Every finding on record at Seabreeze Nursing and Rehabilitation

Based on interview and record review, the facility failed to ensure residents were free from misappropriation of property and exploitation for 1 (Resident #1) of 8 residents reviewed for misappropriation and exploitation.The facility failed to ensure that Resident #1 was free from exploitation as evidenced by CNA A misappropriating funds from Resident #1's payment application. This failure could place residents at risk of misappropriation of property, financial hardship, and mental and emotional distress.Findings included: Record review of Resident #1's face sheet, dated 3/5/26, revealed the resident was a [AGE] year-old male, admitted [DATE], with diagnoses including cerebral infarction (stroke) and unspecified glaucoma (eye disease that gradually deteriorates vision by causing damage to the optic nerve). Record review of Resident #1's quarterly MDS, dated [DATE], section C (Cognitive Patterns) revealed a BIMS score of 11 that indicated moderate cognitive impairment. Record review of Resident 1's bank statement for statement period 10/2/25-10/31/25 revealed a funds transfer on 10/1/25 for $5 to CNA A. Record review of an email, dated 2/6/26, from Resident #1's bank revealed attempted transactions to CNA A of $10, $25 and $100 on 2/5/26 at 11:18 p.m. Record review of Resident 1's checking history on 2/10/26 showed two payment application transfers of $25 to CNA A on 2/6/26 at 7:17 a.m. and 7:18 a.m. through a payment application. Record review of a Provider Investigation Report, dated 2/17/2026, revealed the Administrator's interview with Resident #1 where Resident #1 said his family member called him asking about charges on his personal bank account when the family member received an alert stating transactions were made they did not recognize. The information associated with the transactions were through a payment application to CNA A. Resident #1 said he did not authorize CNA A to make any purchases on his behalf. Resident #1 said he had never asked CNA A to go to the store for him. Resident #1 said he was sleeping one night when CNA A entered his room and asked for his card and that CNA A stated she was going to put money on his card. Resident #1 said he was half asleep and was not fully aware of what was going on at that time. Record review of a Provider Investigation Report, dated 2/17/2026, revealed the Administrator's interview with CNA A where CNA A said she had added Resident #1's personal bank card to her payment application a while ago because she went to the store for Resident #1 and instead of taking his card, she added his card so she could be reimbursed. CNA A said she would go to the store for the resident. CNA A said she accidentally used the wrong card when attempting to transfer money to her account and she had forgotten that Resident #1's card was still connected to her account. CNA A said she did not attempt to take money from Resident #1's account. Record review of CNA A's employee file on 3/5/26 at 12:02 p.m. revealed a New Hire Orientation Checklist, dated 4/11/2024, revealed the topic of abuse prevention, signed by CNA A, indicating they were oriented on the topic and was aware it was their responsibility to comply with all policies and procedures. Record review of CNA A's employee file on 3/5/26 at 12:02 p.m. revealed the Abuse and Neglect Policy and Procedure that included The deliberate misplacement, exploitation or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent was signed by CNA A on 4/11/24. Record review of CNA A's Employee Corrective Action Form, dated 2/13/2026, revealed termination for code of conduct rule violated was misappropriation of resident funds. Record review revealed the incident description, On 2/13/2026 a resident reported that there were transactions that they did not authorize on his personal bank account. The charges on the resident's personal bank account were associated with CNA A. CNA A stated she bought the resident items several months ago and linked his bank card to her payment application to reimburse herself for the purchase and forgot she added the card to her payment application account. CNA A stated that she accidentally used the resident's card that was attached to her payment application when she was trying to transfer money from another card on her account. This incident violates the facility's abuse policy related to misappropriation. Due to the nature and severity of this incident the company will separate employment at this time. Record review of Resident #1's Progress Notes, dated 2/1/2026-3/5/2026, revealed no distress was documented on 12:11 p.m. on 2/15/25, 9:00 a.m. on 2/20/26, and 12:18 p.m. on 2/20/26. Record review of Resident 1's bank statement for statement period 2/1/2026 -2/28/2026 revealed two funds transfers on 2/6/26 at 7:17 a.m. and 7:18 a.m. both for $25 to CNA A through a payment application. During an interview on 3/5/26 at 10:14 a.m., Resident #1 said he was asleep, and CNA A entered his room and asked him for his bank card so she could put some money on it, so he gave her his bank card. Resident #1 said he did not understand the situation. Resident #1 said CNA A said she was going to put $20 on the card and he laid back down and was not paying attention. Resident #1 said CNA A returned the card in 2-3 minutes and said she did not put any money on the card. Resident #1 said he called his family member, who was over his money at the bank. Resident #1 said he called his family member on 2/12/26, before he went on an activity to eat out on 2/17/26, and that was when his family member told him the money was missing. Resident #1 said his family member told him he had drawn $25 from the bank and he told his family member he did not, so his family member looked a little deeper into the situation. Resident #1 said someone tried to get $100 out of his account but it did not go through. Resident #1 said someone tried to take $75 but that did not go through but then $25 and another $25 went through. Resident #1 said his family member told him the name the money went to was CNA A. Resident #1 said his family member said the money was taken out on 2/6/26. Resident #1 said it was two or three days before the money was withdrawn that CNA A asked about his card information. Resident #1 denied any other staff member asking him for his financial information or to borrow money. Resident #1 said he filed charges against CNA A regarding the missing money, but the police had not contacted him with an update. Resident #1 said he was concerned over the missing money and said he had to save his money to make sure he had money for the things he needed. Resident #1 said he was upset regarding the missing money and frustrated that the money had not been replaced. During interview on 3/5/26 at 12:15 p.m., CNA A said she was no longer working at the facility. CNA A said she went to the store a couple of months ago for Resident #1 and never went again. CNA A said she was trying to explain to the facility that she could not take Resident #1's card but could put his card on her payment application. CNA A said she told the facility that she faulted herself for trying to go to the store for Resident #1 and forgot Resident #1 was on her payment application. When explaining the payment application, CNA A said you could have two or three cards on file, and she never deleted Resident #1's card off her payment application. CNA A said she was trying to add someone's card to her payment application, and she did not remember that Resident #1's card was still on there. CNA A said she worked at the facility for two years and never stolen from any residents. CNA A said she was not trying to take anything and did not remember Resident #1's card was on her file. CNA A said she did not know if money was transferred to her from Resident #1, but she was not trying to use anything from Resident #1's card. CNA A said she was not aware of any money being transferred to her from Resident #1. CNA A said she signed in-service trainings regarding abuse and neglect training. CNA A said she felt like it was a big misunderstanding, and she understood at the end of the day you have to face consequences.During interview on 3/5/26 at 3:02 p.m., Resident #1's family member said there was a CNA who stole Resident #1's debit card information and took money out of Resident 1's account. Resident #1's family member said the bank would not give the money back because the transaction had to be more than $50 to be reimbursed. Resident #1's family member said a couple of the transactions were caught and two transactions on 2/6/26 were paid out and once in October 2025. Resident #1's family member said there were some transactions she received an email for and she told Cash App they were not authorized. Surveyor confirmed with Resident 1's family member that transactions that were not authorized were the same as the attempted amounts of $10, $25 and $100 to CNA A from the email dated 2/13/26 . Resident #1's family member said, I am thinking her (CNA A) Cash App account was linked to his (Resident #1) credit card. During interview on 3/5/26 at 11:17 a.m., the Administrator said she was notified by the ADON that there was something with a CNA's name being linked to Resident #1's bank statements that were emailed by Resident #1's family member. The Administrator said the emails showed CNA A and payment application transactions and there were other attempts so they suspended CNA A pending the investigation. The Administrator said she spoke with CNA A regarding the situation and terminated CNA A. The Administrator said CNA A said she did not want to take Resident #1's card, so she linked his card to her payment application to refund herself when she went to buy something for Resident #1. The Administrator said CNA A said she had lots of different cards on her payment application and CNA A had gotten confused and chosen the wrong card. The Administrator said they notified the police, and received a case number. The Administrator said the police spoke to Resident #1 and he wanted to press charges. The Administrator said they did employee safety questionnaires, resident safety questionnaires, in-services/re-education of staff for abuse and neglect, misappropriation, and resident rights, terminated the employee, reported to the state and notified the Ombudsman. During interview on 3/5/26 at 11:46 a.m., the DON said she started at the facility as the DON on 2/9/26. The DON said she did not have any further information to add to the incident regarding Resident #1 and CNA A in addition to the facility's report. The DON said an effect of misappropriation of funds of residents could be all kinds, emotional and financial. The DON said she was not aware of any concerns regarding CNA A prior to the incident. During interview on 3/5/26 at 12:37 p.m., the Administrator said an effect misappropriation could have on residents would be case by case. The Administrator said in relation to the incident with Resident #1, he could experience mental or emotional distress, like anger.Record review of the facility's policy titled, Abuse, Neglect and Exploitation, date reviewed/revised 8/5/2025, revealed, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written polices and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property.

Based on observations, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen. Food items were observed stored in the facility refrigerator without proper sealing. This failure could place residents who received meals from the main kitchen at risk for food borne illness. Findings included: Observation on 1/6/2026 at 8:32 am revealed one 1-gallon full container of ranch dressing with visible food residue and buildup on the exterior surfaces including the lids and surrounding container. Observation on 1/6/2026 at 8:33 am revealed one 1-gallon full container of soy sauce with buildup on the exterior surfaces including surrounding container. In an interview with The Dietary Manager on 1/7/2026 at 3:40 pm. She said it was important to wipe each container completely after use to ensure the date was clearly visible on each container. She said it was her responsibility to ensure food items were cleaned, dated, and labeled. She said all kitchen staff were responsible for labeling, dating, storing, and cleaning all items. She acknowledged the containers appeared unclean. She said the condition of the containers could place residents at risk of potential illness. In an interview with The [NAME] President of Clinical services on 1/8/2026 at 3:08 pm. She said the food server supervisor, dietician and the administrator do rounds in the kitchen. She said the condition of the containers could place residents at risk of potential illness. Record review of the facility's Food Safety Requirements dated 7/23/25 under Policy Explanation and Compliance Guidelines read in part. 1b. Store food in a manner that prevents deterioration or contamination of the food.

The facility failed to ensure, when a discharge was anticipated, to complete a discharge summary, including but not limited to, a recapitulation of stay, a reconciliation of pre-discharge medications, a final summary of the residents' status, and post-discharge plan of care Based on observation, interview and record review, the facility failed to ensure, when a discharge was anticipated for 1 of 3 residents reviewed for discharge summary (Resident # 60). --the facility failed to complete a discharge summary for Resident #60. This failure could place residents at risk of incomplete discharge records.Findings include: Record review of Resident #60's face sheet revealed admission date 7/15/25 with diagnoses including cerebral infarction (disruption of blood flow to brain), carotid artery syndrome (plaques clog blood vessels that deliver blood to the brain), Meniere's disease (inner ear disease), heart disease (conditions affecting the heart and blood vessels), Parkinsonism (neurological condition causing movement-related symptoms), muscle wasting and atrophy loss of muscle tissue), and discharge date [DATE]. Record review of Resident # 60's Discharge MDS dated [DATE] revealed discharge, return not anticipated; planned discharge; discharge to nursing home; BIMS 15 indicating no cognitive deficits; functional ability on discharge: eating-independent, oral hygiene-set up, toileting hygiene-maximum assistance, shower/bathing-maximum assistance, upper body dressing-set up, lower body dressing-maximum assistance, personal hygiene-maximum assistance; catheter due to neurogenic bladder; occasionally incontinent of bowel. Record review of Resident # 60's progress note dated 11/12/25 revealed discharge to another facility today, which was the plan upon admission. All belongings, medications, face sheet sent with resident. Emailed Ombudsman of discharge. In an interview with the VP Clinical Services on 1/13/26 at 3:30 pm, she said the company policy is to complete a Recapitulation of Stay Summary form for all discharges, which includes final diagnosis, brief history, pertinent physical and laboratory findings, course of treatment, condition on discharge, rehabilitation potential, and follow-up and discharge medication instructions. She said the discharge summary for Resident # 60 was not completed due to changes in administrative staff, which caused lack of availability of staff to complete it. She said she has done an in-service with ADON on the Recapitulation of Stay Summary, and she will complete it for discharged residents going forward. She said the risk of not having a discharge summary would be incomplete resident information for the next facility. In an interview with ADON on 1/14/26 at 10:20am, she said she did have an in-service on the discharge summary form, and she will complete it for discharges. She said the risk of not having a discharge summary would be not having accurate discharge information. In an interview with the MDS nurse on 1/14/26 at 12:30pm, she said she completes the Discharge MDS, but she does not complete the discharge documents. She said Resident # 60 came here with plans to go to a place closer to home. Record review of the facility Discharge Summary policy read, in part: a discharge summary is provided upon a resident's discharge which addresses each resident's discharge goals and needs, including caregiver support and referrals to local contact agencies.

Based on interview and record review, the facility failed to ensure individuals with mental health disorders were provided an accurate Preadmission Screening and Resident Review (PASRR) Screenings for 1 of 5 residents (Resident #44) reviewed for PASRR.The facility failed to ensure that Resident #44's PASRR screening was updated accurately as evidenced by Form 1012 not being completed and submitted in a timely manner.These failures could place residents at risk of not receiving needed assessments (PASRR Evaluation), individualized care, and specialized services to meet their needs.Findings included:Record review of Resident #44's face sheet dated 1/8/26, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including unspecified dementia (group of symptoms affecting memory, thinking and social abilities), unspecified severity, with mood disturbance. Record review of Resident #44's quarterly MDS dated [DATE], section C revealed a BIMS score of 11 that indicated cognition was intact. Section I revealed active diagnoses of non-Alzheimer's dementia (group of symptoms affecting memory, thinking and social abilities), anxiety disorder, depression and psychotic disorder with additional active diagnoses of unspecified dementia, unspecified severity, with mood disturbance; anxiety disorder, unspecified; and other schizoaffective disorders. Record review of Resident #44's Continuity of Care Documented dated 1/8/26 revealed problems of unspecified dementia (group of symptoms affecting memory, thinking and social abilities), unspecified severity, with mood disturbance with effective date 7/16/24; dementia (group of symptoms affecting memory, thinking and social abilities) in other diseases classified elsewhere, unspecified with effective date 7/16/24; anxiety disorder, unspecified with effective date of 12/1/25; generalized anxiety disorder with effective date 5/15/24; other specified mental disorders due to known physiological condition with effective date 2/7/24; dementia (group of symptoms affecting memory, thinking and social abilities) in other diseases classified elsewhere, unspecified with effective date 8/16/23; other schizoaffective disorders (disorder with abnormal thought processes and an unstable mood) with effective date 6/16/23; anxiety disorder due to known physiological condition with effective date 6/16/23 and depression, unspecified with effective date of 6/16/23. Record review of Resident #44's care plan revealed problems of taking antipsychotic for depression with start date of 7/3/25, taking antipsychotic for schizoaffective disorder with start date of 7/3/25, cognitive loss/dementia with start date of 6/16/23 and schizoaffective disorder with use of Amitriptyline and Ritalin with start date of 6/16/23.Record review of Resident #44's physician's orders as of 1/8/25 revealed order for psychiatric and psychological services to evaluate and treat as needed with start date of 6/16/23.Record review of Resident #44's SNF History and Physical dated 8/7/2025 revealed past medical history of bipolar disorder (mental illness associated with episodes of mood swings ranging from extreme sadness or excitement) and schizophrenia (chronic mental disorder that affects how a person thinks, feels and behaves).Record review of Resident #44's PASRR Level 1 Screening with date of screening of 3/30/2024 revealed no evidence that dementia was the primary diagnosis and no evidence of mental illness. Record review of Resident #44's Form 1012 revealed PASRR level 1 date of assessment of 3/30/2024 with schizoaffective disorder marked yes under mental illness indication completed by the Clinical Care Manager. Under section D (Nursing Facility Action) it was indicated that a new positive PL1 was submitted but no date was indicated and no signature date under section E (Staff Completing Form). During interview on 1/8/26 at 11:00 a.m., the Clinical Care Manager said regarding PASRR that a resident had to have a mental illness diagnosis prior to a certain age to be answered yes under Section C on PASRR Level 1 Screening form, but she was going to contact someone from corporate to follow up.During interview on 1/8/26 at 11:35 a.m., the Clinical Care Manager said she had a stack of residents that she had been reviewing, and Resident #44 was one. The Clinical Care Manager said she could only send 3-4 PASRR referrals at a time. The Clinical Care Manger said she was in the process of sending a Form 1012 for Resident #44 and he was there a year before she started at the facility. The Clinical Care Manager said Resident #44 would be reevaluated when the referral was received. During interview on 1/8/26 at 11:40 a.m. the ADON said the Clinical Care Manager was responsible for making sure the PASSR came with the resident and was correct and getting completed if the PASSR was not completed. The ADON said she did not deal with the PASSR and could not explain how it would affect the residents if it was not accurately completed and said to ask the Clinical Care Manager as she was the one who deals with the PASSRs. During interview on 1/8/26 at 2:50 p.m., the Clinical Care Manager said if the PASRR was not completed correctly the effect it could have on the residents was that if it was supposed to be positive then they could miss out on PASRR services. The Clinical Care Manager said the #1012 form was how they rectified that and she did an audit of the residents. The Clinical Care Manager said if you see something suspicious you complete the #1012 form to see if the resident qualifies for services. During interview on 1/8/26 at 3:01 p.m., the [NAME] President of Clinical Services saidThe Clinical Care manager was responsible for PASRRs and was responsible for sending in the updated forms. The [NAME] President of Clinical Services said prior to 10/1/25 there was a corporate PASRR person who did the PASRRs for all of the facility and effective 10/1/25 there was no longer a corporate PASRR person, and the facilities had to do the PASRRs. The [NAME] President of Clinical Services said residents could possibly not get the services they were entitled through PASRR if PASRRs were not completed correctly. Record review of the facility's policy titled Preadmission Screening and Resident Review (PASRR) revised 2/1/2023 revealed The facility must use the Mental Illness/Dementia Resident Review form (Form 1012) for assistance in determining whether a resident needs further evaluation if a resident currently has a negative PL1 and is suspected to have or is diagnosed with a mental illness. A. The CCM must ensure that the 1012 form is completed and uploaded into the resident's electronic medical record.

Based on interviews and record reviews, the facility failed to develop a baseline care plan within 48 hours of admission that included the instructions needed to provide effective and person-centered care or 1 or 1 resident (Resident #57) reviewed. The facility failed to complete the baseline care plan within the required 48-hour timeframe following admission for Resident #57. This failure could place the residents at risk for unmet care needs due to inconsistent care, or failure to receive required services.Findings included: Record review of Resident #57's electronic admission record undated revealed she was a [AGE] year-old female admitted on [DATE]. Her diagnoses included Malignant neoplasm of right main bronchus (cancer located in the right main bronchus, which is one of the large airways that carries air from the trachea into the right lung), adult failure to thrive, pressure ulcer of sacral region, unstageable( pressure injury cannot be assigned a stage because the base of the wound is not visible). Record review of Resident#57 revealed no baseline care plan was developed upon admission. Record review of Resident #57's primary physician record dated 12/19/2025 revealed she was admitted to a hospice agency with a diagnosis of lung cancer and a code status of DNR (Do not resuscitate). In an interview on 01/08/2026 at 3:08 PM The Regional Nurse said the facility policy requires baseline care plan completion within 48 hours. She said the Director of Nursing and the Assistant Director of Nursing was responsible for the completion of the baseline care plan. She said the baseline care plan for Resident # 57 was not completed. She said the risk to the residents could lead to potential illness. In an interview on 01/08/2026 at 3:23 PM the Assistant Director of Nursing said she could not explain why the baseline care plan was not completed withing 48 hours of resident admission. She said the Director of Nursing was responsible for completing the baseline care plan. She said the baseline care plan for Resident # 57 was not completed. She said not having the baseline care plan completed the risk could lead to a negative outcome for both residents. Record Review of the facility policy subject titled, Baseline Care Plan date implemented 07/2025, revealed policy statement The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care that meet professional standards of quality care. Policy Explanation and Compliance Guidelines: 1.The baseline care plan will:a. Be developed within 48 hours of residents' admission. b. Include the minimal healthcare information necessary to properly care for a resident including but not limited to: Initial goals based on admission orders. Physician orders . Dietary orders . Therapy services . social services .Preadmission Screening and Resident Review recommendations if applicable.

Based on interviews and record review, the facility failed to ensure that the comprehensive care plan was reviewed and revised by an interdisciplinary team for 1 (Resident #61) of 5 residents reviewed for care plan.The facility failed to ensure that Resident #61's care plan was reviewed and revised regarding her weight changes and reflected both weight gains and losses.This failure could place residents at risk of not being able to attain or maintain their highest practicable level of physical, mental, and psychosocial well-being.Findings included:Record review of Resident #61's face sheet dated 1/8/25, revealed the resident was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses including other encephalopathy (any condition that disrupts the normal functioning of the brain).Record review of Resident #61's quarterly MDS dated [DATE], section C revealed a BIMS score of 13 that indicated cognition was intact (13-15). No weight loss or weight gain of 5% or more in the last month or loss of 10% or more in the last 6 months was documented under section K. Record review of Resident #61's care plan as of 1/7/2026 revealed problem of Resident has experienced weight gain R/T 5/7/24 Weight 232lbs Gain 7.4% (16lbs) in 30 days, 8.2% (17lbs) in 90 days. with problem start date of 5/13/2024 and last reviewed/revised date of 1/6/26. Another problem of I have experienced a significant weight loss within the past 30 days. I am at risk for a significant weight loss, the following conditions contribute to my weight loss and risk comorbidities. with problem start date of 10/24/2023 and last reviewed/revised date of 1/6/2026. Record review revealed progress note by the Registered Dietician on 9/9/2025 at 2:04 p.m. that Resident #61 had a weight loss of 1.4% in the last 30 days, weight gain of 4.2% in the last 90 days and weight gain of 14.5% in the last 180 days. Progress note dated 9/9/2025 at 2:04 p.m. also revealed potential shifts in weight due to diuretic treatment with recent adjustment made could be expected.Record review of Resident #61's weights revealed a weight of 297.2 pounds on 1/6/2026, weight of 310.6 pounds on 10/7/2026 and weight of 312.5 pounds on 7/8/2025. During interview on 1/8/26 at 11:00 a.m., the Clinical Care Manager said if there was something acute like a fall or a skin tear then nursing would update the care plan. The Clinical Care Manager said weight issues on the care plan would be completed by the ADON as she was over weights. During interview on 1/8/26 at 11:40 a.m. the ADON said if it was something specific like weights, then she (the ADON) would be responsible for making changes to the care plans. The ADON said Resident #61 had weight changes due to fluid changes and had gone to the hospital to be diuresed (given medications to have excess fluid removed from the body). The ADON said the care plan entry that said, I have experienced a significant weight loss within the past 30 days. I am at risk for a significant weight loss should just be the resident is at risk of weight loss. The ADON said the weight gain was specific and would check if that would have been resolved since it was from 2024 and updated new weights. The ADON said she would not have changed these sections on the care plan unless Resident #61 had triggered for her. The ADON said if care plans were not updated then residents' care was not specific to them and care plans should be updated to their needs and wants. The ADON said the DON was terminated 1/7/2026.During interview on 1/8/26 at 3:01 p.m., the [NAME] President of Clinical Services said the DON, ADON and CCM were the three people responsible for updating care plans. The [NAME] President of Clinical Services said the DON or ADON was responsible for updating the acute care plans. The [NAME] President of Clinical Services said if the care plans were not updated the residents might not get the level of care they should, and the nursing staff might not know that anything had changed regarding residents' care. The [NAME] President of Clinical Services said the DON should be checking the care plans for accuracy. Record review of facility's policy Comprehensive Care Plans with date implemented 7/2025 revealed The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment.

