementation 1. The nurse will notify the resident's attending physician or physician on call when there has been a (an): Accident or incident involving resident Discovery of injuries of an unknown source Significant change in the resident's physical/emotional/mental condition 2. A significant change of condition is a major decline or improvement in the resident's status that: Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting) Impacts more than one areas of the residents health status Requires interdisciplinary review and/or revision to the care plan 3. Prior to notifying the physician or health care provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by Interact SBAR communication form. 5. Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the residence medical/ mental condition or status. 8. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. Record review of facility's Charting and Documentation revised on July 2017 reflected: All services provided to the resident, progress towards the care plan goals, or changes in the residence medical, physical, functional, or psychosocial condition, shall be documented in the residence medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Policy Interpretation and Implementation 2. The following information is to be documented in the resident medical record: d. changes in the resident's condition. e. events, incidents or accidents involving the resident. 7. Documentation of procedures and treatments will include care-specific details, including. c. assessment data and/or any unusual findings obtained during the procedure/treatment This was determined to be an Immediate Jeopardy (IJ) on 12/19/2023 at 3:40 p.m. The Administrator was notified. The Administrator was provided with the IJ template on 12/19/2023 at 3:40 p.m. The following Plan of Removal submitted by the facility was accepted on 12/21/2023 at 4:00 p.m. Immediate action taken On 12/19/2023 the Charge Nurse who failed to notify the physician of the discoloration was terminated. By 12/19/2023 all residents have updated pain assessments completed by the DON, the ADON, the MDS, and the Treatment Nurse. By 12/19/2023 all residents have updated skin observations documents by the DON, the ADON, the MDS, and the Treatment Nurse. By 12/19/2023 all direct care staff have been in-serviced by the DON, the ADON, the MDS, and Treatment Nurse on immediate notification of any skin observation, new onset of pain, and/or change of condition. 1. The nurse will notify the resident's attending physician or physician on call when there has been a (an): Accident or incident involving resident Discovery of injuries of an unknown source Significant change in the resident's physical/emotional/mental condition 2. A significant change of condition is a major decline or improvement in the resident's status that: Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting) Impacts more than one areas of the residents health status Requires interdisciplinary review and/or revision to the care plan 3. Prior to notifying the physician or health care provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by Interact SBAR communication form. Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the residence medical/ mental condition or status. As of 12/19/2023 the DON, the ADON, the MDS, and the Treatment Nurse educated CNA's on notifying the Charge Nurse regarding any new skin issue identified. The CNA will verbally inform Charge Nurse, and Nurses will document skin issue in Point Click Care and CNA's will document new skin issues or injuries in Point Click Care. Monitoring/Supervision As of 12/19/2023 the DON and the ADON review 24-hour report for documentation and pain/skin assessment daily during the morning clinical meetings. DON and ADON will review Point Click Care documentation during morning clinical meeting. As of 12/19/2023 the DON, the ADON, or the MDS will assess all nonverbal bedridden patients twice a week for a month to verify compliance and then monthly x 3 months. Any new direct care employee will be educated on immediate notification of any new skin observation, new onset of pain, and/or change of condition prior to working with residents. All the above-mentioned education/in-services should serve to resolve questions regarding steps taken during a change of condition. In addition to procedures for monitoring and initiating interventions to ensure residents safety. Verification: started on 12/20/2023 at 2:30 p.m. and included: The following observations, record reviews and interviews were conducted to ensure CNA's and licensed staff's understanding of in-service training received by 12/19/2023. Observations on 12/20/2023 and 12/21/2023 of 3 skin assessment conducted by RN I and LVN J. Record review of all direct care staff In-Serviced Sign In Sheet for the topic of: Notification of changes in condition and new skin issues conducted by the DON/ADON reflected 1of 2 RN's (1 is the DON), 19 of 20 LVN's (1 was out of the country), 23 of 23 CNA's and 6 of 6 Med Aides were in-serviced from all shifts. Interviews on 12/20/2023 and12/21/2023 with the following CNA's C, D, E, G, H, K, L, M, N, O, and P. All stated they were in-serviced on immediate notification of any new skin observations, new onset of pain and/or change of conditions. All understood they were to notify their charge nurse in case they observed any new skin condition and document their findings in PCC. Interviews on 12/20/2023 and 12/21/2023 with the following LVN's/RN F, I, J, Q, R, S, T, U, V, W, X, Y and Z. All stated they were in-serviced on immediate notification of any new skin observations, new onset of pain and/or change of conditions. All understood if a CNA informed them a resident has a new skin observation, new onset of pain and/or change of condition they are to do a head-to-toe assessment, notify their physician, document in PCC, and carry out any new orders. They were to also do a 24-hour report and verbally notify the in-coming nurse to any new discoveries. They also needed to complete an SBAR assessment. The Administrator was informed the Immediate Jeopardy was removed on 12/21/2023 at 4:00 p.m. The facility remained out of compliance at the severity of actual harm with a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.