Based on interview, and record review the facility failed to ensure the residents were being properly supervised to prevent accidents and hazards. The facility staff failed to ensure resident's environment was safe and free from any potential harm. LVN-B did in fact bring in a weapon namely a pellet gun into the facility. The facility failed to ensure that facility staff were trained on how to properly ensure the resident environment remains as free of accident hazards as possible. Findings include: Record review of Resident #1's care plan dated 12/05/2024 revealed Resident#1 was care planned for falls and that his medication should be administered to him as prescribed by his physician. In an interview with CNA-A on 02/06/25 at 11:50am CNA-A said that on 02/05/25 on the overnight shift she asked LVN B if she had the keys to the CMA medication cart. CNA-A said that LVN-B told her no and that when CNA-A said that she saw LVN-B sticking something in her pocket. CNA-A said she asked LVN-B what you put in your pocket. CNA-A said that's when LVN-B put a gun on the counter and said this is what I have. In an interview with DON on 02/06/25 at 1:20pm she said that LVN-B told her that she went to her car to get her bag and that when she returned to the nurse's station, she realized that the gun was in her bag. The DON said that LVN-B told her that it was a pellet gun. The DON said that she does not consider the gun to be lethal because it is a pellet gun. In an interview with Administrator on 02/06/25 at 2:15pm he said that he wasn't made aware by his DON that there was an accusation of a gun being in the facility until 02/05/25. And that he was investigating to see if the accusation was true. He said that any kind of weapon should not be at the facility. In an interview with LVN-B on 02/06/25 at 2:52pm she said I went to my car to get my bag that I carry my computer in and when I got back to the nurse's station and looked in my bag I realized that the gun was in my bag. LVN-B said she removed the gun from the bag and put it in her pocket to take it back to her car when LVN-A and CNA-A accused her of having keys. She said that she told them that she did not have the keys and that she slowly stood up and showed them the gun. LVN-B said she put the gun in her bag and took it to her car. Record review on 02/06/25 of the facilities' policy Professional Behavior dated 12/2019 reflected that staff should not be in Possession of a firearm or other weapons and dangerous devices on facility property.

Based on interview, and record review the facility failed to ensure that Resident#1 medications were properly stored. The facility staff failed to ensure that resident's medication was stored and secured in a secure manner. LVN-A did not secure her keys, nor did she ensure that the med room was secure. As a result, Norco drugs were unaccounted for. This failure could place residents at risk of not having their prescribed medications given to them as directed according to physician orders. Findings include: Record review of Resident #1's face sheet revealed a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included major depressive disorder, bipolar disorder, dementia, shortness of breath, and congestive heart failure. Review of Resident #1's Quarterly MDS (Minimum Data Set) dated 01/11/25, section C revealed a BIMS (Brief Interview for Mental Status) score of 14. Record review of Resident #1's care plan dated 12/05/2024 revealed Resident#1 was care planned for falls and that his medication should be administered to him as prescribed by his physician. Record review of Narcotic sheet for the CMA cart on 02/06/25 at 1:30pm reflected that on 02/05/25 that six pills were missing from Resident#1 Narcotic blister pack. Record review of physician orders dated 12/26/24 on 02/24/25 for Resident#1 narcotic medication Hydrocodone 325mg tablet reflected that medication should be given by mouth 1 tablet every eight hours as needed. - In an Interview with staffing coordinator on 02/06/25 at 12:18pm,. the staffing coordinator said that she received a call on 02/05/25 from LVN-B and LVN-B told her that LVN-A and CNA-A accused her of taking keys to the CMA medication cart. The staffing coordinator said that when she got to the facility, she got LVN-B's keys so that a count of LVN-B medication cart could be conducted. The staffing coordinator said that she and the DON counted LVN-B medication cart and the count was good. In an interview with DON on 02/06/25 at 3:05pm the DON said that she received a call the morning of 02/05/25 at about 4:47am from LVN-A informing her that Norco medication was missing. The DON said that she immediately called the facility and told no one to leave until she arrives. The DON said that when she arrived, she had her staffing coordinator to get all nurses keys. The DON said at that point she and the staffing coordinator began to count meds and that all meds cleared except for LVN-A's. The DON said that a total of six hydrocodone pills were missing. The DON said she drug tested all staff and everyone passed. The DON said she called the local police and when they arrived, she informed them of the missing pills. In an interview with LVN-A on 02/06/25 at 4:42pm LVN-A said that when she came on duty the day of 02/04/25 that her nursing cart medication count cleared. And that at 9:00pm her CMA medication count cleared. LVN-A said that at 12:00am she gave meds to Resident#1 out of the CMA medication cart. LVN-A said that she then put the keys to the CMA cart in the med room on top of the CMA cart in a binder. LVN-A said that the CMA box is locked but the med room where the cart was kept was not locked. LVN-A said that at 4:50am she went back to the med room to get meds out of the CMA cart and when she opened the cart, LVN-A noticed six pills missing. LVN-A said that she immediately called the DON, and the DON told her to tell all staff not to leave. LVN-A said that she along with other staff were given a drug test. LVN-A said the DON informed her that everyone had tested negative, and the DON asked for statements from staff. In an interview with CMA-A on 02/06/25 at 5:32pm CMA-A said that at the end of her shift, that she and LVN-A counted the CMA medication cart at 9:15pm the night 0f 02/04/25 and that there were no missing medications. Record review of the facilities' medication policy on 02/06/25 at 5:00pm dated 06/01/22 reflected that All medication storage areas (carts, medication rooms, central supply) are locked at all times unless in use and under the direct observation of the medication nurse/aide.

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

47215 Based on observation, interview, and record review the facility failed to provide the necessary services to maintain grooming and personal care for 5 (Resident #8, Resident #12, Resident #18, Resident #20, Resident #30) of 73 residents reviewed for ADL care, in that: The facility failed to ensure residents at the facility were provided with hot water and baths/showers for a month, that would allow them to maintain cleanliness and access to activities of daily living. There had been no hot water in the facility for over a month. The residents in the building had not had showers in weeks and there was no documentation to show that residents had a bed bath or a shower for the month of September. -Resident #8 had cried to staff about her discomfort of not having a bed bath or shower in weeks. -Resident #12 was diagnosed with the need for assistance with personal care. She had a urinary tract infection and had not taken a bed bath or shower in a month. -Resident #18 had been diagnosed with a skin rash and other non-specific skin eruption and had not taken a bed bath or shower in a couple of weeks. She had been identified as having a fish like smell and a urine odor. -Resident #20 developed complications with possible bacteria in her urine during the time she went without a bath and shower. She was hospitalized for two days, 9/6/2024 to 9/8/2024 and was given medication to treat a possible urinary tract infection. She was one of 9 resdients at the facility being treated for an UTI. -Resident #30 had a shower in a month and reported his concerns to his family. On 10/15/24 at 3:07 p.m., an Immediate Jepordy (IJ) was identified. While the IJ was lowered on 10/16/24 at 3:17 p.m., the facility remained out of compliance at a a scope of pattern with the potential for more than minimal harm, due to the facility need to evaluate the effectiveness of the corrective systems. This failure affected Residents #8, #12, #18, #20, and #30 and placed an additional 68 residents who were without baths and showers, requiring assistance with incontinent care and personal hygiene, at risk of not receiving assistance with personal care, skin breakdowns, infections, and illnesses which could cause a decline in health. Findings Include: Record Review of the Facility's Event Summary Report for the Infection Tracker with McGreer's Criteria dated 9/1/2024 to 9/24/2024 revealed 9 residents with urinary tract infections and possible urinary tract infections. Record review of Resident #8's Face sheet revealed a [AGE] year-old female who admitted to the facility on [DATE] with the following diagnoses, anoxic brain damage (occurs when the brain is deprived of oxygen, which can lead to brain cell death), bipolar disorder, anxiety disorder, dysphagia (difficulty swallowing can have causes that aren't due to underlying disease), and oropharyngeal phase (the active phase of swallowing, which is a complex movement that involves moving food from the mouth to the throat and protecting the airway). Record review on Resident #8's Admission MDS assessment dated [DATE], revealed she had a BIMS score of 14 out of 15, indicating she was cognitively intact. Further record review revealed partial/moderate assistance, for toileting hygiene, upper body dressing and lower body dressing. She needed substantial/maximal assistance for shower and bath/self and supervision or touching for oral hygiene and eating. She did not walk and used a wheelchair for mobility. She needed substantial/maximal assistance for chair to bed transfer and set-up or clean up assistance to roll left and right. Record review on of Resident #8's Baseline Plan of Care dated 9/18/2024 revealed she had a urinary tract infection, and the goal was to resolve the infection by 12/18/2024. Her care plan edited on 8/16/2024 revealed she preferred to take a bath/shower once a day on Tuesdays, Thursdays, sand Saturdays. Record Review of Resident #8's progress notes dated 09/19/24 revealed, Resident #8 family member called the facility and is upset that there is no hot water. Informed the RP that the water issue is currently being serviced. She said Resident #8 needs a shower. Informed the RP that the resident has refused showers. Staff has tried several offers to do so per the assigned CNA and the charge nurse. The RP requested to then speak to the CNA, to verify whether or not the resident did indeed, refuse her shower. The CNA informed the RP that the resident did refuse her shower. Record Review of Resident #8's progress notes on 09/22/24 Resident: Is being Monitored for an Active Infection. Transmission Based Precautions in Place: Urinary tract Infection: Antibiotic: flagyl/Macrobid. Observation and interview on 09/23/24 at 9:14a.m., with Resident #8 revealed her resting in bed. Observation and interview on 09/23/24 at 3:10p.m., with Resident #8 said she had not had a bath or shower in two weeks. She said she was independent and had been wiping herself off with wet wipes. Interview on 9/23/2024 at 5:15p.m., with LVN B, said the residents were refusing showers because they did not want to take cold showers. She said she did not have documentation to show that the residents refused to take a shower. She said she had been off, but on the Wednesday before 9/16/24, the hot water was fine. She said on Monday, 9/16/24, a family member told her Resident #8 had not had a shower and she was crying. She said she told the Administrator at that time, that there was no hot water, and they could not make the water work. She said the Administrator said maintenance was working on it. She said not having hot water in the building could spread germs and if the residents are not taking showers, it can cause skin breakdowns and infections. Observation and interview on 09/24/24 at 10:15a.m., with Resident #8 revealed her in her room and her hair was wet. She said she had a shower this morning, after making a complaint to the surveyors. She said the water was warm. Record review of Resident #12's Face sheet revealed a [AGE] year-old female who admitted to the facility on [DATE] with the following diagnoses, muscle weakness (commonly due to lack of exercise, ageing, muscle injury of pregnancy), major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), need for assistance for personal care (bathing, teeth and mouth care, dressing and grooming, toileting, eating, ambulation, etc.), constipation, neuromuscular dysfunction of bladder (a condition that affects the bladder's ability to function properly due to nerve damage in the brain, spinal cord, or nerves). Record review on Resident #12's Admission MDS assessment dated [DATE], revealed she had a BIMS score of 15 out of 15, indicating she was cognitively intact. She needed partial/moderate assistance with toileting hygiene, upper body, lower body, and personal hygiene. She needed substantial/maximal assistance for shower/bath self and supervision or touching assistance for eating and oral hygiene. She did not walk and used a wheelchair for mobility. She needed substantial/maximal assistance for chair to bed transfer and set-up or clean up assistance to roll left and right. Record review of Resident #12's care plan edited 8/26/24 revealed she preferred to have showers on specific days of the week and her hair washed on Mondays and Fridays. Her care plan also revealed she has pressure sores/skin care, and she has thin and fragile skin. Observation and interview on 9/23/24 at 9:30a.m., with Resident #12 revealed she was in bed awake and alert. She said she did not receive assistance as needed. She said sometimes she did not get help when she needed to be changed. She had her glasses were dirty and stained with brown substances. She said she would spray her glasses from time to time. On her wall it stated she gets up during her shower time, but she said she had not received a shower and had not gotten out of bed for a while. Follow-up interview on 09/23/24 at 1:00p.m., with Resident #12, said she would get up when she had her shower, but she did not want to take a cold shower. She said the last time she took shower was over three weeks ago because there was no hot water. Observation and interview on 9/26/2024 at 3:20p.m., with Resident #12 revealed her lying in bed. She said she felt better becuase she had received a bath/shower, after the grievances she made to the surveyors about not receiving a bath/shower for a long period of time. She had a neck brace. She had a bed side table over her with a lot of items and a bag of chips. She had straps on both feet. She said when she felt yucky when she did not have a shower for a very long time. She said she needed her nails clipped. She said she complained to many people about the showers. Record review of Resident #18's Face sheet revealed a [AGE] year-old female who admitted to the facility on [DATE] with the following diagnoses, rash and other nonspecific skin eruption , morbid obesity, type 2 diabetes (a long term condition in which the body has trouble controlling blood sugar and using it for energy), chronic obstructive pulmonary disease (a group of lung disease that block airflow and make it difficult to breathe), dry eye syndrome of bilateral lacrimal glands (occurs when the lacrimal glands in the eyes don't produce enough tears), and major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Record review on Resident #18's Admission MDS assessment dated [DATE], revealed she had a BIMS score of 15 out of 15, indicating she was cognitively intact. She needed substantial/maximal assistance for toilet transfer, chair/bed to chair transfer, and tub/shower transfer. She required setup or clean-up assistance to roll left and right, and partial/moderate assistance for sit to lying. Record review of Resident #18's care plan edited 7/12/24 revealed she would perform task at her highest practicable level. It revealed the care plan was edited on 9/26/24 under approach and it revealed the resident preferred to take a bath/shower once a day on Mondays, Wednesdays, and Fridays, 6:00p.m.-6:00p.m. Observation and interview on 9/23/2024 at 8:30a.m., with Resident #18 revealed her sitting on an uncovered mattress, that was soiled. Her right and left legs were swollen with red marks on both feet. She had a pile of dirty linen at bedside. Resident #18's room smelled of urine. There were gnats by her food near the sink area. C-pap mask was hanging on her dresser drawer. She had an electric wheelchair in the corner of the room. There were cases of briefs and nutrient bottles underneath the sink. She said she had not had a bath in several weeks and was told there was an issue with the hot water. She said she was receiving bed baths by staff. Observation and interview on 9/23/2024 at 9:00a.m., with Resident #18 revealed her lying in bed and had a fish and urine odor. She said she had not had a shower in a month. Record review of Resident #20's Face sheet revealed a [AGE] year-old female who admitted to the facility on [DATE] with the following diagnoses, diffuse traumatic brain injury with loss of consciousness of unspecified duration (occurs when the brain is jarred or moves around in the skull, which can happen from a penetrating injury to the skull or other trauma), bipolar disorder, diarrhea (when your stools are loose and watery), and urinary tract infection (an illness in any part of the urinary tract, the system of organs that makes urine). Record review on Resident #20's Admission MDS assessment dated [DATE], revealed she had a BIMS score of 15 out of 15, indicating she was cognitively intact. She required substantial/maximal assistance for toileting hygiene, shower/bathe self, lower body dressing and putting on/taking off footwear. She required supervision and touching assistance for oral hygiene and setup or cleanup assistance for eating. She did not walk and used a wheelchair for mobility. She needed substantial/maximal assistance for chair to bed transfer and partial/moderate assistance to roll left and right. Record review of Resident #20's care plan edited on 8/16/24 revealed she preferred to take a bath/shower on Tuesdays, Thursdays, and Saturdays. Her care plan edited on 9/9/24, revealed she had recurring UTI's. Observation and interview on 9/23/2024 at 3:09p.m., with Resident #20 revealed her eating a sandwich while sitting in her wheelchair near the nurse's station. She said she had not showered nor given a bed bath in almost a month. She said she had been having diarrhea for five weeks with no showers. She said she had no deodorant. She said at first, she refused showers because of the frequency of the diarrhea but when she was ready to take a shower she couldn't because there was no hot water in the facility. She said the only time she was cleaned is when they used wipes when changing her briefs. Follow-up observation and interview on 9/24/2024 at 10:45a.m., with Resident #20 revealed her sitting in a wheelchair, attending resident council. She said when she did not receive a bed bath or shower, she smelled a lot and went to the hospital for two days. She said she did not feel good. She said she believed she had E. Coli and bacteria in her urine. She said she was put on antibiotics. She said she believe the antibiotics caused her diarrhea. She said not having a shower while having diarrhea made her feel dirty. She said it did not make her feel good going without a shower for over a month. Record review of Resident #30's Face sheet revealed a [AGE] year-old male who admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses, quadriplegia (a condition that causes a complete or severe loss of motor function in all four limbs), urinary tract infection (an illness in any part of the urinary tract, the system of organs that makes urine), generalized anxiety disorder (severe on going anxiety that interferes with daily activities), gross hematuria (a condition where blood is visible in the urine), need assistance for personal care (bathing, teeth and mouth care, dressing and grooming, toileting, eating, ambulation, etc.), major depressive disorder, and pressure ulcer of sacral region (a wound that forms on the lower back, tailbone, or rear of the body due to prolonged pressure on the area). Record review on Resident #30's Admission MDS assessment dated [DATE], revealed he had a BIMS score of 15 out of 15, indicating he was cognitively intact. He was dependent for toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, and personal hygiene. He required partial/moderate assistance for oral hygiene and eating. He could not walk and used a motorized wheelchair and a mechanical lift for mobility. Record review of Resident #30's care plan edited on 7/29/24 revealed, itching and dry skin to scalp, treatment and dosage: selenium sulfide shampoo. Approach: apply medication as ordered, notify MD if symptoms persist or worsen. Resident #30's care plan edited 9/12/2024 revealed, Recurring UTI's, have a suprapubic catheter. Edited 7/29/24, resolve infections without complications. Resident #30's care plan edited 8/19/2024 revealed, ADL functional/rehab potential, approach: bathing/hygiene amount of assistance: extensive/dependent every shift, 6:00a.m.-6:00p.m. Shift 2, 6:00p.m.-6:00a.m. Observation and interview on 9/25/2024 at 11:40a.m. with Resident #30 revealed him lying in bed watching tv. He was covered in a blanket. He has a catheter bag as well. He said he did not receive showers when there was no hot water. He said he almost got sick from the water being so cold. He said he did not have an issue with a particular staff member regarding showers. Interview on 9/26/2024 at 11:47a.m., with CNA C said she was aware that Resident #30 complained about not having a bath in a month. She said he believed he told his family about it. She said any CNA can give the residents their showers. She said it was the night shift aide that the resident was complaining about, and she is no longer at the facility. Observation on 9/23/2024 at 1:30p.m. revealed there were two shower rooms on hall 100. The water for the shower rooms was turned on for 5 minutes. The water was lukewarm at 80 degrees Fahrenheit-F. Interview on 9/23/2024 at 1:40p.m., with the Maintenance Director, said the issues with the hot water had been going on for almost two months and he had been adjusting the thermostat. He said the water was getting hot randomly on one side of the building at a time until it finally broke. He said the hot water stop working about a week ago. Interview on 9/23/2024 at 1:45p.m., with CNA K, said she was working in central supply. She said she had not given any residents showers. She explained how showers were provided to residents. She said the even numbered rooms were Mondays, Wednesdays, and Fridays. She said morning CNAs gives showers to A-bed and evening CNAs gives showers to the B bed on their shower days. She did not answer how long the hot water had been off. She said she did not know. She said she washed her hands with the cold water. She was not able to provide showers sheets or any documentation that showed the residents she was assigned to had been given showers for the month of September. Interview on 9/23/2024 at 2:50p.m., with the facility Administrator and the DON, the Administrator said he first heard of the hot water not working last week. He said it was an ongoing problem for over a month. He said at first, the facility thought it was the thermostat and the Maintenance Director tried adjusting the temperature. He said he thought the thermostat got broken through the back and forth of the adjustment process. He said once he noticed that the hot water was out, he contacted a local company for repair. He provided an invoice dated 09/16/24. The DON said the aides were warming up the water in the microwave to give bed baths to residents. She said she had other things going on at the facility, so she left it up to the charge nurses to make sure the aides were doing their jobs. She said she found out about the water being cold sometime last week. She did not have any documentation showing the CNAs were warming water in the microwaves nor that showers or baths were given to the residents. Observation and interview on 9/23/2024 at 4:00p.m., with the Maintenance Director revealed water temperatures, specifically for hot water temperatures in 10 different rooms, ranging from 73-84 degrees. He said he received a text from the plumber, and they would be at the facility soon. Interview on 9/24/2024 at 10:50a.m., with CNA J, said he had not given showers to residents for about two weeks but only provided bed baths because the hot water was off. He said he did not know how long the water had been off because the hot water had been on and off at different times. He said he gave bed baths as needed. Interview on 9/25/2024 at 9:48a.m., with the Doctor, said if baths and showers are not given within a month it would not be proper incontinent care for the residents. He said it could cause the residents to have an infection. He said if a resident is having diarrhea and BMs without proper care, it could cause skin problems, irritation, infections, and open sores. He said not cleaning the residents could cause infections especially females. He said not having proper incontinence care could lead to a serious problem. He said it is important for residents to take baths for hygiene and to be clean. He said the Mcgreer criteria follows a specific criterion for urinary tract infections. He said even if they do not meet the criteria, they can still have the infection. He said it could still count it as a urinary tract infection especially if a resident was still complaining of the infection and taking antibiotics. Record review of the facility's policy titled Activities of Daily Living (ADLs), Supporting revised (3/2018) read in part . Residents will provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: Hygiene (bathing, dressing, grooming, and oral care); Mobility (transfer and ambulation, including walking); Elimination (toileting); Dining (meals and snacks); and Communication (speech, language, and any functional communication systems). Care and services to prevent and/or minimize functional decline will include appropriate pain management, as well as treatment for depression and symptoms of depression. A resident's ability to perform ADLs will be measured using clinical tools, including the MDS. Functional decline or improvement will be evaluated in reference to the Assessment Reference Date (ARD) and the following MDS definitions: Independent - Resident completed activity with no help or staff oversight at any time during the last 7 days. Supervision - Oversight, encouragement or cueing provided 3 or more times during the last 7 days. Limited Assistance - Resident highly involved in activity and received physical help in guided maneuvering of limb(s) or other non-weight bearing assistance 3 or more times during the last 7 days. Extensive Assistance - While resident performed part of activity over the last 7 days, staff provided weight-bearing support. Total Dependence - Full staff performance of an with no participation by resident for any aspect of the ADL activity. Resident was unwilling or unable to perform any part of the activity over entire 7-day look-back period . This was determined to be an Immediate Jeopardy (IJ) on 10/15/24 at 3:07 PM. The Administrator and DON were notified. The Administrator was provided the Immediate Jeopardy template on 10/15/24 at 3:20 PM. The following Plan of Removal was submitted and accepted on 10/16/24 at 10:52 AM. Plan of Removal October 16, 2024 Submission #3 Immediate action: Action: All residents were offered a shower 9/25/2024. All residents were offered showers. All other residents that were interview able were offered and if they refused it was documented in their chart. All residents who were nonverbal/non interview able were offered and given showers with no refusals. Person(s) Responsible: Clinical Staff to include Certified Nurse Aides, Charge Nurses, Assistant Director of Nurses, and Director of Nurses Date: 9/25/2024 by 10PM How the Facility Identified Other Possibly Effected Residents: o How the Facility Identified Other Possibly Effected Residents: Action: All interview able residents were interviewed to address who did not receive showers on their scheduled shower days, the interviews included when they last received a shower and if they were experiencing any emotional distress due to not receiving a shower. All residents that were non/verbal or non-interview able were assessed for hygiene and cleanliness and received a shower. Behavior sheets and progress notes were reviewed for all nonverbal residents to determine if there were any signs of emotional distress. All residents were receiving incontinent care as they normally would, with prepackaged wet wipes. Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, and/or Designee. Date: 9/25/2024 by 10PM Date: 9/25/2024 by 10PM o Action: All active infections were reviewed on 9/25/2024 by the Director of Nursing. 1 UTI that met McGeer's Criteria and 1 UTI being treated per the direction of the physician (indwelling catheter and colonized), 2 residents out of 72 were being treated for possible urinary tract infections. Person(s) Responsible: Director of Nursing Date: 9/25/2024 by 10PM Measures Put into Place/System Changes to remove the immediacy, and what date these actions occurred: o Action: Plumber Vendor serviced the boiler system on 09/23/24. The boiler was unable to be repaired so he temporarily rerouted the boiler so that the the center was able to continue to reset the boiler to have manageable temperatures to care for the residents. The new hot water system was ordered at this time. The new hot water system was installed and will be completed on 10/16/24. Person(s) Responsible: Administrator Date: 9/23/2024 by 10PM & 10/16/2024 by 12PM o Action: All facility laundry was done in house using a laundry sanitation system using chemicals that were effective in cold water and not dependent on hot water. Person(s) Responsible: Administrator Date: 09/23/2024 by 12PM o Action: The facility policy/procedure was reviewed for ADL Care and Monitoring and no needed changes were identified Person(s) Responsible: [NAME] President of Clinical Services Date: 10/16/2024 by 12PM o Action: Education provided to Nurses & CNAs regarding the policy for ADLs and identifying residents that appear to be unkempt or have odors and actions to take if they note any issues or resident concerns, peri-care, hand hygiene, communication/reporting on maintenance issues, showers/baths & documentation, and abuse & neglect. Education was provided to the Maintenance Director on equipment maintenance and monitoring water temperatures, Person(s) Responsible: Administrator, Director of Nursing, Assistant Director of Nursing, and/or Designee Date: 9/27/2024 by 10PM o All identified staff will educated prior to working their next shift, facility is not utilizing temporary staff, and new staff will be educated prior to working their first shift. How the Corrective Actions Will be Monitored, by whom and for how long: o Action: Shower/bath assignment sheet is being completed by the CNA and nurses to sign off that showers/baths have indeed been completed. Director of Nursing monitoring shower/bath assignment sheets M-F. Person(s) Responsible: CNAs & Charge Nurses Date: 9/30/2024 by 10PM o Action: Water temperature log continued to monitor water temperature. Person(s) Responsible: Maintenance Director and/or Designee Date: 9/25/2024 by 10PM o Action: Ad hoc QAPI performed with Medical Director during survey (9/25/2024) & on 10/15/2024 to inform the Medical Director of the water issue, the immediate jeopardy template, and the facility's plan to remove the immediacy. Person(s) Responsible: Administrator and Director of Nursing Date: 10/15/2024 by 3:15PM Surveyor Monitored the plan of removal as follows: On 10/15/2024 12 residents from each hall between 11:00am to 12:00pm, about showers/baths and the presence of hot water. All 12 residents verified they are getting baths, and the water has been hot instead of lukewarm. Observation on 10/15/2024 at 12:20 p.m. in Laundry, revealed 1 staff was present. She revealed that she worked at 6:00 a.m. to 2:00 p.m. shift, and another staff member worked 2:00 p.m. to 10:00 p.m. Observation revealed clean clothes were hanging on racks, ready to be distributed to the resident's rooms, and clean linens were stacked on shelves ready to be put in linen closets. There was a clothes rack of unidentified clothing and donated clothes stacked on shelves in the corner. There were two operational washers and two operational dryers. POR Monitoring: 10/16/24 Facility POR binder had evidence via census sheet checked that all residents were offered showers on 9/25/24. If resident refused showers, it was documented in the resident's record. CNAs, charge nurses, ADON, DON implemented. ***verified by observation, interviews, record reviews 10/16/24. Facility POR binder had evidence via checked census sheet that all interview able residents were asked when their last shower was, and if they had any emotional distress if their shower was missed. Non-interview able residents were assessed for hygiene and cleanliness and assessed for signs of emotional distress. Completed 9/25/24. ***verified by observation, interviews, record reviews 10/16/24. Facility POR binder had evidence that all active infections were reviewed by the DON. One UTI met McGreer's criteria and was treated by MD. Two residents were treated for possible UTI. Completed 9/25/24. *** Verified by observation, interviews, record reviews 10/16/24. Facility POR binder had evidence a plumber serviced the boiler on 9/23/24. The boiler could not be repaired so water was re-routed. A new hot water system was ordered 9/23/24 and should be completed by 10/16/24. **surveyors were in facility on 9/23/24 and can verify the hot water issue on 9/23/24. Surveyors were in facility 10/16/24 and can verify the new boiler installed on that day, and water was hot by the end of the day. Facility POR binder had evidence the laundry was being done by a sanitation system with chemicals effective in cold water. ***this was verified by observations and interviews in laundry on 9/23/24 and 10/15/24. Facility POR binder has evidence of ADL policy and procedure: Review and education provided to staff on ADL policy. Completed 9/25/24. ***interviews with staff on each hall verified in-services on ADL care policy was conducted regularly 10/16/24. Facility POR binder had evidence the Administrator and DON were educated on equipment, water temperatures, neglect on 9/25/24. ***verified by interviews 10/16/24. Facility POR binder had evidence nurses, CNA's were educated on ADL policy and identifying residents who appeared unkempt, and reporting issues of care or maintenance issues, on 9/25/24. ***verified by interviews with nurses, CNAs 10/16/24. Facility POR binder had evidence the Maintenance Director was educated on equipment, monitoring water temperatures on 9/25/24. ***verified by interview with the Maintenance Director 10/16/24. Facility POR binder had shower/bath assignment sheet for CNAs and nurses to sign off, completed 9/30/24. ***verified by interviews with CNAs, nurses 10/16/24. Facility POR binder had water temperature log, completed 9/25/24. ***verified by observation, interview 10/16/24. Facility POR binder had evidence of ad HOC QAPI meeting with Medical Director 9/25/24 and 10/15/24 to inform of water issue, IJ template and plan of removal. ***verified by interview, documentation. Observation, testing of water temperature in shower room on 200 Hall revealed it was lukewarm after running several minutes, and became hot after running 2-3 minutes longer. Per interview with the Administrator, the new boiler is being installed today 10/16/24, and water temperatures may fluctuate, but once it is installed, water temperatures would be stable. This was verified by water temp testing on 10/16/24 at 3:30p.m. The Administrator was informed the Immediate Jeporady was lowered on 10/16/24 at 3:17 p.m. The facility remained out of compliance at a scope of isolated and severity of no actual harm with potential for more than minimal harm that is not immediate threat, at a scope of pattern due to the facility'n need to evaluate the effectiveness of the corective systems that were put in place.

Based on observation, interviews and record reviews, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plane, and the resident's choices for 1 (Resident #18) of 73 residents reviewed for quality of care. The facility failed to apply compression wraps to Resident #18's legs as ordered and Resident #18 experienced increased swelling and discomfort in her lower extremities. This failure placed resident at risk for further injury or harm. Findings include: Record review of medical records indicated Resident #18 was a [AGE] year-old female admitted on [DATE] with the following diagnoses: Type 2 diabetes mellitus with diabetic neuropathy, unspecified (Primary, Admission), Dry eye syndrome of bilateral lacrimal glands, Pain in right leg, Localized swelling, mass and lump, right lower limb, and Varicose veins of right lower extremities. Record review of the MDS dated [DATE] Record review of the care plan dated 7/23/24, indicated Resident #18 required the use of compression wraps to manage the edema. The care plan specified that the compression wraps should be applied Monday, Wednesday and Friday and monitored for effectiveness and skin integrity. Record review of medical records dated 8/15/24, indicated Resident #18 was assessed with chronic venous insufficiency and significant lower extremity edema. Record review of a resident assessment dated [DATE], written by: indicated Resident #18 had a need for compression therapy to manage the edema and prevent complications. Observation on 9/23/24 at 9:00 a.m., Resident #18's was lying in bed and legs and feet were swollen, compression wraps and compression stockings were on top of Resident #18 bed side table Interview on 9/23/24 at 8:10 a.m., Resident #18 reported increased swelling and discomfort in the lower extremities. Resident #18 reported her legs was to be wrapped 3 times a week with compression wraps. Resident #18 stated she was going to clinic to have her legs wrapped with compression wraps but was told by facility they could not provide transportation to clinic due to insurance stop paying for transportation. Resident #18 stated legs have not been wrapped for several weeks. Interview on 9/23/24 at 12:00 p.m., the MDS nurse stated Resident #18 was care planned for leg wraps three times a day and care plan were updated as needed. The MDS nurse stated she was not sure when the order was changed. Interviews on 9/23/24 at 12:30 p.m., the nursing staff (LVN A and CNA A) revealed that the compression therapy had not been administered for the past 30 days due to a lack of supplies and oversight. Interview on 9/23/24 at 1:30 p.m., the DON stated based on physical examination Resident #18's showed signs of worsening edema and early stages of skin breakdown, indicating a risk for infection and further complications. Interview with NP on 9/23/24 at 3:45pm, NP stated she changed order to have Resident#18 legs wrapped with compression wraps or compression stockings 5 times weekly or as needed. NP stated original order was for 3 times weekly wrap with compressions wraps or compression stockings.

Based on interview and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week, for 9 of 61 days reviewed for staffing, in that: There was no proof of RN coverage for 9 days of 61 days reviewed for RN coverage. This failure placeds all residents at risk of not receiving adequate medical care and supervision of an RN. Findings included: Record review of the facility's RN staffing hours from the period of 04/01/24 through 06/31/24 revealed there was no proof of RN coverage for the following days 05/17/24, 05/18/24, 05/20/24, 05/21/24, 5/22/24, 05/23/24, 05/24/24, 05/31/24 and 06/01/24. Record review of CMS PBJ report revealed the facility had no RN coverage [NAME] 04/06/24, 04/07/24, 04/16/24, 04/19/24, 04/21/24, 05/17/24, 05/18/24, 05/20/24, 05/21/24, 5/22/24, 05/23/24, 05/24/24, 05/31/24 and 06/01/24. During an interview with the facility Administrator on 09/05/24 at 2:00 p.m., he said the PBJ report was wrong. He said there was an RN coverage for the month of April. He said the cooperate DON left sometimes in August and the new DON started 08/23/24. He provided an RN time sheet for 67.27 hours for 04/06/24 through 04/21/24. He explained that the hours for the RN coverage did not showu because the facility used what is called shift key a term used for agency staffing. He said he had RN coverage for May and June but did not have the proof for the following days 05/17/24, 05/18/24, 05/20/24, 05/21/24, 5/22/24, 05/23/24, 05/24/24, 05/31/24 and 06/01/24. He said not having an RN coverage poses no harm to the residents because an RN can be called in at any time in an emergency. Record review of facility's provided staffing policy dated 2001 revised July 2001, titled Staffing did not an RN coverage for 8 hours in 24 hour a day.

Based on observation, interview, and record review, the facility failed to maintain all mechanical, electrical, and patient care equipment (boiler room equipment) in safe operating condition for 1 of 1 hot water heater heaters system in the facility in that - The facility did not have hot water for resident's use in two weeks . This failure could place the residents at risk of not having their ADL care in a timely manner and as needed. Findings included: Interview and observation on 09/23/24 at 1:28 p.m ., revealed the facility did not have hot water for resident's use. During an interview, Resident #12 said she did not want to take shower with cold water. She said the facility had no hot wat ER and she had not had her showers for about two to three weeks. She said she only have bed baths. Observation on 09/23/24 at 1:30 PM revealed there are two shower rooms on hall 100. The water for the shower room was turned on for 5 minutes. The water was lukewarm at 84 degrees Fahrenheit-F). During an interview on 09/23/24 at 1:45 PM, CNA K she said she had did not given resident showers today. She explained how showers are provided to residents. She said even rooms are Mondays, Wednesdays, and Fridays. She said morning CNA gives showers to A-beds and evening CNAs gives showers to the B beds on their shower days. She did not answer how long the hot water had been off. She said she did not know. She said she washed her hands with the luck luke warm water (not too cold). During an interview with the ADON on 09/23/21 at 1:50 PM, she said the hot water had been called in by the facility Administrator. She said the hot water stop working last week 9/16/24 and she immediately told the Administrator. She did not give any date. She said the hot water had been on and off at different parts of the facility. She said it was her understanding that the Administrator had reported the incident to the state . During an interview with the Maintenance Director on 09/23/24 at 2:10 PM, he said he had been trying to find out what the problem was for sometimes. He said he tried adjusting the thermostat thinking the thermostat was the problem. He said the hot water was on and off at different parts of the facility for almost a month. He said he found out last Friday the thermostat broke and that was when a local plumbing company was called in to detect the problem. Observation with the Maintenance Director on 09/23/24 from 2:10 p.m. to 2:30 Pp.m., revealed the water temperature on randomly selected rooms ranged from 84-86-degrees Fahrenheit. During an interview on 09/23/24 at 3:00PM, Resident # 27 said, she used wipes and face sheet to clean herself in the bathroom . During an interview on 09/23/24 at 3:30 PM, with a group of unidentified residents in the smoking area, 5 of the residents said the hot water has not worked for over three weeks and 2 said for a month . They could not give date range. During an interview with the facility Administrator on 09/23/24 at 4:00 PM, he said the facility was an old building. He said the hot water had been on and off at different parts of the building and he cannot put a timeline. He said he was out on vacation and came back August 26 . He said the Maintenance Director had worked on and off on the hot water for a sometimes. He said the maintenance Director adjusted the thermostat on and off and it makes the water either too hot on one side of the building and cold on the other side. He said it was brought to his attention on 09/16/24. He said he called a local plumbing company, and the facility was trying to get approval and eventually fall on the weekend . He said he called the incidents of the hot water to state on 09/20/24 expecting the plumbing company to start the work on Monday 09/24/24. During an interview with CNA J in the secured unit on 09/24/24 at 10:50 AM, he said he had not given showers to residents for about two weeks but only provided bed baths because the hot water was off. He said he did not know how long because the hot water had been on and off at different times. He said he gave bed baths as needed . During an interview with the facility Administrator on 09/26/24 at 2:30 p.m., he said the facility lack of hot water makes it harder for the staff to complete their job if they had to heat hot water for those who needed hot water to take a bath. He did not answer questions on how the lack of hot water affected residents . Record review of facility's policy titled Supplies and Equipment; Environmental Services read in part, .Policy Statement Housekeeping/laundry department supplies, and equipment shall be readily available so that department personnel can perform necessary tasks. Policy Interpretation and Implementation 1. Equipment must be ready for use at all times of the day and night to serve the residents' needs. Care should be exercised in the handling and in the use of our equipment to prevent damage or breakage .

Based on interviews and records reviews, the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality of care for 1 (Resident #19) of 8 residents reviewed for base-line care plans. The facility failed to ensure (Resident #19) had a baseline care plan developed within 48-hours after admission with goals, services, and interventions. The failure could place newly admitted residents at risks of not receiving the care and services for health promotion and continuity of care. Findings included: Record review of Resident #19's Face Sheet (undated) revealed, a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included, but not limited to Unspecified fracture to the left femur (broken leg), Diabetes Mellitus(condition when your blood sugar is too high), End Stage Renal Disease (condition in which the kidneys lose ability to remove waste and balance fluids), and Unspecified Systolic Congestive Heart Failure(Heart failure when the heart's left ventricle cannot contract normally, preventing the heart from pumping enough blood to the body). Record review of Resident # 19's clinical records revealed that there was no Care Plan in the facility's electronic health record system. Record review of Resident #19's Admission MDS assessment dated [DATE] revealed a BIMS score of 14 indicating cognitively intact. She required Partial/moderate assistance with personal hygiene and upper body dressing. She required substantial/maximal assistance with sit to lying and lying to sitting on side of bed. Interview on 09/26/2024 at 1:18 PM, the MDS Coordinator/LVN, said it was the responsibility of the admitting nurse to create the Baseline Care Plan. She said she only initiates the comprehensive care plan. Interview on 09/26/2024 at 3:20 PM, the ADON said the Baseline Care Plan should be created by the admitting nurse. She said the base line care plan was not done and only care plan in the Electronic medical record was the comprehensive care plan. She said the purpose of a baseline care plan was to establish care for the resident. She said the risk of not having a baseline care plan was the resident's care was not resident specific or resident centered care. Interview on 09/26/2024 at 3:30 PM, the DON said the purpose of the Baseline Care Plan was to make sure the resident's needs were met. She said that resident's needs are specialized and person/resident centered care. The baseline care plan also mimics the plan of care that the resident's receive, and when the base line care plan was not completed, the resident was not receiving the person-centered care. Interview on 09/26/2024 at 3:41 PM, the Administrator said the Base Line Care Plans were the responsibility of the nursing staff. He said the Base Line Care Plans should be done within 48 hours per CMS policy. He said that having a Baseline Care Plan was a regulation for a reason, and the staff should follow to the policy to initiate and implement person-care when the resident was admitted . He said the risk of not having a Baseline Care Plan was not having continuity of care. Record review of the facility's policy titled, Baseline Care plan, dated 07/2024, read in part . Policy interpretation and implementation:1. Completion and implantation of the comprehensive car plan within forty-eight (48) hours of a resident's admission is intended to promote continuity of care and communication among nursing home staff, increase resident safety, and safeguard against adverse events that are most likely to occur right after admission; and to ensure the resident and representative, if applicable, are informed of the initial plan of delivery of care and services by receiving a written summary of the baseline care plan. 2. To assure that the resident's immediate care needs are met and maintained, a baseline care plan will be developed within forty-eight (48) hours of the resident's admission .

Based on interviews and record review the facility failed to provide pharmaceutical services that assured the accurate acquiring, receiving, dispensing, and administering of controlled medications for 1 of 6 residents (Residents #60) reviewed for pharmaceutical services. The facility failed to ensure that LVN A accurately documented on the narcotic count sheet for Resident #60's scheduled pain medication administration for Percocet 5/325 mg. This failure could place residents at risk of misappropriation by drug diversion and could result in diminished health and well-being. Findings included: Record review of Resident #60's face sheet, undated revealed Resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include but not limited to dementia (memory loss), Atherosclerotic Heart Disease (buildup of fats, cholesterol in and on the artery wall), Hypertension (high blood pressure), schizoaffective disorder (mood disorder), and chronic pain. Record review of Resident #60's Quarterly MDS Assessment, dated 08/12/2024 revealed a BIMS summary score of 12 indicating moderately impaired cognition. She required Partial/moderate assistance with toileting hygiene, shower/bathe self, putting on/taking off footwear and lower body dressing. Record review of Resident #60's care plan, initiated 11/03/23 and edited on 9/04/24, revealed the resident had pain due to necrotic right hip and on pain medication to include Percocet. Record review of Resident #60's Physician order, dated 08/15/24 revealed a medication order of Oxycodone-Acetaminophen (Percocet) Tablet 5/325 mg, give 1 tablet oral every 6 hours related to chronic pain, osteoarthritis. \Observation and Controlled medication count of medication cart #2 on 09/26/24 at 12:35 PM with LVN B revealed Resident #60's Oxycodone-Acetaminophen (Percocet) 5/325mg blister pack had total count of 76 tablets. Record review of Resident #60's Resident's Narcotic Drug Record for Oxycodone-Acetaminophen (Percocet) 5/325mg, documented that on 9/26/24 at 0500 AM, LVN A signed out 1 tab for Resident #60 leaving a record count of 77. Record review of Resident #60's Medication Administration Record (MAR) revealed, that LVN B did not administer Oxycodone-Acetaminophen (Percocet) 5/325mg, to Resident #60 on 9/26/24 at 5:00 am but on 09/25/24 at 8:03 PM. During an interview with LVN B on 09/26/24 at 3:04 PM, she said she did the count with LVN A that morning during change of shift, and they both must have made a mistake in the count that morning. She said she spoke with LVN A, who said she gave the medication but did not sign it out on the narcotic sheet. She said the purpose of having the narcotic record and the MAR was to make sure the medication was administered as ordered and the residents were getting their medications as intended. She said the risk of not having the correct count was drug diversion, and the narcotics were not used as intended. She said the worst thing that could happen would be a resident overdose. During an interview on 09/26/24 at 3:20 PM, ADON said staff should perform the narcotic count at the end and beginning of each shift. She said the staff should be signing for meds in 2 places, which was on the narcotic sheet and the MAR. She said if it was not documented, that means it was not done. She said having the incorrect count can cause a resident to be over medicated, which can cause other issues such as increased drowsiness, falls, and decreased respiration. She said the risk of not having the correct count could lead to misappropriation ordrug diversion and/or the resident taking too much medication. During an interview on 09/26/24 at 3:33 PM, the DON said she expected the staff to document on the MAR and the narcotic count sheet and expects the counts to be performed each shift. The DON said she performed a narcotic audit on 09/26/24 and was able to reconcile the missed medication for Resident #60, and the count was corrected on the narcotic count sheet. She said she was aware of the issue and had been doing her best to implement changes in the last 2 months since she was hired. She said the risk of not documenting correctly and timely was not being able to track when medications were administered, not following MD orders, and overdosing or underdosing residents. She said she will plan an in-service on this issue, and she have several Performance improvements plans in place. During an interview on 09/26/24 at 3:41 PM, the Administrator said he expected the nursing staff to have an accurate narcotic count. He said nothing good can come out of having discrepancies with the narcotic count, and that was why there was a double entry system put in place to reduce inaccuracies and discrepancies. He said the purpose of the narcotic count was to help prevent or minimize drug diversions. Record review of facility provided policy, Controlled Substances, revised April 2019 revealed in part . The facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications. Policy Interpretation and Implementation. 8.Controlled substances are reconciled upon receipt, administration, disposition, and at the end of each shift. at the end of each shift. 10.Upon Administration: a. The nurse administering the medication is responsible for recording: (1) Name of the resident receiving the medication; (2) Name, strength, and dose of the medication; (3) Time of administration; (4) Method of administration; (5) Quantity of the medication remaining; and (6) Signature of nurse administering medication. 12. At the End of Each Shift: a. Controlled medications are counted at the end of each shift. The nurse coming on duty and the nurse going off duty determine the count together. b. Any discrepancies in the controlled substance count are documented and reported to the Director of Nursing Services immediately. c. The Director of Nursing Services investigates all discrepancies in controlled medication reconciliation to determine the cause and identify any responsible parties and reports the findings to the Administrator .

Based on observation, interview, and record review, the facility failed to maintain medical records on each resident in accordance with accepted professional standards and practices for 1 of 18 residents reviewed for clinical record accuracy (Resident # 2). --the facility did not have documentation of the results of Resident # 2' s PASRR evaluation in the resident's clinical record. This failure could place residents at risk of having incomplete clinical records and decrease in staff knowledge of resident's medical history. Findings include: Record review of Resident # 2's face sheet revealed admitted [DATE] with diagnoses including intracranial injury (bleeding inside the brain caused by an outside force), aneurysm (abnormal swelling in the wall of a blood vessel), muscle wasting and atrophy (decrease in muscle tissue), dysphagia (difficulty swallowing foods or liquids), cognitive communication deficit (disruption in concentration, memory, responding, comprehending), encephalopathy (brain disease that alters brain function), dementia (loss of cognitive function). Record review of Resident # 2's Annual MDS dated [DATE] revealed the PASRR Level II evaluation resulted in no serious mental illness or developmental disorder, was rarely or never understood, rarely or never understands, severely impaired cognitive skills, dependent for all ADL's, always incontinent, and presence of a feeding tube for nutrition. Record review of Resident # 2's care plan, undated, revealed no goals or interventions to address PASRR status. Observation of Resident # 2 on 9/23/24 through 9/26/24 revealed she was in bed, alert to person only, not responding to questions but maintaining eye contact, in no apparent distress, with enteral feeding tube infusing formula for nutrition. In an interview with the MDS nurse on 9/26/24 at 10:40 am, she said she received the denial letter for PASRR specialized services for Resident # 2 from the local authority on 9/26/24, after surveyor intervention, and it would be added to the resident's medical record. She said she was not working in the facility then, but Resident #2 had a PASRR assessment and evaluation in 2020, and the local authority denied specialized services. She said the PASRR denial letter should have been added to her medical record to have an accurate medical history in the facility. In an interview with the DON on 9/26/24 at 5:40 pm, she said the records should be accurate and PASRR recommendation should have been added to the medical record for an accurate medical history for Resident # 2. Record review of Resident # 2's PASRR letter dated 10/31/2020 read, in part, .based on evaluation, the local authority determined you are not eligible for specialized services because you do not have a qualifying diagnosis of mental illness, intellectual disability, or developmental disability as required by 42 CFR 583.102 (b) (1) . Facility policy on clinical records was not available by the time of exit.

Based on observation, interview, and record review the facility failed to conduct regular inspections and maintenance of resident bed frames, mattresses, and bed rails, leading to potential entrapment hazards for 1 (Resident #49) of 13 residents reviewed for safety in rooms. The facility failed to conduct regular inspections of resident bed frames and mattresses to identify risks and problems. Resident #49's bed had a significant gap between the mattress and bedframe. The mattress was torn with mattress foam coming away from the mattress cover and was covered with stains and rips in the center of the mattress. The finding Include: Record review on 9/24/24 at 9:00 am of Resident #49 admission face sheet revealed she was a [AGE] year-old female with Parkinson's, osteomyelitis, and dementia. Record review on 9/24/24 at 9:30am Resident #49's MDS dated [DATE], revealed a BIMS score of 9, which indicated cognitive impairment to make decision. Section GG (function abilities) revealed Resident#49 needed substantial assistance for bed mobility. Observation on 9/24/24 at 8:20 a.m., several resident beds were found with loose bed rails and gaps between the mattress and bed frame, torn and stained mattress. Observation on 9/24/24 at 8:30 a.m., Resident #49's bed had a significant gap between the mattress and the bed frame. Resident #49 mattress was torn with mattress foam coming away from mattress cover. Resident #49's mattress was covered with stains and rips in the center of mattress. Resident #49 was on a low bed with fall mat that was torn around edges. Interview on 9/24/24 at 10:30 a.m., a family member of Resident #49 stated they spoke with staff to have mattress replaced due to mattress looked worn out and was torn on the sides and foam was coming out. The FM stated Resident #49's mattress was still on bed despite asking for it to be replaced. Interview on 9/24/24 at 11:00 a.m., the Administrator stated that residents will let the nursing staff know when they want a new mattress if the resident can speak for themselves and those that cannot it was the nursing staff and department head responsibility to bring it up when doing Angel rounds. The Administrator stated that the facility maintenance director does not have a schedule or plan to check all beds, but we have new beds in facility residents just have to ask. Adminstrator stated the facility did not have a policy on replacing beds or mattress for beds. Interview on 9/24/24 at 11:30 a.m., the facility maintenance director stated the staff will have to tell my staff and will get the mattress replaced. He said he ordered new mattresses all the time but need the nursing staff to tell him who or what resident needed a new mattress. Facility manintenance directored stated he was not aware of any policies on replacing beds or mattress. Interview on 9/24/24 at 12:15 p.m., the facility DON stated the nurses are required to inspect mattresses to ensure the mattresses are in good condition as well as the beds. Interview on 9/24/24 at 12:45 p.m., CNA B, CNA C stated they mention some of the residents having torn mattress and needed new ones, but nothing was done. Interview on 9/24/24 at 1:00, charge nurse, stated the aides will tell them if the resident needs a new mattress because they are the ones that make up the beds during ADL care and if a resident needs a new mattress or something was wrong with the bed we tell the Administrator or Maintenance.

Based on observations, interviews, and record review, the facility failed to obtain laboratory services when ordered by a physician in accordance with the State law, including scope of practice laws for 1 of 12 residents (CR #1) reviewed for laboratory services. 1. LVN A failed to document physician's orders and obtain weekly laboratory services (CMP, CBC, and CPK) as ordered by CR #1's infectious disease physician when she was discharged from an acute care hospital on 03/29/2024 and resulted in re-hospitalization on [DATE] with elevated WBC values, which indicated infection. 2. LVN A failed to document physician's orders and obtain weekly laboratory services (BMP and CBC) as ordered by CR #1's NP when she reconciled (the process of comparing a patient's medication orders) medication orders on 03/29/2024 and resulted in re-hospitalization on [DATE]. She was diagnosed with polymicrobial (multiple bacteria) skin and soft tissue infections and multifocal (having more than one location) osteomyelitis of the pelvis. On 04/25/2024 at 3:20 p.m. an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 04/27/2024, the facility remained out of compliance at a scope of pattern with the severity level at a potential for more than minimal harm that is not immediate jeopardy, due to the facility continuing to monitor the implementation and effectiveness of their Plan or Removal. These findings placed residents at risk of experiencing pain, worsening of symptoms/condition, and possible death from not having vital laboratory tests completed to monitor/diagnose infection, disease, and other health conditions. Findings included: Record review of CR #1's face sheet dated 04/24/2024 revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. She was diagnosed with metabolic encephalopathy (a series of neurological disorders caused by systemic illness), quadriplegia (paralysis that affects all of a person's limbs and body from the neck down), local infection of the skin and subcutaneous (under the skin) tissue, acute kidney failure (when the kidneys suddenly cannot filter waste from the blood), acute respiratory failure (sudden inability of the respiratory system to meet the oxygenation, ventilation, or metabolic requirements of the patient), sepsis (life-threatening complication of an infection; when chemicals released in the bloodstream to fight an infection trigger inflammation throughout the body) due to staphylococcus, osteomyelitis (inflammation of bone or bone marrow, usually due to infection) - multiple sites, chronic pain (persistent pain that lasts weeks to years), hypotension (low blood pressure), anemia (a condition in which the blood does not have enough healthy red blood cells and hemoglobin), bipolar disorder (a disorder associated with episodes of mood swings ranging from depression lows to manic highs), epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures), stage 4 pressure ulcer (full thickness skin loss extends through the fascia with considerable tissue loss), and muscle wasting and atrophy (a decrease in size of muscle tissue). She was discharged from the facility to an acute care hospital on 04/17/2024 at 3:12 a.m. Record review of CR #1's quarterly MDS, dated [DATE] revealed she had a BIMS score of 15 (cognitively intact). CR #1 did not experience hallucinations or delusions. CR #1 did not exhibit behaviors which indicated rejection of care (bloodwork, taking medications, or ADL assistance). CR #1 had functional limitations in range of motion in both upper extremities and both lower extremities. CR #1 used a motorized wheelchair for ambulation. CR #1 required substantial/maximal assistance from staff for oral hygiene, toileting, showers, upper body dressing, personal hygiene, sitting, transfers, and rolling left and right. CR #1 received pain medications. CR #1 had six unhealed stage 4 pressure ulcers upon admission and was prescribed antibiotic medications. Record review of CR #1's care plan, revised on 04/22/2024 revealed the following care areas: * CR #1 refused wound treatments and labs at times. Goals included: Resident will allow wound treatments and labs to be complete as scheduled. Approach included: Staff will encourage wound treatments and labs as scheduled. * CR #1 was at risk for pressure sore infections. CR #1 was admitted with infected pressure injuries. CR #1 had osteomyelitis with recurring infections. Goals included: CR #1's pressure ulcer will not exhibit purulent discharge, foul odor, or peri ulcer inflammation (inflammation around the ulcer). Approach included: Enhanced barrier precautions, central line care per facility policy and MD orders, and administer antibiotics as ordered. Evaluate/record/report effectiveness/adverse side effects, observe and report signs of purulent discharge, foul odor, or peri ulcer inflammation. Report signs of cellulitis (bacterial skin infection), sepsis, tachycardia (increased heart rate), and osteomyelitis. On low air-loss alternating mattress for the treatment of pressure injuries. Record review of CR #1's progress notes for March 2024 and April 2024 revealed the following: On 03/22/2024 at 6:53 p.m., LVN D wrote, Resident stated she wants to go to the hospital because she feels her wounds are infected. Writer noted yellow discharge to wound during wound care. Resident refused protein supplement because she said it is nasty. New order per NP to send resident to ED for evaluation . On 03/23/2024 at 7:41 a.m. (recorded as late entry from 03/22/2024), LVN C wrote, Received order from medical provider to transfer resident to hospital ER. Transfer order obtained from physician . Primary reason for transfer: Foul odor from wounds . Resident left the facility at 8:45 p.m. On 03/30/2024 at 1:59 p.m. (recorded as late entry from 03/29/2024), Treatment LVN B wrote, Resident arrived at facility on 03/29/2024 at 5:00 p.m. Primary admitting diagnosis: Osteomyelitis . Admission orders entered into system and medication orders sent to pharmacy: 5:20 p.m. Referrals made for the following: No referrals at time of admission . Additional Notes: Resident returned to facility with new orders for IV ABT's and with IJ tunnel catheter with CVC double lumen to right chest, dressing is clean, dry, and intact, with no signs and symptoms of infection observed at this time . On 04/04/2024 at 5:15 p.m., Treatment LVN B wrote, . Transmission based precautions in place: Type: Skin/Soft Tissue Infection: osteomyelitis/wound. Resident is receiving antibiotic: Daptomycin reconstituted (recomposed) solution (500 mg) and Ceftriaxone, IV administration. Resident has received treatment for 4 days . Resident has experienced the following signs/symptoms of infection during this shift: purulent discharge or drainage from wound . On 04/05/2024 at 2:26 p.m., Agency LVN E wrote, IV ABT therapy in progress due to osteomyelitis. Resident afebrile (no fever) with no adverse reactions noted . Resident has received treatment for 5 days . Resident has experienced the following signs/symptoms of infection during this shift: purulent discharge or drainage from wound . On 04/09/2024 at 12:57 a.m., LVN F wrote, Resident is being monitored for an active infection . Resident has received treatment for 8 days . The resident has experienced the following signs/symptoms of infection during this shift: purulent discharge or drainage from wound . On 04/09/2024 at 9:48 p.m., LVN F wrote, Resident is being monitored for an active infection . Resident has received treatment for 9 days . The resident has experienced the following signs/symptoms of infection during this shift: purulent discharge or drainage from wound . On 04/11/2024 at 4:32 p.m., LVN G wrote, Resident is being monitored for an active infection . Resident has received treatment for 10 days . The resident has experienced the following signs/symptoms of infection during this shift: purulent discharge or drainage from wound . On 04/13/2024 at 5:16 p.m., Treatment LVN B wrote, Resident is being monitored for an active infection . Resident has received treatment for 14 days . The resident has experienced the following signs/symptoms of infection during this shift: purulent discharge or drainage from wound . On 04/15/2024 at 1:12 a.m., LVN F wrote, Resident is being monitored for an active infection . The resident has experienced the following signs/symptoms of infection during this shift: purulent discharge or drainage from wound . On 04/15/2024 at 5:13 p.m., LVN G wrote, Resident noted sweating and complained of not feeling well. Resident's vitals are 100.4 temperature, pulse 84, blood pressure 145/86, O2 saturation 98% on room air, respirations 18. Placed call to NP. She instructed this writer to give 500 ml of normal saline per IV. Fluids were given as ordered. On 04/16/2024 at 3:37 p.m., Treatment LVN B wrote, Weekly Skin Assessment: 04/16/2024 at 12:30 p.m. Transmission Based Precautions in place: osteomyelitis/wounds . Resident has received treatment for more than 14 days . The resident has experienced the following signs/symptoms of infection during this shift: Fever . 500 ml of normal saline per IV. Laboratory/Diagnostic: wound culture was done. Spoke to medical provider at: 04/15/2024 at 1:30 p.m. Record review of CR #1's laboratory orders, dated 04/16/2024 revealed, CR #1; Start Date: 04/16/2024; Order Choices: CBC with Auto Differential, Basic Metabolic Panel; Recurrence Schedule: Starting on Tuesday, 04/16/2024, repeat every 1 week, on Tuesday, until 05/21/2024 . Record review of CR #1's wound culture laboratory results dated [DATE] revealed, Collected: 04/15/2024 at 10:35 a.m. Received: 04/16/2024 at 3:44 p.m. Reported: 04/19/2024 at 11:55 a.m. Pathogens Detected: Acinetobacter Baumannii complex (Heavy Growth); Escherichia coli (Heavy Growth) . Record review of CR #1's laboratory results (collected at the facility) dated 04/16/2024 revealed, Collection date/Time: 04/16/2024 at 10:55 a.m. Received Date/Time: 04/16/2024 at 2:44 p.m. Reported Date/Time: 04/16/2024 at 3:57 p.m. CBC with differential - WBC: 10.6 (high; range: 4.0 - 10.0) . Record review of CR #1's Observation Details, created by LVN C, dated 04/17/2024 revealed CR #1 was transferred to an acute care hospital on 04/16/2024 at 7:44 p.m. The document read in part, This resident was transferred to an acute care hospital. She was having severe pain, low O2 saturation, and severe shivers. She requested to go to the hospital . No vitals have been recorded for this observation . There are no associated progress notes. Record review of CR #1's hospital Nursing Note, dated 03/29/2024 revealed, Date of Service: 03/29/2024 at 4:04 p.m. Gave report to LVN A at the facility about the patient current vitals and discharge information . Record review of CR #1's hospital After Visit Summary dated 03/29/2024 (provided by facility) revealed CR #1 was admitted to the acute care hospital on 03/23/2024 and discharged on [DATE]. The electronic orders listed each medication CR #1 was discharged from the hospital with. Some of the listed medications had hand-written notes beside them, indicating they were new medications from the hospital which CR #1 did not take at the facility before she was discharged to the hospital. The document read in part, Sodium Chloride 100 ml with Daptomycin 500 mg Solution 500 mg . Last dose taken: 03/29/2024 at 2:25 p.m. New. CBC/BMP Once (per) week was hand-written in the box next to the listed medication. Record review of CR #1's hospital discharge records sent to the facility from the hospital (provided by facility) dated 03/29/2024 revealed, . [AGE] year-old female with past medical history significant for gunshot wound complicated by quadriplegia complicated by sacral and lateral left buttock decubitus ulcers now complicated by polymicrobial (multiple bacteria) skin and soft tissue infections and multifocal (having more than one location) osteomyelitis of the pelvis . Will treat for 6 weeks with empiric Ceftriaxone and Daptomycin to minimize dosing complications and monitoring. Patient has historic venous access difficulty due to anatomic reasons and requires tunneled CVC catheter for IV antibiotic administration outpatient. She will need a SNF committed to turning her, aggressive wound care, and appropriate administration of IV antibiotics and lab monitoring as ordered . Overall plan will be . 2. 6 weeks IV abx and smoking cessation with monitoring of labs, ESR, CRP . quadriplegia secondary to gunshot wound, complicated by sepsis secondary to acute on chronic, multifocal polymicrobial osteomyelitis of the pelvis . [NAME] Instructions: . Obtain weekly CMP, CBC with differential and Creatine Kinase. Fax lab results to hospital: Attention Infectious Disease Doctor . Recommendations Summary: . When preparing for discharge, [NAME] instructions below: . Obtain weekly CMP, CBC with differential and Creatine Kinase. Fax lab results to hospital: Attention Infectious Disease Doctor . Labs: CBC with differential - Collection time: 03/28/2024 at 6:17 a.m. Result: WBC - 8.90 (normal range) . CBC with differential - Collection time: 03/29/2024 at 5:12 a.m. Result WBC - 7.95 (normal range) . admitted : 03/22/2024. discharge date : 03/29/2024 . Record review of CR #1's hospital records dated 04/24/2024 revealed, Date of Service: 04/16/2024 at 8:34 p.m. Emergency Department Note: . History of Present Illness: Resident is a [AGE] year-old female presents today with a chief complaint of weakness and wound (multiple sacral). Patient endorses that she has a fever taken yesterday temporarily of 100 degrees Fahrenheit. Has had nausea without emesis (vomiting) yesterday as well. Today has been having shaking chills . Physical Exam: Blood Pressure - 137/97 . Temperature - 99 degrees Fahrenheit . Skin: Skin is pale . Lab Results: CBC with differential - Abnormal. WBC - 12.32 (high) . Diagnosis/Impression: Chills, pain associated with wound, sepsis due to unspecified organism . Laboratory Results - . Erythrocyte sedimentation rate (monitored for the detection of inflammation in the body): 03/24/2024 - 127 (elevated); 04/16/2024 - 127 (elevated) . Record review of CR #1's physician's orders for March 2024 and April 2024 revealed the following order: * RN may access Central Line and perform blood draw as needed. Start Date: 03/29/2024. End Date: Open Ended. Further review of CR #1's physician's orders for March 2024 and April 2024 revealed no documentation of any routine laboratory orders. In an interview with Treatment LVN B on 04/24/2024 at 10:45 a.m., she stated CR #1 was not compliant with care and she liked to stay in her wheelchair all the time. She said if she was not able to get to CR #1's wounds right when she wanted them done, CR #1 would tell her to come back, or she said she would get them done on the night shift (the staff worked 12-hour shifts, 7:00 a.m. - 7:00 p.m. and 7:00 p.m. - 7:00 a.m.). She said sometimes, the night shift nurse did not get a chance to do CR #1's wound care because she stayed in her wheelchair until 2:00 a.m. She said CR #1 complained of pain in her joints, so sometimes, she did not want to be turned or bothered. She said she sometimes talked to CR #1 about staying in the same position all the time, but she said her joints felt better in that position. She said on 04/15/2024, CR #1 was in the bed and the wound doctor did a culture on her wounds himself because they were milky and opaque. She said the wound doctor cleaned the wounds out. She said CR #1's wounds did not have an odor, but CR #1 always complained they did have an odor. She said the wounds did not smell foul, but they smelled like it would if a female left a menstrual pad on too long, like old blood, but not an infected smell. She said CR #1 was already on two oral antibiotics at that time and the wound doctor said maybe those were not the right antibiotics for CR #1's wounds. She said CR #1 was on antibiotics for her wounds since she was admitted to the facility in September 2024. She said the wound culture results came back after CR #1 was already gone. She said the only weekly lab orders she knew about were the CBC and CMP the NP ordered for every Tuesday. She said she was the nurse who put the orders into the computer system for the weekly draws on 04/15/2024 (to be drawn on 04/16/2024). Treatment LVN B looked through CR #1's MAR and said she did not see the order for the weekly labs. She said she did not know why it was not there. She said on 04/15/2024, LVN G called CR #1's NP and said she was not feeling well. She said the NP asked LVN G to put in orders for a CBC and BMP. Observation and interview with CR #1 at a local acute care hospital on 04/24/2024 at 3:30 p.m. revealed she was alert and oriented. CR #1 was on contact isolation. CR #1's hands were contracted but she could move her arms enough to operate her cellular phone. She said her wounds had an odor at the facility, but they did not stink at the hospital. She said she knew she was supposed to get weekly labs done after she left the hospital in March (03/29/2024) but she never had any labs drawn until right before she left. In a telephone interview with the hospital's infectious disease doctor on 04/24/2024 at 7:10 p.m., he stated whenever he sent a patient out (discharge from the hospital to a SNF) for IV antibiotic therapy, he always put all the details in the patient's orders. He stated all instructions for CR #1's weekly lab orders were in his notes. He said he went to the hospital's case manager and asked her what they needed to send to the facility to make sure they got the instructions. He said the case manager told him she was sending everything to the facility. He said a hospital nurse always called the facility before discharge, so CR #1's orders should have been communicated very well. He said the type of antibiotics he prescribed for CR #1 could have caused Rhabdomyolysis (a breakdown of muscle tissue that releases a damaging protein into the blood), so CR #1's Creatine Kinase levels needed to be monitored for this. He said failure to monitor CR #1's blood chemistry could have resulted in renal failure, Rhabdomyolysis, sludge in the gallbladder, and increased liver enzymes, which were adverse effects of the antibiotics. He said CR #1 was oriented and she told him the facility did not check any of her labs. He said CR #1's pressure ulcers developed infections that went into her bone. He said he was surprised to see her back at the hospital on 04/16/2024 and her wounds were smelly with pus. He said CR #1's inflammatory markers (erythrocyte sedimentation rate), which tracked the bone infection were exactly the same when she returned to the hospital on 04/16/20524 as when she discharged on [DATE]. He said he expected at least a small decrease based on the amount of time she was on the antibiotics. In an interview with the DON on 04/25/2024 at 9:00 a.m., she said the facility did not usually get a resident's discharge summary from the hospital which documented everything that happened in the hospital. She said the hospital usually sent clinical updates and progress notes, which were very seldom completed by the actual doctor. She said she did not see any orders for labs on CR #1's discharge paperwork. She said the lab orders were not listed on the signed electronic orders. She said normally, the hospital called in report before the resident was discharged from the hospital. After review of the handwritten notes on the electronic hospital orders the facility received from the hospital, which read, New. CBC/BMP once (per) week, the DON said she assumed the handwritten notes were written by one of their (facility) nurses. She said she could not say the facility nurse who wrote the notes on the electronic orders was aware CR #1 was supposed to have weekly labs. She said she could not speak on what the nurse's handwriting meant or what she knew, but she would find out which nurse completed CR #1's admission on 03/29/2024. In a telephone interview with CR #1's physician (who was also the facility's medical director) on 04/25/2024 at 10:49 a.m., he stated he was familiar with CR #1 because she had very bad wounds and to his understanding, she was non-compliant with treatments. He said facility staff usually reconciled medications for residents who discharged from the hospital, but he did not reconcile CR #1's medications. He said the NP reconciled CR #1's medications and he was aware of CR #1's order for weekly labs (the labs ordered by the NP), either through conversations with the NP or reading her notes. He said he thought the labs were supposed to be done because he was concerned about the infection getting worse. He said part of it was to see if the infection got better or if it was the same or worse. He said it was usual protocol for them (him or his NP's) to request weekly labs on all residents on IV antibiotics. He said he was not aware the weekly labs were not being done. He said he assumed the labs were being done but never saw any results. He said some infectious disease doctors do not care to see the lab results, but they request the labs. In a telephone interview with the NP on 04/25/2024 at 11:00 a.m., she stated a facility nurse (she could not recall which nurse) reconciled CR #1's medications with her on 03/29/2024. The NP said she ordered weekly labs (CBC and BMP) for CR #1 on 03/29/2024 based on the antibiotics she was prescribed at the hospital. She said the weekly labs she ordered would have showed her if CR #1's infection was getting better and her kidney function. The NP said she asked for CR #1's lab results each time she visited the facility (she visited weekly), but she thought the facility nurses said CR #1 refused the labs. The NP said she did not think it was unusual because refusals were not uncommon for CR #1. She said she did not recall the nurse telling her that the hospital doctor requested weekly labs. She said it was normal to order weekly labs for residents on IV antibiotics like the ones CR #1 was prescribed, to make sure the kidneys functioned properly and to track the infection. She said she requested weekly labs on 03/29/2024 and on 04/15/2024 or 04/16/2024. In an interview with LVN A on 04/27/2024 at 11:45 a.m., she stated she normally worked the 7:00 a.m. - 7:00 p.m. shift. She said CR #1 was admitted to the hospital on 03/22/2024 for infection symptoms. She said she was on shift when CR #1 returned to the facility on [DATE]. LVN A said she did not receive report from the hospital on 03/29/2024. She said CR #1 returned to the facility an hour before her shift ended. She said nobody from the hospital called her ahead of CR #1's return. She said CR #1 just showed up at the facility and she (LVN A) did not talk to anybody from the hospital at all that day. She said if the hospital had her name listed as the person, they gave report to, then it had been a while since that day, and she could not recall if she got report or not. She stated report sheets were handwritten and if she did not have a form, she wrote on a blank sheet of paper. She said the report sheet should go into the resident's admission packet and sent to medical records. She said eventually the report sheet would be scanned and put in the computer system for that resident. She said she did not recall if she did or did not do a report sheet for CR #1. She said she could have done a sheet for CR #1, but she did not recall. She said she recalled calling the NP to reconcile CR #1's medication. She said she got CR #1's discharge medications (from the hospital) from the packet the resident brought with her from the hospital. She said when she reconciled medications for readmitting residents from the hospital, she let the doctors know if anything was new, and they either approve the new medication or discontinue it. She said she also asked the doctors if they wanted to continue the medications the resident was on before they left the facility. She said she usually tried to read every page of the discharge packet sent from the hospital. She said she usually looked for the diagnosis to determine why the resident went to the hospital and if they started anything new at the hospital. She said usually, recurrent orders for labs were not on the electronic orders from the hospital. She said when she called the doctor to reconcile medications, they would usually add recurrent orders then. She said it was unusual for the hospital doctors to order recurring labs. She said she called the NP to reconcile CR #1's medication when she returned from the hospital on 03/29/2024. She said she informed the NP that CR #1 had two new IV antibiotics and the NP ordered a weekly CBC and BMP. She said she thought she wrote the requested labs on a piece of paper. She said after she got off the phone with the NP, she started reconciling the medications and entered the new medication orders into the computer system. She said she wrote the requested labs on the hospital discharge paperwork and on a little piece of paper. She said the little piece of paper probably got lost in the shuffle (possibly lost in a stack of paperwork). She said she forgot to enter the NP's requested orders for weekly labs. She said she was the admitting nurse, and it was her responsibility to enter the orders into the computer system. She said she guessed the requested labs were to determine if CR #1 still had infection, or something like that because the NP really did not say why she wanted the orders. She said it was important to get the labs done because the labs told you everything going on in the body and if something was off, it would tell you. She said it was easy to get distracted while admitting residents because she still had residents asking for PRN medications and other things. In an interview with an RN at a local acute care hospital on 04/29/2024 at 10:30 a.m., she stated she was the hospital nurse who called to give report to the facility when CR #1 was discharged on [DATE]. She said she wrote the nurse's name on the discharge paperwork (LVN A), and she specifically gave thorough instructions regarding CR #1's wounds. She said she could not recall if they talked about the labs the infectious disease doctor requested, but she knew about the labs because the infectious disease doctor always requested labs in CR #1's circumstances. In an interview with the DON on 04/30/2024 at 11:45 a.m., she stated she was the facility's interim DON and had only been working at the facility for a few days. She said she did not know if the facility's previous DON or the ADON (the facility recently hired a new ADON who had not started working at the facility yet) completed quarterly audits of physician's orders as referenced in the facility's Laboratory Tracking System policy (see below). She stated she did not find any documentation, as of 04/30/2024 to verify the audits were being done. She said it was important to carry out all physician's orders for the safety and well being of the residents. She said the nurses were supposed to read each page of the hospital discharge record if it was available. In an interview with the Administrator on 04/30/2024 at 1:19 p.m., he stated it was important to make sure physician's orders were carried out because following orders was how they cared for their residents. Record review of the facility's undated policy titled, Laboratory, Radiology, and Diagnostic Testing Services revealed, Policy Statement: This facility will provide the appropriate diagnostic services (laboratory and radiology) required to maintain the overall health of its residents and in accordance with State and Federal guidelines. Policy Interpretation and Implementation: 1. The facility must provide or obtain laboratory, radiology, and other diagnostic services to meet the needs of its residents. 2. The facility is responsible for the timeliness of the services. 3. The facility will maintain a schedule of diagnostic tests (laboratory and radiology) in accordance with the physician's orders. No diagnostic tests will be performed without specific physician, physician assistant, nurse practitioner or clinical nurse specialist orders in accordance with State law to include scope of practice laws . Record review of the facility's policy titled, Medication Orders revised November 2014 revealed, Purpose: The purpose of this procedure is to establish uniform guidelines in the receiving and recording of medication order. Supervision by a Physician: . 2. A current list of orders must be maintained in the clinical record of each resident. 3. Orders must be written and maintained in chronological order . 5. Intravenous Orders - When recording orders for IV solutions, specify the type of solution, rate of flow and volume to be infused. 6. Treatment Orders - When recording treatment orders, specify the treatment, frequency, and duration of the treatment . This was determined to be an Immediate Jeopardy (IJ) on 04/25/2024 at 3:20 p.m. The Administrator and the DON were notified. The Administrator was provided with the IJ template on 04/25/2024 at 3:20 p.m. The following Plan of Removal submitted by the facility was accepted on 04/25/2024 at 8:56 p.m.: PLAN OF REMOVAL: Laboratory Services, F-773 Name of Facility Date: 4/25/2024 The facility failed to obtain laboratory services as ordered by a physician in accordance with the State law, including scope of practice laws. The facility failed to obtain weekly laboratory services (CMP, CBC, and CPK) as ordered by a hospital infectious disease doctor for CR #1, who was diagnosed with sepsis secondary to acute on chronic multifocal polymicrobial osteomyelitis of the pelvis, when she was discharged from an acute care hospital on 03/29/2024. The facility failed to obtain weekly laboratory services (CMP and CBA) as ordered by CR #1's NP when LVN A reconciled medication orders on 03/29/2024. Immediate Action: Action: CR#1 is currently in the hospital and is not returning to the facility Person(s) Responsible: Charge Nurse Date/Time: 4/16/2024 at 7:44 p.m. Facilities Plan to Ensure Compliance Quickly: Action: Lab audit performed facility wide to ensure no other labs were missed. If any other labs are identified the physician will be notified and the facility will follow orders. Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, and/or Designee Date/Time: 4/25/2024 by 10:00 p.m. Action: Residents who have been admitted /readmitted in the past 30 days will have their admission/readmission orders reviewed to ensure lab orders, if present, were transcribed appropriately into the orders, we have the lab results, the MD has been notified, and new orders, if any, have been followed. Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, and/or Designee Date/Time: 4/25/2024 by 10:00 p.m. Action: Laboratory, Radiology, and Diagnostic Testing Service Policy reviewed by Director of Clinical Operations and no changes are identified as needed at this time. Person(s) Responsible: Director of Clinical Operations Date/Time: 4/25/2024 by 10:00 p.m. Action: Director of Nursing and Assistant Director of Nursing have been educated regarding reviewing admission/readmission paperwork, transcribing orders (such as labs), lab communication to the MD and/or their extender and following physician orders by the Director of Clinical Operations. Charge Nurses will be educated over reviewing admission/readmission paperwork, transcribing orders (such as labs), lab communication to the MD and/or their extender and following physici [TRUNCATED]

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

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

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

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

Based on observation, interview, and record review, the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 1 of 5 residents (CR#4) reviewed for incontinent care in that: -The facility failed to document treatment orders and collect the urine sample for CR #4 for three days after order was given on [DATE] after experiencing altered mental status, the resident was transferred to another facility on [DATE], and confirmed to have an UTI. This failure could place residents with urinary catheters at risk for discomfort, trauma, and possibly urinary tract infections. The findings included: Record review of CR #4's undated face sheet revealed she was a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis that included orthopedic aftercare and left leg femoral fracture. Her discharge date was [DATE] to be transferred to another facility. Record review of CR#4's Admission Observation Report dated [DATE] and completed by LVN D, indicated CR#4 admitted with indwelling catheter. Record review of CR #4's physician order summary report dated [DATE]-[DATE] revealed that there were no orders entered addressing residents' treatment for a catheter. Record review of CR #4's MAR dated from [DATE] revealed no information addressing residents' treatment for a catheter. Record review of CR #4's baseline care plan dated [DATE] and completed by the CCM did not address focus, goals, or intervention for an indwelling catheter. Record review of CR #4's MDS assessment dated [DATE] revealed CR #4 was cognitively intact with a BIMS score of 12 in section C. She was triggered for an indwelling catheter in section H for Bladder and Bowel. Record review of urinary intake/out worksheet for CR#4 revealed that staff tracked output each shift from [DATE]-[DATE]. Record review of progress note dated [DATE] completed by NP read in part, .Chief Complaint/Nature of Present Problem: SNF/ f/u. Reported that patient has been hallucinating at times. UA is still pending. Patient is pending transfer. Due to recent mental status change we will go ahead and check patient's ammonia level and UA C&S. If negative will consult psychiatry Record review of CR#4's discharge summary report dated [DATE] did not indicate that there were any outstanding labs for CR#4 to test for UTI. Record review of CR#4's laboratory order history report undated indicated the UA ordered [DATE] had a status of collection pending, no results. Record review of CR #4's medical records from a local hospital dated [DATE] revealed that CR#4 was admitted to the hospital on [DATE] and discharged on [DATE], while admitted CR#4 was confirm with a UTI. Records revealed that CR#4 expired while at the hospital on [DATE] with a preliminary cause of death of acute hypoxemic respirator failure. In an interview and observation on [DATE] at 9:08am with LVN A, she said that she has worked at the facility since [DATE], and she usually works the 6am-6pm shift. She said that the admitting nurse is responsible for completing the admission observation, admission progress notes, entering the physician orders, and baseline care plan for newly admitted residents. She said that she had not completed a baseline care plan since she started her position, and they are completed by the ADON. She said that the ADON or CCM check to make sure the admission process for newly admitted residents were completed accurately. She said that CR#4 was admitted with a catheter, it was removed, but she could not remember the date of removal. She said that she completed catheter care for CR#4, and she documented the tasks in the EMR. She said that on [DATE] CR#4 started hallucinating, she notified the NP, the NP ordered a UA to check for an UTI, and she sent the order to the lab. She did she did not collect the sample, because the lab only picked up on Tuesday and Thursday, with the exception of stat orders, and the NP did not order the UA stat. She said that she told LVN B to collect the sample on the 6pm-6am shift, so that the sampled could be picked up on [DATE], and she entered a progress note. She said that when she started her shift on [DATE] LVN B told her that she collected the sample. She said that CR#4 discharged on [DATE]. She reviewed the physician order summary report, baseline care plan, and MAR for CR#4. She said that the documents did not address the catheter for CR#4. She said that based on the progress notes the admitting nurse was LVN D, and there were no orders entered at the time of admission to address the catheter for CR#4. She said that she could not remember what orders were being used when providing catheter care. She stated that without the orders entered there was no place to capture catheter care on the MAR, and she had no documentation that she completed the tasks. She reviewed the progress notes and said that she did not enter a progress note that LVN B would [NAME] CR#4 UA. She reviewed the laboratory order history report, and said the labs were still pending. She stated that the risks to CR#4 not receiving the UA was an untreated UTI. She stated that the risk of not entering physician orders and completing the baseline care plan upon admission is not receiving appropriate care. In a phone interview on [DATE] at 9:44am with the Relative, she said that CR#4 admitted to the facility with a catheter, she expressed concern with the tube of the catheter being red, and the NP just gave an order to remove the catheter. She said that after the catheter was removed the CR#4 start hallucinating, and the NP order labs to see if CR#4 had a UTI on [DATE]. She said that staff never took the sample, and CR#4 was discharge with the sample never being taken on [DATE]. She said that CR#4 was taken to a new facility on [DATE], the sample was collected, diagnosed with an UTI, and started on antibiotics. She said that CR#4 was sent to the hospital on ,d+[DATE]//2023 after she fainted and had respiratory problems. She said that while at in the emergency room CR#4 was eating, choked, was revived, placed on a ventilator, but continued to decline. She said that CR#4 died while in the hospital, and hospital was looking to see if the resident was septic. She said that the facility delayed getting the urine sample for CR#4, and that caused a delay in treatment for the UTI. In an interview on [DATE] at 10:38pm with the CRN, she said that the admitting nurse is responsible for entering the physician orders and baseline care plan for newly admitted residents. She said upon her review, LVN D did not entering physician orders for catheter care for CR#4, so catheter care was not included on the MAR for nursing staff to chart that care was provided. She said that the facility has a standard ordered for catheter care that should have been entered upon admission. She said if there was no documentation enter that the tasks were completed. She said that the baseline care plan was completed on [DATE] by the CCM, but catheter care was not included. She said that the IDT should meet to ensure that the admission process is completed with accuracy for newly admitted residents, but she was not sure if the IDT meet met regarding CR#4. She said that the IDT should consist of the CCM, DON, ADON, and DOR. She said that the DON is the oversite oversight and should ensure that all admission tasks are completed accurately. She said that LVN B should have ensured that the urine sample was collected for CR#4 on [DATE], LVN B disclosed that she failed to collect the sample because the resident did not have urine output on the shift and based on her review LVN B failed to document the efforts to collect the sample. She was not sure if LVN B contacted the doctor of CR#4, and she was not aware that the sample had not been collected until SSA requested documentation. She stated that the risk to residents of not having systems in place could cause residents to not receive appropriate care, delay in diagnosis, delay in treatment, and infection to include UTI. In an interview on [DATE] at 11:01am with the CCM, she said that she is an LVN. She said that she has worked at the facility since [DATE], she completes all MDS assessments for the facility. She said that the admitting nurse is responsible for completing the admission observation, admission progress notes, entering the physician orders, and baseline care plan for newly admitted residents. She said the ADON checks for accuracy of the admission process. She stated that the IDT consists of the DON, ADON, CCM, DOR, and SW, and the IDT meets Monday-Friday, and review admission process for newly admitted residents. She said that she could not remember if the IDT meet regarding CR#4. She said that she helps the ADON audit baseline care plans, and the ADON and she will complete the care plan if had not been completed within 48 hours. She said that CR#4 admitted to the facility with catheter. She reviewed the baseline care plan, physician orders summary report, and MAR for CR#4. She said that the documents did not address the catheter for CR#4 from admission, and it was missed by everyone. She said that it should have been caught by anyone that needed to chart catheter for the resident. She stated that the risk of not having the systems in place could cause a resident not to receive appropriate care, and with out appropriate catheter a resident could get an infection. In an interview on [DATE] at 11:49am with the DON, she said that the admitting nurse is responsible for completing the admission observation, admission progress notes, entering the physician orders, and baseline care plan for newly admitted residents. She said that the ADON is the oversite oversight to ensure that admitting nurse completed the admission process with accuracy. She said that the CCM is the oversite for ensure that baseline care plans are completed timely and accurately. She said that she is the oversite for the ADON and CCM. She stated that she completed an audit twice each week to ensure that the admitting nursing and ADON have completed the admission process accurately, she could not remember if she audited the records for CR#4, and she did not keep a record of her audits. She stated that IDT meets to discuss newly admitted residents a few days after admission. She stated that she could not recall if IDT reviewed the admission process CR#4. She said that if physician orders are not entered the tasks will not be triggered for documentation on the MAR. She stated that CR#4 did not have admission orders for a catheter, and it was not care planned. She said that LVN D was the admitting nurse and she was terminated on [DATE] after she did not show for two shifts that week. She said that LVN B attempt to collect a urine sample for CR#4 on [DATE], the resident did not have urine output, and LVN B failed to document efforts to collect the sample. She said that she was not sure if LVN B called the physician to inform that the sample had not been collected. She said that LVN B should have notified the physician as the physician could have given a new order to collect the sample by an alternative method, since the resident did not have output. She was not aware that the sample had not been collected until SSA requested documentation. She stated that the risk to the resident of not having systems in place is not receiving appropriate care a delay in diagnosis of the UTI, resident could have had delay in treatment, and that could have resulted in hospitalization . In a phone interview on [DATE] at 12:30pm with LVN B, she said that she has worked at the facility since September of 2022, and she works the 6pm-6am shift. She said that she remembered CR#4. She said that during shift change on [DATE] LVN A told her that the doctor ordered a urine sample for labs for the resident. She said she did not collect the sample because CR#4 did not have urine output during the shift. She said that she could not remember if she called the physician. She said she would like to be able to review her documentation before she answered anymore questions, and she would be at the facility for a shift on [DATE] at 6pm. In an interview on [DATE] at 12:57pm with the ADON, she said that she is a LVN, and she has worked at the facility for 16 months. She said that the admitting nurse is responsible for completing the admission observation, admission progress notes, entering the physician orders, and baseline care plan for newly admitted residents. She stated that she audits the admission process the next business day for accuracy and completion. She said that CR#4 was admitted on [DATE] with a catheter. She said that she did not work on [DATE]-[DATE], and she worked the floor for the remaining days of the week. She said that the DON is the oversite, and ifs is not able to audit the DON is to complete the task. She said that she reviewed physician orders for CR#4, the resident did not have an order for catheter care, and that caused catheter care not to appear on the MAR for documentation. She said that she was aware that CR#4 was to have a UA completed to determine if she had a UTI at the time of her discharge on [DATE]. She stated that she completed the discharge for the resident, and at the time of discharge the relative present asked if the sample had been collected. She stated that when she told the relative that she would need to check, they declined to wait, and she did not follow up. She stated that the risk of not having the system in place is that a resident may not receive appropriate care and would be at risk for an UTI. She said that the IDT should meet to ensure that the admission process is completed with accuracy for newly admitted residents, but she was not sure if the IDT meet regarding CR#4. In an interview on [DATE] at 5:16pm with the Admin #2, he said that the DON is clinical oversite, and she should inform him of any clinical concerns. He said that the admitting nurse should enter orders upon admission. He said that he had not had a chance to look of admitting process since starting his position on [DATE]. He said that he was aware that CR#4 did not have a UA collected as ordered by the physician, as he spoke with relative after the resident discharged who inquired about the result. He said that he had a nurse whose name he could not remember to lock up the result, and he was told that the sample was not collected, and he relayed the information to the relative. He said that it would be concerning if a resident did not have physician orders, care plan, or MAR, or progress notes in place for catheter. He said that if a tasks is not documented it did not happen. He said that the risk of not having the system in place could cause a resident to not to receive proper care that could cause an infection or UTI. In a follow-up interview and observation on [DATE] at 5:40 pm with LVN B, she said that the admitting nurse is responsible for completing the admission observation, admission progress notes, entering the physician orders, and baseline care plan for newly admitted residents. She said that baseline care plans are completed by the ADON. She said that the ADON or CCM check to make sure the admission process for newly admitted residents were completed accurately. She said that CR#4 was admitted with a catheter, it was removed, she could not remember the date of removal, or the staff that removed it. She said that she completed catheter care for CR#4, and she documented the tasks in the EMR. She said that on [DATE] CR#4 LVN A told her that the NP ordered a UA to test for a UTI and asked her to collect the sample. She said that the lab collects samples on Tuesday and Thursday unless the orders are stat. She said that she could not remember if she collected the sample before the resident discharged , or if she notified the physician. She reviewed the physician order summary report, baseline care plan, progress notes, lab summary report, and MAR for CR#4. She said that she could not remember what orders were being used when providing catheter care. She said that the based on the documents the UA sample was not collect and there was no documentation that CR#4 received catheter care. She said that the admitting nurse LVND did not enter the orders for catheter and the baseline care plan did not address catheter care for CR#4. She said that the risk to CR#4 was having an untreated infection when she discharged charge, and without having orders, MAR, and care plan to address catheter care the resident could not have received appropriate care while the catheter was in place. In an interview on [DATE] at 10:41am with LVN C, she said that she has worked at the facility since [DATE], and she works the 6am-6pm shift. She said that the admitting nurse is responsible for completing the admission observation, admission progress notes, entering the physician orders, and baseline care plan for newly admitted residents. She said that baseline care plans are completed by the ADON. She said that the ADON or CCM check to make sure the admission process for newly admitted residents were completed accurately. She said that if a resident is admitted with a catheter the admitting nurse should entering the standard order for catheter, and that would trigger the care on the MAR. She said that she provided care for CR#4 while she was admitted to the facility, and the resident admitted with a catheter. She said that she provided catheter care to resident. She said that the NP gave an order to remove the catheter on approximately [DATE] in the 11:00am hour, and she removed the catheter. She said that the NP ordered that urine output be monitored for ,d+[DATE] hours after the catheter was removed and be notified if the resident had no urine output. She stated that when she removed the catheter CR#4 had urine output of 400cc in the catheter bag, and the resident voided her bladder in her brief sometime in the afternoon. She stated that she entered a progress note on the date that she removed the catheter, and she would have documented catheter care on the MAR in the EMR. She reviewed the physician order summary report, baseline care plan, progress notes, and MAR for CR#4. She said that the admitting nursing, LVN D, did not enter the standard order upon admission so catheter care for CR#4 was not on the MAR, and did not complete the baseline care plan time, and when it was competed it did not include catheter care. She said that she could not remember what orders were being used when providing catheter care. She said that all staff that provided catheter should have saw the error when it was time to chart and corrected the error. She said that the risk of not having physician orders, baseline care plan, and MAR in place is that a CR#4 may have not received care to the catheter, and without care the resident could have developed an UTI. She said that based on the progress notes there was concern that CR#4 had signs of UTI and the NP requested urine sample collected. She said that if the sample was not collected and the NP was not notified the resident was at risk of being discharged with an untreated infection that could caused the resident to be hospitalized . In an interview on [DATE] at 1:42pm with LVN D, she said that she only worked at the facility for a short period of time, and her last day would have been the week of [DATE]. She said that the admitting nurse is usually responsible for entering physician orders for newly admitted residents. She said that she could not remember if she provided care for CR#4, and she did not feel comfortable with answering any more questions. In a phone interview on [DATE] at 2:00pm with NP, he said that he was familiar with CR#4, and she admitted to the facility with a catheter from a local hospital after having a stroke and fall prior to admission. He said that he was not sure of what orders CR#4 had for catheter care upon admission, but the facility uses a standard order unless hospital discharge summary provided an order. He said that he gave an order for CR#4 to have the catheter removed on [DATE]. He said that staff notified him that resident was having behaviors on [DATE], and he ordered a UA as he wanted to confirm if the resident had a UTI before referring for a psychiatry consult. He said that the lab usually because of samples on Tuesday and Thursday, and he would have expected that the sample would have been collected and sent to the lab on [DATE]. He said that when he saw the resident on [DATE] the facility had not collected the sample. He said that he was not notified that there were problems with completing the lab after the order was given. He said that if the staff was having problems with collecting the sample, he should have been notified, and he could have given an order to collect the urine sample by straight cath (used for quick drainage of the bladder). He said that CR#4 was transferred on [DATE] to another facility. He said that since the physician he practiced under services the facility CR#4 transferred to, he updated his progress notes, and notified the receiving facility to collect the sample upon admission. He said that he is not the nurse practitioner for the facility that CR#4 transferred to, but he made the nurse practitioner aware of his concerns for UTI. He said resident labs confirmed a UTI, but he was not sure what treatment was given. Record review of the facility policy and procedure entitled Catheter Care, Urinary dated 2018 read in part, .Purpose: The purpose of this procedure is to prevent catheter-associated urinary tract infections. Preparation: 1. Review the residents care plan to assess for any special needs of the resident. Input/Output: 2. Maintain an accurate record of the resident's daily output, per facility policy and procedure. Documentation: The following information may be recorded in the resident's medical record: 1. The date and time that catheter care was given. 2. The name and title of the individual(s) given the catheter care. 3. All assessment data obtained when giving catheter care

Based on interview and record review the facility failed to immediately consult with the resident's physician of a significant change in the resident's physical, mental, or psychosocial status, that was a deterioration in health, mental, or psychosocial status in either a life threatening condition or clinical complications for 2 of 12 residents (CR#1, Resident #2) reviewed for resident rights. The facility failed to notify the physician was consulted when CR#1 and Resident #2 were bathed in bleach by CNA A. CR #1 was reported to have difficulty breathing, was later found and Resident. An Immediate Jeopardy (IJ) was identified on [DATE] at 1:30 PM. While the IJ was removed on [DATE] at 8:00 AM, the facility remained out of compliance at a scope of isolated and severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed residents at risk for delays in life saving treatments and care which could result in clinical complications and/or death. Findings Included: In an interview on [DATE] at 1:00 PM, the Physician stated CR#1 potentially died from bleach intoxication. She said once she got to the facility today ([DATE]), she was told by several staff that CR#1 was given a bath in bleach. CR#1 was given a bath on [DATE] around 10 AM. She was told it was a strong pervasive bleach smell in the room and was reported that throughout the day CR#1 declined. A staff member witnessed CR#1 gasping for air and he was very upset. CR#1 was assessed by one of the nursing staff, and was found unresponsive, CPR was initiated, the resident was sent to the hospital and he passed away. The staff was upset and afraid of losing their jobs but was concerned because the Administrator was not addressing the issue, and felt the interim DON and Administrator covered up the incident. The physician said it was also reported to her hat Resident #2 was bathed in bleach also on [DATE]. She had not got a chance to assess Resident #2 yet. She stated from what was reported Resident #2 was assessed by nursing staff as well. She was not called or notified of either incident. She said if she was told that the residents were bathed in bleach, she would have ordered vital signs every two hours, stat labs, increased monitoring based on the resident's vitals and condition and they would have been sent out to the hospital. She said this could have contributed or caused CR#1's demise. The DON was interim and just left yesterday. She had not determined a cause of death and had not certified the death certificate. 1. Record review of CR#1's face sheet revealed CR#1 was a [AGE] year-old male that was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . CR#1 was discharged on [DATE]. Record review of CR#1's MDS dated [DATE] revealed CR#1 did not have a BIMS. CR#1 required extensive assistance with two-person assistance for personal hygiene. CR#1 required physical help in part of bathing activity with two-person assistance. Record review of CR#1's Care Plan dated [DATE] revealed CR#1 required total dependence with bathing with one-person assistance. Staff are to set up, assist, give shower, shave, oral, hair, nail care per schedule and PRN. Record review of [CR#1] Progress Notes revealed .Nursing [RN A] RN [DATE] 01:31 AM Transfer to Hospital Progress Note (Nursing) Received Order from Medical Provider to Transfer Resident to: Hospital ER (Name of Hospital) Transfer Order Obtained from: Nurse Practitioner (Name) [NP name] Transfer Order Entered in Resident Record.: Yes Primary Reason for Transfer: Unresponsive Responsible Representative Notified of Transfer: Yes (Name) [RP Name] Time Responsible Representative Notified of Transfer: [DATE] 01:24 AM Transportation notified of Transport: EMS (911) called Report Called to Hospital, spoke with: Name: na, Department: na, Phone Number: na CPR (Check all that apply): CPR Initiated before transport / EMS arrival, AED Used, Time CPR Initiated (Time) 0110, EMS Took Over CPR upon arrival, Emergency Cart / AED Arrived at Site of CODE, Oxygen Applied (liters) 2 Documentation Sent to Hospital (Check all that apply): Face Sheet Resident Condition at time of Transfer: Unresponsive Resident left facility at: [DATE] Disposition of Medication: Medications Remain Secured on Medication Cart. Disposition of Belongings: Personal Belongings Remain at Facility. Bed Hold Notification: Resident / Responsible Representative will be Notified of Bed Hold Notification Information within 24 hours of Transfer Record review of CR#1's hospital records dated [DATE] revealed Chief Complaint Cardiac Arrest, found down Patient expired at 0152, informed patients' guardian .Clinical Impression Primary Impression: Cardiopulmonary arrest . In an interview on [DATE] at 1:42 PM the Physician stated she was sending Resident #2 to the hospital because she was shaking, and cold. She was hyper salivating, her respiratory rate was up, her skin was flush. She could not rely on the staff at the facility. She did not want to chance it. A family member also complained Resident #2 was shaking and could not get warm. She was looking for a nurse but could not find one, she did not want to wait another minute, especially knowing she had this exposure to bleach. 2. Record review of Resident #2's face sheet revealed Resident #2 was an [AGE] year old female that was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #2 was discharged on [DATE]. Record review of Resident #2's MDS dated [DATE] revealed she did not have a BIMS. Resident #2 required extensive assistance with two-person assistance with personal hygiene. Resident #2 required total dependence with bathing. Resident #2 was at risk for pressure ulcers, she had no pressure ulcers or skin issues documented. Record review of Resident #2's Physician Orders dated [DATE] revealed .Cleanse wound to right lower buttock with normal saline, apply Santyl and calcium alginate and skin prep to peri wound and apply gauze island w/BDR dressing Q Day start date [DATE] . Record review of Resident #2's Care Plan dated [DATE] revealed Resident #2 required extensive assistance with bathing with one-person assistance. Staff were to set up, assist, give-shower, shave, oral care, hair, nail care per schedule and PRN. Record review of Resident #2's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . There was a verbal report to me that this patient may have been bathed during the bath with water with bleach in it. State is present at the building at this time, incident under investigation. Family member, [person], at the bedside, states patient has been sweaty, less responsive, appears to be flushed. He stated that patient looks like she is warm but appears to be cold, has been shaking a lot. Patient had a lower blood pressure documented yesterday, blood pressure reported as normal today. Due to dementia, I am unable to obtain history from the patient. Patient will be sent to the ER due to concern for progressive respiratory symptoms and changes from baseline . Note written by Physician. Observation on [DATE] at 1:28 PM, revealed Resident #2 was lying in bed, resident shaking, crying, labored breathing, saliva coming from her mouth. Resident #2 was non-verbal. In an interview on [DATE] at 3:55 PM, RN B stated Resident #2 had a pressure sore. She asked the aides to contact her when they finished the bath so she could treat the wound. On [DATE] CNA A yelled down the hallway she was finished bathing Resident #2 and when she got to the room, she could smell the bleach in the hallway, it was very strong. When she opened the door, the odor was strong in the room. The wound was bubbling, CNA A then stated the wound was cleaned with soap and water very well. CNA A told her she used the bleach to clean the room. This incident occurred around 11:15 AM. CNA B made an off-hand comment about bleach, but she was not sure what was going on that day. Later she figured out what was going on. The next day CNA B told her about the bleach and that CNA A put bleach in Resident #2's bath water. She was not sure who assessed Resident #2. She asked the interim DON what happened, and she told her she was not supposed to know about the incident and asked her who reported this to her. The interim DON was aware and was supposed to do an assessment and contact the physician. Resident #2 looked bug-eyed and was moaning during the wound treatment, she had pain in her wound. She cleaned and packed the wound. Resident #2 was alert. She was not sure about CR#1 she was told he had some trouble breathing and he had been moved to another side of the facility but that was it. In an interview on [DATE] at 3:39 PM, the Interim DON, stated on [DATE] it was reported to her by Housekeeper B that CNA A was washing CR#1 with bleach and water. CNA A reported she was just cleaning out the bed pan with the bleach cleanser. The resident did not have any issue or trouble breathing. None of the staff reported they actually saw her put bleach in CR#1's bath water. She assessed CR#1 and he was fine. She fed CR#1 in the dining room due to staffing challenges that day. She reported this to the Administrator, and he was still investigating. She said did not document the assessment and she was sorry; she said she was doing a number of things that day. The physician was not notified. The Interim DON said staff were saying two different things and there was confusion about what happened between CR#1 and Resident #2. She was not sure what happened. There was a lot going on that day and a lot of confusion. The staff are not supposed to be using bleach on the floor at the nursing home. She was not sure where CNA A got the bleach from. In an interview on [DATE] at 5:13 PM, the interim ADON stated she found out the following day about the bleach bath incident with CR#1. CNA A was then placed on suspension and taken off the schedule until further notice. There had been a lack of communication between her and the interim DON due to turmoil at the facility. She had not seen CR#1 the day the incident happened. She knew he passed during the night shift on [DATE]. She said the interim DON exited the facility yesterday, there was a lot of things going on with her which was an issue. She said she was not aware of the incident with Resident #2. The interim ADON said the interim DON was notified and was supposed to do an assessment on CR#1 and Resident #2 and the physician should have been notified. The interim DON would refuse to work the floor. The Administrator was in a tough position, the interim DON could not complete a task, she had short focus, she was the cause of a lot of issues at the facility. In an interview on [DATE] at 5:30 PM the Administrator stated on [DATE] he was notified by the interim DON that CNA A bathed CR#1 with bleach. CNA A was placed on suspension. He started interviewing staff. The interviews did not produce anything. The situation had been a confusing mess. CNA A said she did not bathe CR#1 in bleach, and he was not sure if he believed her. He was made aware of this incident Wednesday ([DATE]) afternoon. Supposedly this occurred on Wednesday morning. He did not have an incident report for the incident. He was not aware of the allegation that Resident #2 was given a bed bath in bleach. The interim DON said she did an assessment, but she did not document the assessment. He was not sure if she contacted the physician. The assessment should have been documented and physician notified. The interim DON was a loose cannon and caused a lot of turmoil in the facility. He did not report this to the state agency because it was discussed at the corporate level and since it was just a bath in bleach, they were going to take any disciplinary action. This was not considered abuse. Staff are not supposed to use bleach to clean in the facility. The bleach was taken from CNA A and the staff were informed that they were to use sanitation wipes and not bleach to clean. The nurse aide reported she got the bleach from kitchen, but the kitchen denied that. CNA A had been a troublemaker at the facility, he was not sure who she got the bleach from. In an interview on [DATE] at 12:13 PM, the ADON stated she was not privy to the incident regarding the bleach with CR#1. CR#1 passed away that same night. She had not seen CR#1 the day of the incident. She saw Resident #2 the next day, she assessed the resident because someone came to her and asked her to assess her due to possible bleach exposure the previous day. She checked her all her vitals and they were within normal limits. She assessed Resident #2 on Thursday [DATE]. She did not document the assessment of Resident #2. She just did the assessment due to the mention of the exposure. She had only been at the facility for three weeks. She overhead talk about the incident but the Administrator had not shared any information with her. If it was reported to her that a resident was exposed to bleach, she would have completed an assessment, reported this to the physician and notify the Administrator who was the abuse coordinator. In an interview on [DATE] at 2:12 PM, the DON stated it was important for staff to assess residents and report changes of condition so the physician can follow up on the issues which could cause death. This was a resident's rights issue and could lead to neglect. The Administrator needed to be notified so an investigation could be completed. Record review of the facility Abuse Prevention Program dated ,d+[DATE] revealed 1. The Administrator is responsible for the overall coordination and implementation of our Center's abuse prevention program policies and procedures Identification Assessment and Recognition of Abuse: 1. The nurse will assess the individual and document related findings 2. The nurse will report findings to the physician. As needed, the physical will assess the resident/patient to verify or clarify such findings, especially if the cause or source of the problem is unclear. Investigation Role of the Administrator: 1. The Administrator has the overall responsibility for the coordination and implementation of our Center's abuse prevention program policies and procedures. The Administrator is the Abuse Prevention Coordinator. In absence of the Administrator the Director of Nursing will serve in this capacity. 6. The Administrator will suspend immediately any employee who has been accused of resident abuse, pending the outcome of the investigation. 7. The Administrator will ensure that any further potential abuse, neglect exploitation or mistreatment is prevented. Reporting 1. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the Center Administrator, or his/her designee, to the following person or agency's required: a. The State licensing/certification agency responsible for surveying/licensing Center 2. An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than: 3. Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury; or Twenty-four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury . Review of Clorox Regular-Bleach1 JW [DATE] at https://www.osha.gov/sites/default/files/,d+[DATE]/Sample%20SDS%20Handout.pdf accessed [DATE] indicated Precautionary Statements - Response Immediately call a poison center or doctor . If on skin (or hair): Take off immediately all contaminated clothing. Rinse skin with water .If inhaled: Remove person to fresh air and keep comfortable for breathing. Specific treatment (see supplemental first aid instructions on this label . Hazards not otherwise classified (HNOC) Although not expected, heart conditions or chronic respiratory problems may be aggravated by exposure to high concentrations of vapor or mist such as irate respiratory tract and cause coughing. Inhalation high concentrations may cause pulmonary [CONDITION(S)]. Skin contact may cause [NAME] skin irritations and [CONDITION(S)]. Record review of the Safety Data Sheet for Liquid Destainer 8% dated [DATE] revealed .4. First Aid Measures EYES: Immediately flush eyes with plenty of water for at least 15 minutes. Get medical attention, if irritation persists. SKIN: Wash with soap and water. Get medical attention if irritation develops or persists .INHALATION: Remove from area to fresh air. Seek medical attention if respiratory irritation develops or if breathing becomes difficult. SIGNS AND SYMPTOMS OF OVEREXPOSURE ACUTE EFFECTS: Irritation or [CONDITION(S)] to eyes, skin, mouth and throat. Inhaling this product may cause irritation, [CONDITION(S)], and pulmonary [CONDITION(S)]. CHRONIC EFFECTS: The effects of long-term exposure to this product have not been determined. Safe handling of this product on a long term basis should emphasize the avoidance of all effects from repetitive acute exposure Record review of the facility policy Change in a Resident's Condition or Status dated ,d+[DATE] revealed 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): a. accident or incident involving the resident .d. significant change in the resident's physical/emotional/mental condition; e. need to alter the resident's medical treatment significantly; g. need to transfer the resident to a hospital/treatment center; .i specific instruction to notify the physician of changes in the resident's condition . This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 1:30 PM. The Administrator and DON were notified. The Administrator was provided the Immediate Jeopardy template on [DATE] at 1:43 PM. The following Plan of Removal was submitted and accepted on [DATE] at 10:20 PM: [DATE] PLAN OF REMOVAL OF IMMEDIATE JEOPARDY STAFF WILL NOT BE ALLOWED TO WORK UNLESS THEY HAVE RECEIVED TRAINING AND REEDUCATION. Abuse & Neglect Issue: The facility failed to prevent and stop abuse of CR# 1 on [DATE] when CNA B witnessed CNA A provide bed bath to CR#1 using bleach and water. o On [DATE], CR #1 transferred to the hospital from the facility at 1:31am and expired at the hospital. o On [DATE], (Resident #2 was transferred to the hospital after assessment by the physician. Resident #2 was hyper salivating, her respiratory rate was increased, and her skin was flush. o On [DATE] the Administrator, will conduct safe surveys with the cognitive residents and will follow up with any unusual findings. o On [DATE] the Director of Nurses, will educate all staff on notifying the Licensed Nurse on any residents they've identified to have had a change in condition and alleged abuse and neglect. o [DATE] the Director of Nurses re-educated all staff on the importance of reporting all allegations of abuse to their immediate supervisor as well as to the Abuse Coordinator. If a staff member feels that nothing is being done related to an allegation of abuse, they have been instructed to report to the next person in charge immediately which is the Director of Nurses. o On [DATE], the Regional Director of Operations educated the Administrator, and Director of Nurses on the State of Texas Provider letter ,d+[DATE], and the SLP Abuse and Neglect Policy that specifically states when and what to report to HHS and the required time frame. o Upon discovery of an alleged abuse or neglect incident involving a resident, staff are expected to stop immediately ensure the resident is safe, which includes not leaving the resident alone, and calling immediately for help. It is expected the staff member to yell for immediate assistance and pull the resident's call light if in a resident's room. Issue: the facility failed to implement their abuse policy by allowing alleged perpetrator CNA A and CNA B to continue working their shifts. CNA A then worked a double shift that day and was not suspended until the next day o CNA A was suspended on [DATE] o CNA B was suspended on [DATE] o On [DATE] the Administrator, will educate all staff on abuse and neglect, protecting the resident, reporting, abuse prevention and who is the abuse coordinator. o On [DATE], the Regional Director of Operations educated the Administrator, and Director of Nurses on the State of Texas Provider letter ,d+[DATE], and SLP Abuse and Neglect Policy that specifically states when and what to report to HHS and the required time frame. o On [DATE], the Regional Director of Operations educated the Regional Nurse Manager, Administrator, and Director of Nurses, on suspension of involved staff immediately with all allegations of abuse and neglect and the first course of action which is to protect the resident and make sure he/she is safe. o [DATE] the Director of Nurses re-educated all staff on the importance of reporting all allegations of abuse to their immediate supervisor as well as to the Abuse Coordinator. If a staff member feels that nothing is being done related to an allegation of abuse, they have been instructed to report to the next person in charge immediately which is the Director of Nurses. Anytime an allegation of abuse is made, the staff is to immediately ensure the safety of the resident Issue: The DON was made aware of the incident and assessed CR#1 however there was no documentation of an assessment. - Interim DON departed [DATE] and never returned to facility - On [DATE]- Regional Nurse Manager educated new DON on resident assessments and documentation. - On [DATE] - DON initiated education with the licensed nurses on completing head to toe assessments and accurately documenting both the assessment and findings in the resident's Electronic Medical Record. Issue: The allegation was not immediately reported to HHSC. The incident was reported on [DATE] after surveyor-initiated investigation of incident On [DATE], the Regional Director of Operations educated the Administrator and Director of Nurses on the State of Texas Provider letter ,d+[DATE], that specifically states when and what to report to HHS and the required time frame Quality of care Issue: The facility failed to promptly assess and monitor CR#1 and Resident #2's to change in condition following incident of chemical (Bleach) exposure o On [DATE], the Director of Nurses in-serviced all staff on the correct chemicals to use within the nursing center related to bathing and sanitation and staff also educated on not to bring in unauthorized chemicals for bathing and sanitation. o On [DATE], the Director of Nurses, will educate all licensed nurses on timely assessing residents, identifying changes of conditions and timely notification to NP/MD/RP. Issue: CR#1 and Resident #2 did not have any documented assessment or monitoring, after the bleach exposure, by the DON or LVN A after being reported that CNA A bathed CR#1 and Resident #2 with bleach. - Interim DON departed [DATE] and never returned to facility and LVN A is an agency Nurse and not on the current schedule to return. - On [DATE] the Director of Nurses in-serviced the Staff Coordinator on making sure that all staff that are scheduled to work in the facility, including agency staff, is aware of the importance of reporting allegations of abuse and neglect immediately to the Abuse coordinator. - On [DATE]- Regional Nurse Manager educated new DON on resident assessments and documentation. - On [DATE] skin assessments initiated on all residents to ensure no one has any skin impairments related to the use of an unapproved chemical in the water for bathing or sanitation and will follow up with any unusual findings. On [DATE] at 7:45p.m. all skin assessments were completed, and no skin impairments noted. The skin assessments were documented in the resident's Electronic Medical Record. - On [DATE] an assessment of all residents will be completed by Director of Nursing and /or designee - Moving forward, allegations of abuse /neglect regarding a staff member will immediately be removed from the facility, placed on suspension pending investigation. Resident Rights Issue: - Interim DON departed [DATE] and never returned to facility and LVN A is an agency Nurse and not on the current schedule to return. - On [DATE] the Director of Nurses in-serviced the Staff Coordinator on making sure that all staff that are scheduled to work in the facility, including agency staff, is aware of the importance of reporting allegations of abuse and neglect immediately to the Abuse coordinator. - On [DATE], the Director of Nurses, will educate all licensed nurses on assessing residents, identifying changes of conditions and timely notification to NP/MD/RP. This education will be completed on [DATE]. - On [DATE] the Director of Nurses, will educate all staff on notifying the Licensed Nurse on any residents they've identified to have had a change in condition. - On [DATE] Regional Nurse Manager instructed Administrator and Interim ADON to initiate facility wide audit to remove unauthorized chemicals from the facility. On [DATE] the Administrator audited the facility and there are no unauthorized chemicals in the facility. AdHOC QAPI meeting was held at facility on [DATE] at 8:10p.m. with Administrator, Director of Nursing, Regional Nurse Manager, Regional Director of Operations, and Medical Director to review these findings and this Plan of Correct. Please review and accept this Plan of Removal. All items above have been completed and or initiated with completion date and time of [DATE], at 5:00pm. After this time, any staff that have not completed their in-service will not be allowed to work until in-service is completed. Surveyor Monitored the plan of removal as follows: Observation were started on [DATE] at 2:05 PM and continued through [DATE] at 7:24 AM. Observations of Resident #4, Resident #5, Resident #6, Resident #7, and Resident #8 revealed no bleach odors in residents' rooms. Resident did not have any visible skin issues. Observation of facility common areas and hallways revealed no smells of bleach. Interviews were started on [DATE] at 11:59 AM and continued through [DATE] at 6:57 AM with 32 staff across all three shifts, including weekdays, weekends, and multiple departments. The staff interviewed regarding the plan of removal: LVN A, Dietary Manager, LVN C, Dietary Aide, Housekeeper C, MA A, Activity Director, LVN D, ADON, BOM, Laundry Aide, CNA D, CNA E, OTA, Housekeeper B, LVN B, CNA C, MA B, CNA G, CNA G, DON, Administrator, CNA H, CNA I, CNA J, CNA K, CNA L, LVN F, CNA M, LVN H, LVN G, and LVN E. All staff interviewed verbalized adequate understanding of plan of remove training received. Record review of facility in-service training revealed: [DATE] - Use of chemical in the Nursing Home. Approved supplies during bath and peri care. [DATE] - Abuse, Neglect, and Immediate Staff Suspension related to Abuse and Neglect. State Provider Letter ,d+[DATE]. [DATE] - Changes in Condition and Timely Notification to Physician, Family, DON, Administrator, Medical Director. Documentation of Assessment and Notification in Medical Record [DATE] - Change of Condition report to Nurse immediately by staff. Record review of Resident #4, Resident #5, Resident #6, Resident #7, and Resident #8's medical records revealed they had skin assessment completed on [DATE] with no concerns noted. Record review of Employee Memorandum dated [DATE] revealed CNA A was suspended, notified via phone. Record review of Employee Memorandum dated [DATE] revealed CNA B was suspended, notified via phone. Record review of the facility POR binder revealed the facility completed an QAPI on [DATE]. The DON was informed the Immediate Jeopardy was removed on [DATE] at 8:00 AM. The facility remained out of compliance at a scope of isolated and severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on observation, interview, and record review the facility failed to ensure residents were free from abuse for 2 of 12 residents (CR #1, Resident #2) reviewed for abuse. - The facility failed to prevent abuse of CR#1 on [DATE] when CNA B witnessed CNA A provide a bed bath to CR#1 using bleach and water. - The facility failed to protect Resident #2 from abuse when CNA B failed to reported CNA A for giving CR#1 a bed bath using bleach and water, resulting in Resident #2 also receiving a bed bath with bleach and water. An Immediate Jeopardy (IJ) was identified on [DATE] at 1:30 PM. While the IJ was removed on [DATE] at 8:00 AM, the facility remained out of compliance at a scope of isolated and severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk of abuse, neglect, pain, decline in health, being displaced or hospitalized , and death. Findings Included: In an interview on [DATE] at 1:00 PM, the Physician stated CR#1 potentially died from bleach intoxication. She said once she got to the facility today ([DATE]), she was told by several staff that CR#1 was given a bath in bleach. CR#1 was given a bath on [DATE] around 10 AM. She was told it was a strong pervasive bleach smell in the room and was reported that throughout the day CR#1 declined. A staff member witnessed CR#1 gasping for air and he was very upset. CR#1 was assessed by one of the nursing staff, and was found unresponsive, CPR was initiated, the resident was sent to the hospital and he passed away. The staff was upset and afraid of losing their jobs but was concerned because the Administrator was not addressing the issue, and felt the interim DON and Administrator covered up the incident. The physician said it was also reported to her hat Resident #2 was bathed in bleach also on [DATE]. She had not got a chance to assess Resident #2 yet. She stated from what was reported Resident #2 was assessed by nursing staff as well. She was not called or notified of either incident. She said if she was told that the residents were bathed in bleach, she would have ordered vital signs every two hours, stat labs, increased monitoring based on the resident's vitals and condition and they would have been sent out to the hospital. She said this could have contributed or caused CR#1's demise. The DON was interim and just left yesterday. She had not determined a cause of death and had not certified the death certificate. In an interview on [DATE] at 3:23 PM, the Administrator stated the facility called the incident to the state on [DATE] because he heard that CR#1was killed due to the bleach. The police were notified as well. 1. Record review of CR#1's face sheet revealed CR#1 was a [AGE] year old male that was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . CR#1 was discharged on [DATE]. Record review of CR#1's MDS dated [DATE] revealed CR#1 did not have a BIMS. CR#1 required extensive assistance with two-person assistance for personal hygiene. CR#1 required physical help in part of bathing activity with two-person assistance. Record review of CR#1's Care Plan dated [DATE] revealed CR#1 required total dependence with bathing with one-person assistance. Staff are to set up, assist, give shower, shave, oral, hair, nail care per schedule and PRN. Record review of [CR#1] Progress Notes revealed .Nursing [RN A] RN [DATE] 01:31 AM Transfer to Hospital Progress Note (Nursing) Received Order from Medical Provider to Transfer Resident to: Hospital ER (Name of Hospital) Transfer Order Obtained from: Nurse Practitioner (Name) [NP name] Transfer Order Entered in Resident Record.: Yes Primary Reason for Transfer: Unresponsive Responsible Representative Notified of Transfer: Yes (Name) [RP Name] Time Responsible Representative Notified of Transfer: [DATE] 01:24 AM Transportation notified of Transport: EMS (911) called Report Called to Hospital, spoke with: Name: na, Department: na, Phone Number: na CPR (Check all that apply): CPR Initiated before transport / EMS arrival, AED Used , Time CPR Initiated (Time) 0110, EMS Took Over CPR upon arrival , Emergency Cart / AED Arrived at Site of CODE, Oxygen Applied (liters) 2 Documentation Sent to Hospital (Check all that apply): Face Sheet Resident Condition at time of Transfer: Unresponsive Resident left facility at: [DATE] Disposition of Medication:: Medications Remain Secured on Medication Cart. Disposition of Belongings: Personal Belongings Remain at Facility. Bed Hold Notification: Resident / Responsible Representative will be Notified of Bed Hold Notification Information within 24 hours of Transfer Record review of CR#1's hospital records dated [DATE] revealed Chief Complaint Cardiac Arrest, found down Patient expired at 0152, informed patients' guardian .Clinical Impression Primary Impression: Cardiopulmonary arrest . In an interview on [DATE] at 1:42 PM the Physician stated she was sending Resident #2 to the hospital because she was shaking, and cold. She was hyper salivating, her respiratory rate was up , her skin was flush. She could not rely on the staff at the facility. She did not want to chance it. A family member also complained Resident #2 was shaking and could not get warm. She was looking for a nurse but could not find one, she did not want to wait another minute, especially knowing she had this exposure to bleach. 2. Record review of Resident #2's face sheet revealed Resident #2 was an [AGE] year old female that was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #2 was discharged on [DATE]. Record review of Resident #2's MDS dated [DATE] revealed she did not have a BIMS. Resident #2 required extensive assistance with two-person assistance with personal hygiene. Resident #2 required total dependence with bathing. Resident #2 was at risk for pressure ulcers, she had no pressure ulcers or skin issues documented. Record review of Resident #2's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .Cleanse wound to right lower buttock with normal saline, apply Santyl and calcium alginate and skin prep to periwound and apply gauze island w/BDR dressing Q Day start date [DATE] . Record review of Resident #2's Care Plan dated [DATE] revealed Resident #2 required extensive assistance with bathing with one-person assistance. Staff were to set up, assist, give-shower, shave, oral care, hair, nail care per schedule and PRN. Care did not address wounds. Record review of Resident #2's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . There was a verbal report to me that this patient may have been bathed during the bath with water with bleach in it. State is present at the building at this time, incident under investigation. Family member, [person], at the bedside, states patient has been sweaty, less responsive, appears to be flushed. He stated that patient looks like she is warm but appears to be cold, has been shaking a lot. Patient had a lower blood pressure documented yesterday, blood pressure reported as normal today. Due to dementia, I am unable to obtain history from the patient. Patient will be sent to the ER due to concern for progressive respiratory symptoms and changes from baseline . Note written by Physician. Observation on [DATE] at 1:28 PM, revealed Resident #2 was lying in bed, resident shaking, crying, labored breathing, saliva coming from her mouth. Resident #2 was non-verbal. In an interview on [DATE] at 3:15 PM Housekeeper A stated, she was coming down hallway with the housekeeping cart, when she smelled a loud bleach odor. CNA A opened the door to CR#1's room and the smell got stronger. Housekeeper A asked CNA A what was going on and CNA A said she bathed CR#1 with bleach, soap and water. She reported the incident to her supervisor Housekeeper B. They went to look at him, CR#1 was lying in the bed, he was wrapped up and his hair was wet, he was shivering and lying on his side. Housekeeper B went and told the interim DON. She was called in for an interview with DON and the Administrator . She told them she smelled bleach with the door closed, and she asked CNA A what was going on, and CNA A told her she used bleach with soap and water to clean CR#1. In an interview on [DATE] at 1:32 PM, Housekeeper B stated on [DATE] Housekeeper A reported to him that CNA A used bleach and water to bathe CR#1. Housekeeper B w ent into CR#1's room and the resident was shaking and gasping for air. He immediately got the interim DON and she assessed him. She said he looked to be okay. The room door was closed during the bed bath and the fumes were strong. He heard that CNA B said that she asked CNA A to stop the bath . Later that night he was sent out with breathing problems. Later that same morning Resident #2 was given a bath and the staff noticed her wound was bubbling. CR#1 and Resident #2 were non-verbal. Resident #2 had a big open wound. Staff are not supposed to use bleach to clean at the facility. Bleach was not supposed to be in the building. CNA A continued to work that day and was not placed on suspension. The Administrator did not report this incident to the state agency. CNA A had bleach because it was taken by the Administrator after he found out about the incident. In a interview on [DATE] at 2:55 PM, Housekeeper B stated when he got to duty Housekeeper A reported to him that CNA A bathed CR#1 in bleach this was around 10 AM. He ran immediately and got the interim DON. The interim DON assessed CR#1 said he was okay. The agency nurse RN B was aware of the situation, but he was not sure if she reported this to anyone. RN B said she smelled the bleach on the hallway but was not sure where it came from or who had the bleach. In an interview on [DATE] at 2:37 PM, CNA B stated on [DATE] CNA A asked her to assist with giving CR#1 a bed bath. When she walked into the room there was a strong bleach odor. CNA A reported to her that she put a little bleach in the water. CNA B said she told CNA A that those chemicals were strong and should not be used on the resident's skin. CNA A then told her she did it all the time and she used it to wash CR#1's hair. CNA B said she asked CNA A to stop the bath. CNA A replied to her lets just hurry up and finish . During the bed bath CR#1 started having difficulty breathing. After the bath he was dressed and put in the wheelchair. She reported this incident to the nurse on duty RN B that CR#1 had a reaction to the bleach. During the bed bath Housekeeper A walked in and asked had they been using bleach in the room. The staff are not supposed to use bleach in the facility. CNA A told her she got the bleach from the kitchen. CNA A was interviewed by the Administrator and she lied and said she was using the bleach to clean the room. The Administrator did take the bottle of bleach from CNA A and she was not suspended immediately after the incident. CNA A had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . She later found out CR#1 passed away and this hurt her. Later that morning RN B walked into Resident #2's room and noticed the bleach odor in her room. She helped CNA A reposition Resident #2 but she did not help with the bath. CNA A used bleach and water to clean that resident as well. She reported this to RN B. RN B looked at Resident #2's wound and it was bubbling. She reported to the nurse that CNA A used bleach to clean Resident #2. RN B did not want to do anything about the situation and said she did not want anyone to lose their job. Interview on [DATE] at 12:55 PM, CNA B stated she was called to CR#1's room to assist with his bath. She smelled and witnessed CNA A had bleach in a small pan with water during CR#1's bath. CNA A only used a small amount of water, just enough to wipe residents down. During the bed bath CR#1 was gasping for air but after CNA A finished, he started breathing normal. She asked CNA A to stop during the bath but was told by her just hurry. CNA A washed CR#1's hair as well. She reported this to RN B. She was not interviewed about the incident until the next day. She did not assist with Resident #2's bath but helped dry her off. She noticed Resident #2's wound was bubbling she reported to RN B that CNA A used bleach to clean Resident #2. In an interview on [DATE] at 3:55 PM, RN B stated Resident #2 had a pressure sore. She asked the aides to contact her when they finished the bath so she could treat the wound. On [DATE] CNA A yelled down the hallway she was finished bathing Resident #2 and when she got to the room, she could smell the bleach in the hallway, it was very strong. When she opened the door, the odor was strong in the room. The wound was bubbling , CNA A then stated the wound was cleaned with soap and water very well. CNA A told her she used the bleach to clean the room. This incident occurred around 11:15 AM. CNA B made an off-hand comment about bleach , but she was not sure what was going on that day. Later she figured out what was going on. The next day CNA B told her about the bleach and that CNA A put bleach in Resident #2's bath water . She was not sure who assessed Resident #2. She asked the interim DON what happened, and she told her she was not supposed to know about the incident and asked her who reported this to her. The interim DON was aware and was supposed to do an assessment and contact the physician. Resident #2 looked bug-eyed and was moaning during the wound treatment, she had pain in her wound. She cleaned and packed the wound. Resident #2 was alert. She was not sure about CR#1 she was told he had some trouble breathing and he had been moved to another side of the facility but that was it. In an interview on [DATE] at 12:31 PM, RN A stated when she got to her shift at 10:30 PM CR#1 was asleep. She usually checks to make sure residents were breathing, she was not too familiar with the resident he had just moved to her side. She said at 1:00 AM it was reported to her that CR#1 was gasping for air, so she went to assess him. She could not palpate a pulse, his pupils were fixed and he was unresponsive. She started CPR and 911 was notified. 10 minutes later the paramedics showed up and they took over. CR#1 was transferred to the hospital. During that night Resident #2 was fine, she was sleeping, she took her morning medication and had no issues. She heard that a staff member was cleaning residents with bleach. She had never witnessed anything like that, if that was reported to her she would had done something right away. She would have assessed the patient, took their vital signs and notified the physician, the family, and sent the residents out more than likely. That was a chemical, something poison control may have to deal with. In an interview on [DATE] at 4:29 PM, CNA A stated she did not give CR#1 a bath with bleach, she used bleach to clean the room and she was not aware it could not be used in the facility. She got the bleach from the kitchen, and a former Administrator allowed the staff to use bleach. She also used bleach to clean around the unit. She said there was a lot of misunderstandings and jealousy in the facility. She said she would not harm anyone. Staff were going around the facility accusing her of murdering residents. She only used the bleach to clean the resident's mattress and mop the rooms. She said she mopped the floors and cleaned the mattresses with bleach because housekeeping does not clean, and the night shift do not change the residents so they beds are soaked with urine. Housekeeping uses bleach as well but they will not report on themselves. She bathed CR#1 and CNA B helped put on his brief. CNA B told her she was going to tell the Administrator that she did not use bleach to bathe CR#1. CNA A said Resident #2 had a wound and she would not use bleach to clean the resident She was not sure if they were assessed. She worked a double that day because the facility had nobody to work. The residents were moved away from the memory care unit. She was later placed on suspension pending the investigation. In an interview on [DATE] at 3:39 PM, the Interim DON, stated on [DATE] it was reported to her by Housekeeper B that CNA A was washing CR#1 with bleach and water. CNA A reported she was just cleaning out the bed pan with the bleach cleanser. The resident did not have any issue or trouble breathing. None of the staff reported they actually saw her put bleach in CR#1's bath water. She assessed CR#1 and he was fine . She fed CR#1 in the dining room due to staffing challenges that day. She reported this to the Administrator, and he was still investigating. She said did not document the assessment and she was sorry; she said she was doing a number of things that day. The physician was not notified. The Interim DON said staff were saying two different things and there was confusion about what happened between CR#1 and Resident #2. She was not sure what happened. There was a lot going on that day and a lot of confusion. The staff are not supposed to be using bleach on the floor at the nursing home. She was not sure where CNA A got the bleach from. In an interview on [DATE] at 5:13 PM, the interim ADON stated she found out the following day about the bleach bath incident with CR#1. CNA A was then placed on suspension and taken off the schedule until further notice. There had been a lack of communication between her and the interim DON due to turmoil at the facility. She had not seen CR#1 the day the incident happened. She knew he passed during the night shift on [DATE]. She said the interim DON exited the facility yesterday, there was a lot of things going on with her which was an issue. She said she was not aware of the incident with Resident #2. The interim ADON said the interim DON was notified and was supposed to do an assessment on CR#1 and Resident #2 and the physician should have been notified. The interim DON would refuse to work the floor. The Administrator was in a tough position, the interim DON could not complete a task, she had short focus, she was the cause of a lot of issues at the facility. In an interview on [DATE] at 5:30 PM the Administrator stated on [DATE] he was notified by the interim DON that CNA A bathed CR#1 with bleach. CNA A was placed on suspension . He started interviewing staff. The interviews did not produce anything. The situation had been a confusing mess. CNA A said she did not bathe CR#1 in bleach, and he was not sure if he believed her . He was made aware of this incident Wednesday ([DATE]) afternoon. Supposedly this occurred on Wednesday morning. He did not have an incident report for the incident. He was not aware of the allegation that Resident #2 was given a bed bath in bleach. The interim DON said she did an assessment, but she did not document the assessment. He was not sure if she contacted the physician. The assessment should have been documented and physician notified. The interim DON was a loose cannon and caused a lot of turmoil in the facility. He did not report this to the state agency because it was discussed at the corporate level and since it was just a bath in bleach, they were going to take any disciplinary action. This was not considered abuse. Staff are not supposed to use bleach to clean in the facility. The bleach was taken from CNA A and the staff were informed that they were to use sanitation wipes and not bleach to clean. The nurse aide reported she got the bleach from kitchen, but the kitchen denied that. CNA A had been a troublemaker at the facility, he was not sure who she got the bleach from. In an interview on [DATE] at 11:51 AM, Dietary Manager stated CNA A came to the kitchen about two weeks ago asking for bleach to clean the rooms with because they were smelling foul. She told her the kitchen did not keep bleach. The bottle of bleach that was taken from CNA A was from a company that did not service the facility . She spoke to the Administrator and told him the kitchen did not keep bleach or give it to CNA A. The facility was not supposed to have bleach on the premises. In an interview on [DATE] at 4:45 PM, the Maintenance Director stated he believed CNA A got the bleach from the container connected to the washing machine. It's called Liquid Destainer 8%. It is an industrial type of bleach and can burn the skin and needs to be handled with gloves. A special tool is needed to open the container, but the CNA A may have a straw or tool to pour it into a smaller container. In an interview on [DATE] at 12:13 PM, the ADON stated she was not privy to the incident regarding the bleach with CR#1. CR#1 passed away that same night. She had not seen CR#1 the day of the incident. She saw Resident #2 the next day, she assessed the resident because someone came to her and asked her to assess her due to possible bleach exposure the previous day. She checked her all her vitals and they were within normal limits. She assessed Resident #2 on Thursday [DATE]. She did not document the assessment of Resident #2. She just did the assessment due to the mention of the exposure. She had only been at the facility for three weeks. She overhead talk about the incident but the Administrator had not shared any information with her. If it was reported to her that a resident was exposed to bleach, she would have completed an assessment, reported this to the physician and notify the Administrator who was the abuse coordinator. In an interview on [DATE] at 4:00 PM, the DON stated Resident #2's family came and picked up her belongings. The resident was at the hospital and did not have more than two weeks to live, she was terminally ill. Resident #2 was going to another facility on hospice. In an interview on [DATE] at 1:40 PM, the Administrator stated he did suspend CNA A and take the bleach once he found out on Wednesday. He could not remember what day or time CNA A was suspended. In a follow up telephone interview on [DATE] at 7:37 AM, CNA B stated she was called and placed on suspension. She did not understand because she told the nurse on duty, RN B about the incident with the bleach and the interim DON was aware. CNA A was sent to the office and spoke with the DON and Administrator, the day of the incident. CNA A was sent back to the unit. The next day she had to write a statement. In an interview on [DATE] at 2:12 PM, the DON stated it was important for staff to assess residents and report changes of condition so the physician can follow up on the issues which could cause death. This was a resident's rights issue and could lead to neglect. The Administrator needed to be notified so an investigation could be completed. In an interview on [DATE] at 2:56 PM, the Administrator stated it was important for staff to immediately notify him of allegations of abuse and neglect so he can start his investigation and immediately initiate the abuse protocol and guidelines. Record review of the facility timeline attached to the Provider Investigation Report dated [DATE] provided by the Administrator revealed Notified of incident around 3:00 PM on [DATE]. I sent [interim] DON for the C.N.A. [CNA A] at that time. Apx. 3:20 pm the C.N.A. [CNA A] came to the office where she was questioned. I told the C.N.A. [CNA A] to bring any bleach she was using to me. She explained that she was only using the bleach to clean and disinfected. I instructed her to use authorized sanitary wipes only for sanitation (purple top). Apx. 3:30 pm the C.N.A. [CNA A] brought the bottle to me. I confiscated the bottle and instructed the employee that she could not use unapproved substances in the facility. I directed the [interim] D.O.N to start an in-service of the use of non-approved chemicals in the facility (in-services not located). Apx. 8pm or 8:30 pm I instructed the interim ADON to take the employee off the schedule until further notice. [DATE] Apx 10 am during the morning shift I interviewed other employees that work in that area about the use of bleach for any purposes. I interviewed [CNA B] who admitted to this writer that she smelled bleach when she was in the resident's room (#220A). [CNA B] stated she was in the room when the alleged performed a bed bath. I asked [CNA B] to write a statement. Two housekeeping personnel reported that they smelled bleach in the hallway but did not see it in use. One additional C.N.A. indicated she smelled bleach but did not see it being used. Apx. 11 am I consulted with [Regional Nurse Consultant] regarding the use of bleach by the C.N.A. [CNA A] for sanitation purposes. She consulted with [Director of Clinical Operations] regarding the use of bleach for sanitation. The result was to educate the staff members on what chemicals are appropriate for use in the Nursing center for cleaning and sanitation purposes. Apx. 3:00 pm an additional 2 C.N.A.'s was interviewed and had not smelled the bleach on their shift. [interim] DON did not return on the 11th. On [DATE] Apx. 5:15 pm I was provided a written statement from [CNA B] and it indicated the resident [CR#1] was having difficulty breathing because the aide put bleach in her bath water, but later recovered. At that time, I escalated this to a reportable event. I consulted with [Regional Nurse Consultant] who agreed to report the event to HHS. Record review of the facility Abuse Prevention Program dated ,d+[DATE] revealed 1. The Administrator is responsible for the overall coordination and implementation of our Center's abuse prevention program policies and procedures Identification Assessment and Recognition of Abuse: 1. The nurse will assess the individual and document related findings 2. The nurse will report findings to the physician. As needed, the physical will assess the resident/patient to verify or clarify such findings, especially if the cause or source of the problem is unclear. Investigation Role of the Administrator: 1. The Administrator has the overall responsibility for the coordination and implementation of our Center's abuse prevention program policies and procedures. The Administrator is the Abuse Prevention Coordinator. In absence of the Administrator the Director of Nursing will serve in this capacity. 6. The Administrator will suspend immediately any employee who has been accused of resident abuse, pending the outcome of the investigation. 7. The Administrator will ensure that any further potential abuse, neglect exploitation or mistreatment is prevented. Reporting 1. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the Center Administrator, or his/her designee, to the following person or agency's required: a. The State licensing/certification agency responsible for surveying/licensing Center 2. An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than: 3. Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury; or Twenty-four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury . Review of Clorox Regular-Bleach1 JW [DATE] at https://www.osha.gov/sites/default/files/,d+[DATE]/Sample%20SDS%20Handout.pdf accessed [DATE] indicated Precautionary Statements - Response Immediately call a poison center or doctor . If on skin (or hair): Take off immediately all contaminated clothing. Rinse skin with water .If inhaled: Remove person to fresh air and keep comfortable for breathing. Specific treatment (see supplemental first aid instructions on this label . Hazards not otherwise classified (HNOC) Although not expected, heart conditions or chronic respiratory problems may be aggravated by exposure to high concentrations of vapor or mist such as irate respiratory tract and cause coughing. Inhalation high concentrations may cause pulmonary [CONDITION(S)]. Skin contact may cause [NAME] skin irritations and [CONDITION(S)]. Record review of the Safety Data Sheet for Liquid Destainer 8% dated [DATE] revealed .4. First Aid Measures EYES: Immediately flush eyes with plenty of water for at least 15 minutes. Get medical attention, if irritation persists. SKIN: Wash with soap and water. Get medical attention if irritation develops or persists .INHALATION: Remove from area to fresh air. Seek medical attention if respiratory irritation develops or if breathing becomes difficult. SIGNS AND SYMPTOMS OF OVEREXPOSURE ACUTE EFFECTS: Irritation or [CONDITION(S)] to eyes, skin, mouth and throat. Inhaling this product may cause irritation, [CONDITION(S)], and pulmonary [CONDITION(S)]. CHRONIC EFFECTS: The effects of long term exposure to this product have not been determined. Safe handling of this product on a long term basis should emphasize the avoidance of all effects from repetitive acute exposure . This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 1:30 PM. The Administrator and DON were notified. The Administrator was provided the Immediate Jeopardy template on [DATE] at 1:43 PM. The following Plan of Removal was submitted and accepted on [DATE] at 10:20 PM: [DATE] PLAN OF REMOVAL OF IMMEDIATE JEOPARDY STAFF WILL NOT BE ALLOWED TO WORK UNLESS THEY HAVE RECEIVED TRAINING AND REEDUCATION. Abuse & Neglect Issue: The facility failed to prevent and stop abuse of CR# 1 on [DATE] when CNA B witnessed CNA A provide bed bath to CR#1 using bleach and water. o On [DATE], CR #1 transferred to the hospital from the facility at 1:31am and expired at the hospital. o On [DATE], (Resident #2 was transferred to the hospital after assessment by the physician. Resident #2 was hyper salivating, her respiratory rate was increased, and her skin was flush. o On [DATE] the Administrator, will conduct safe surveys with the cognitive residents and will follow up with any unusual findings. o On [DATE] the Director of Nurses, will educate all staff on notifying the Licensed Nurse on any residents they've identified to have had a change in condition and alleged abuse and neglect. o [DATE] the Director of Nurses re-educated all staff on the importance of reporting all allegations of abuse to their immediate supervisor as well as to the Abuse Coordinator. If a staff member feels that nothing is being done related to an allegation of abuse, they have been instructed to report to the next person in charge immediately which is the Director of Nurses. o On [DATE], the Regional Director of Operations educated the Administrator, and Director of Nurses on the State of Texas Provider letter ,d+[DATE], and the SLP Abuse and Neglect Policy that specifically states when and what to report to HHS and the required time frame. o Upon discovery of an alleged abuse or neglect incident involving a resident, staff are expected to stop immediately ensure the resident is safe, which includes not leaving the resident alone, and calling immediately for help. It is expected the staff member to yell for immediate assistance and pull the resident's call light if in a resident's room. Issue: the facility failed to implement their abuse policy by allowing alleged perpetrator CNA A and CNA B to continue working their shifts. CNA A then worked a d [TRUNCATED]

Based on observation, interview and record review, the facility failed to implement written policies and procedures that prohibit and prevent the abuse and neglect of residents for 2 of 12 residents, (CR#1 and Resident #2) reviewed for abuse and neglect. The facility failed to ensure: 1. CNA B, RN B and interim DON immediately reported to the Administrator when CR#1 was bathed with bleach by CNA A. 2. The Administrator was not aware of an allegation that Resident #2 was bathed in bleach and water by CNA A after the incident with CR#1. 3. The Administrator immediately reported to the State Survey agency an allegation of abuse and neglect within 2 hours. 4. The Administrator immediately suspend CNA A after he was made aware of the allegation of her bathing CR#1 in bleach. An Immediate Jeopardy (IJ) was identified on [DATE] at 1:30 PM. While the IJ was removed on [DATE] at 8:00 AM, the facility remained out of compliance at a scope of isolated and severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems. These failures placed residents at risk of abuse, neglect, pain, decline in health, being displaced, hospitalized and death Findings Included: In an interview on [DATE] at 1:00 PM, the Physician stated CR#1 potentially died from bleach intoxication. She said once she got to the facility today ([DATE]), she was told by several staff that CR#1 was given a bath in bleach. CR#1 was given a bath on [DATE] around 10 AM. She was told it was a strong pervasive bleach smell in the room and was reported that throughout the day CR#1 declined. A staff member witnessed CR#1 gasping for air and he was very upset. CR#1 was assessed by one of the nursing staff, and was found unresponsive, CPR was initiated, the resident was sent to the hospital and he passed away. The staff was upset and afraid of losing their jobs but was concerned because the Administrator was not addressing the issue, and felt the interim DON and Administrator covered up the incident. The physician said it was also reported to her hat Resident #2 was bathed in bleach also on [DATE]. She had not got a chance to assess Resident #2 yet. She stated from what was reported Resident #2 was assessed by nursing staff as well. She was not called or notified of either incident. She said if she was told that the residents were bathed in bleach, she would have ordered vital signs every two hours, stat labs, increased monitoring based on the resident's vitals and condition and they would have been sent out to the hospital. She said this could have contributed or caused CR#1's demise. The DON was interim and just left yesterday. She had not determined a cause of death and had not certified the death certificate. In an interview on [DATE] at 3:23 PM, the Administrator stated the facility called the incident to the state on [DATE] because he heard that CR#1was killed due to the bleach. The police were notified as well. 1. Record review of CR#1's face sheet revealed CR#1 was a [AGE] year old male that was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . CR#1 was discharged on [DATE]. Record review of CR#1's MDS dated [DATE] revealed CR#1 did not have a BIMS. CR#1 required extensive assistance with two-person assistance for personal hygiene. CR#1 required physical help in part of bathing activity with two-person assistance. Record review of CR#1's Care Plan dated [DATE] revealed CR#1 required total dependence with bathing with one-person assistance. Staff are to set up, assist, give shower, shave, oral, hair, nail care per schedule and PRN. Record review of [CR#1] Progress Notes revealed .Nursing [RN A] RN [DATE] 01:31 AM Transfer to Hospital Progress Note (Nursing) Received Order from Medical Provider to Transfer Resident to: Hospital ER (Name of Hospital) Transfer Order Obtained from: Nurse Practitioner (Name) [NP name] Transfer Order Entered in Resident Record.: Yes Primary Reason for Transfer: Unresponsive Responsible Representative Notified of Transfer: Yes (Name) [RP Name] Time Responsible Representative Notified of Transfer: [DATE] 01:24 AM Transportation notified of Transport: EMS (911) called Report Called to Hospital, spoke with: Name: na, Department: na, Phone Number: na CPR (Check all that apply): CPR Initiated before transport / EMS arrival, AED Used , Time CPR Initiated (Time) 0110, EMS Took Over CPR upon arrival , Emergency Cart / AED Arrived at Site of CODE, Oxygen Applied (liters) 2 Documentation Sent to Hospital (Check all that apply): Face Sheet Resident Condition at time of Transfer: Unresponsive Resident left facility at: [DATE] Disposition of Medication:: Medications Remain Secured on Medication Cart. Disposition of Belongings: Personal Belongings Remain at Facility. Bed Hold Notification: Resident / Responsible Representative will be Notified of Bed Hold Notification Information within 24 hours of Transfer Record review of CR#1's hospital records dated [DATE] revealed Chief Complaint Cardiac Arrest, found down Patient expired at 0152, informed patients' guardian .Clinical Impression Primary Impression: Cardiopulmonary arrest . 2. Record review of Resident #2's face sheet revealed Resident #2 was an [AGE] year old female that was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #2 was discharged on [DATE]. Record review of Resident #2's MDS dated [DATE] revealed she did not have a BIMS. Resident #2 required extensive assistance with two-person assistance with personal hygiene. Resident #2 required total dependence with bathing. Resident #2 was at risk for pressure ulcers, she had no pressure ulcers or skin issues documented. Record review of Resident #2's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .Cleanse wound to right lower buttock with normal saline, apply Santyl and calcium alginate and skin prep to periwound and apply gauze island w/BDR dressing Q Day start date [DATE] . Record review of Resident #2's Care Plan dated [DATE] revealed Resident #2 required extensive assistance with bathing with one-person assistance. Staff were to set up, assist, give-shower, shave, oral care, hair, nail care per schedule and PRN. Record review of Resident #2's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . There was a verbal report to me that this patient may have been bathed during the bath with water with bleach in it. State is present at the building at this time, incident under investigation. Family member, [person], at the bedside, states patient has been sweaty, less responsive, appears to be flushed. He stated that patient looks like she is warm but appears to be cold, has been shaking a lot. Patient had a lower blood pressure documented yesterday, blood pressure reported as normal today. Due to dementia, I am unable to obtain history from the patient. Patient will be sent to the ER due to concern for progressive respiratory symptoms and changes from baseline . Note written by Physician. Observation on [DATE] at 1:28 PM, revealed Resident #2 was lying in bed, resident shaking, crying, labored breathing, saliva coming from her mouth. Resident #2 was non-verbal. In an interview on [DATE] at 1:42 PM the Physician stated she was sending Resident #2 to the hospital because she was shaking, and cold. She was hyper salivating, her respiratory rate was up , her skin was flush. She could not rely on the staff at the facility. She did not want to chance it. A family member also complained Resident #2 was shaking and could not get warm. She was looking for a nurse but could not find one, she did not want to wait another minute, especially knowing she had this exposure to bleach. In an interview on [DATE] at 3:15 PM Housekeeper A stated, she was coming down hallway with the housekeeping cart, when she smelled a loud bleach odor. CNA A opened the door to CR#1's room and the smell got stronger. Housekeeper A asked CNA A what was going on and CNA A said she bathed CR#1 with bleach, soap and water. She reported the incident to her supervisor Housekeeper B. They went to look at him, CR#1 was lying in the bed, he was wrapped up and his hair was wet, he was shivering and lying on his side. Housekeeper B went and told the interim DON. She was called in for an interview with DON and the Administrator . She told them she smelled bleach with the door closed, and she asked CNA A what was going on, and CNA A told her she used bleach with soap and water to clean CR#1. In an interview on [DATE] at 1:32 PM, Housekeeper B stated on [DATE] Housekeeper A reported to him that CNA A used bleach and water to bathe CR#1. Housekeeper B w ent into CR#1's room and the resident was shaking and gasping for air. He immediately got the interim DON and she assessed him. She said he looked to be okay. The room door was closed during the bed bath and the fumes were strong. He heard that CNA B said that she asked CNA A to stop the bath . Later that night he was sent out with breathing problems. Later that same morning Resident #2 was given a bath and the staff noticed her wound was bubbling. CR#1 and Resident #2 were non-verbal. Resident #2 had a big open wound. Staff are not supposed to use bleach to clean at the facility. Bleach was not supposed to be in the building. CNA A continued to work that day and was not placed on suspension. The Administrator did not report this incident to the state agency. CNA A had bleach because it was taken by the Administrator after he found out about the incident. In a interview on [DATE] at 2:55 PM, Housekeeper B stated when he got to duty Housekeeper A reported to him that CNA A bathed CR#1 in bleach this was around 10 AM. He ran immediately and got the interim DON. The interim DON assessed CR#1 said he was okay. The agency nurse RN B was aware of the situation, but he was not sure if she reported this to anyone. RN B said she smelled the bleach on the hallway but was not sure where it came from or who had the bleach. In an interview on [DATE] at 2:37 PM, CNA B stated on [DATE] CNA A asked her to assist with giving CR#1 a bed bath. When she walked into the room there was a strong bleach odor. CNA A reported to her that she put a little bleach in the water. CNA B said she told CNA A that those chemicals were strong and should not be used on the resident's skin. CNA A then told her she did it all the time and she used it to wash CR#1's hair. CNA B said she asked CNA A to stop the bath. CNA A replied to her lets just hurry up and finish . During the bed bath CR#1 started having difficulty breathing. After the bath he was dressed and put in the wheelchair. She reported this incident to the nurse on duty RN B that CR#1 had a reaction to the bleach. During the bed bath Housekeeper A walked in and asked had they been using bleach in the room. The staff are not supposed to use bleach in the facility. CNA A told her she got the bleach from the kitchen. CNA A was interviewed by the Administrator and she lied and said she was using the bleach to clean the room. The Administrator did take the bottle of bleach from CNA A and she was not suspended immediately after the incident. CNA A had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . She later found out CR#1 passed away and this hurt her. Later that morning RN B walked into Resident #2's room and noticed the bleach odor in her room. She helped CNA A reposition Resident #2 but she did not help with the bath. CNA A used bleach and water to clean that resident as well. She reported this to RN B. RN B looked at Resident #2's wound and it was bubbling. She reported to the nurse that CNA A used bleach to clean Resident #2. RN B did not want to do anything about the situation and said she did not want anyone to lose their job. Interview on [DATE] at 12:55 PM, CNA B stated she was called to CR#1's room to assist with his bath. She smelled and witnessed CNA A had bleach in a small pan with water during CR#1's bath. CNA A only used a small amount of water, just enough to wipe residents down. During the bed bath CR#1 was gasping for air but after CNA A finished, he started breathing normal. She asked CNA A to stop during the bath but was told by her just hurry. CNA A washed CR#1's hair as well. She reported this to RN B. She was not interviewed about the incident until the next day. She did not assist with Resident #2's bath but helped dry her off. She noticed Resident #2's wound was bubbling she reported to RN B that CNA A used bleach to clean Resident #2. In an interview on [DATE] at 3:55 PM, RN B stated Resident #2 had a pressure sore. She asked the aides to contact her when they finished the bath so she could treat the wound. On [DATE] CNA A yelled down the hallway she was finished bathing Resident #2 and when she got to the room, she could smell the bleach in the hallway, it was very strong. When she opened the door, the odor was strong in the room. The wound was bubbling , CNA A then stated the wound was cleaned with soap and water very well. CNA A told her she used the bleach to clean the room. This incident occurred around 11:15 AM. CNA B made an off-hand comment about bleach , but she was not sure what was going on that day. Later she figured out what was going on. The next day CNA B told her about the bleach and that CNA A put bleach in Resident #2's bath water . She was not sure who assessed Resident #2. She asked the interim DON what happened, and she told her she was not supposed to know about the incident and asked her who reported this to her. The interim DON was aware and was supposed to do an assessment and contact the physician. Resident #2 looked bug-eyed and was moaning during the wound treatment, she had pain in her wound. She cleaned and packed the wound. Resident #2 was alert. She was not sure about CR#1 she was told he had some trouble breathing and he had been moved to another side of the facility but that was it. In an interview on [DATE] at 12:31 PM, RN A stated when she got to her shift at 10:30 PM CR#1 was asleep. She usually checks to make sure residents were breathing, she was not too familiar with the resident he had just moved to her side. She said at 1:00 AM it was reported to her that CR#1 was gasping for air, so she went to assess him. She could not palpate a pulse, his pupils were fixed and he was unresponsive. She started CPR and 911 was notified. 10 minutes later the paramedics showed up and they took over. CR#1 was transferred to the hospital. During that night Resident #2 was fine, she was sleeping, she took her morning medication and had no issues. She heard that a staff member was cleaning residents with bleach. She had never witnessed anything like that, if that was reported to her she would had done something right away. She would have assessed the patient, took their vital signs and notified the physician, the family, and sent the residents out more than likely. That was a chemical, something poison control may have to deal with. In an interview on [DATE] at 4:29 PM, CNA A stated she did not give CR#1 a bath with bleach, she used bleach to clean the room and she was not aware it could not be used in the facility. She got the bleach from the kitchen, and a former Administrator allowed the staff to use bleach. She also used bleach to clean around the unit. She said there was a lot of misunderstandings and jealousy in the facility. She said she would not harm anyone. Staff were going around the facility accusing her of murdering residents. She only used the bleach to clean the resident's mattress and mop the rooms. She said she mopped the floors and cleaned the mattresses with bleach because housekeeping does not clean, and the night shift do not change the residents so they beds are soaked with urine. Housekeeping uses bleach as well but they will not report on themselves. She bathed CR#1 and CNA B helped put on his brief. CNA B told her she was going to tell the Administrator that she did not use bleach to bathe CR#1. CNA A said Resident #2 had a wound and she would not use bleach to clean the resident She was not sure if they were assessed. She worked a double that day because the facility had nobody to work. The residents were moved away from the memory care unit. She was later placed on suspension pending the investigation. In an interview on [DATE] at 3:39 PM, the Interim DON, stated on [DATE] it was reported to her by Housekeeper B that CNA A was washing CR#1 with bleach and water. CNA A reported she was just cleaning out the bed pan with the bleach cleanser. The resident did not have any issue or trouble breathing. None of the staff reported they actually saw her put bleach in CR#1's bath water. She assessed CR#1 and he was fine . She fed CR#1 in the dining room due to staffing challenges that day. She reported this to the Administrator, and he was still investigating. She said did not document the assessment and she was sorry; she said she was doing a number of things that day. The physician was not notified. The Interim DON said staff were saying two different things and there was confusion about what happened between CR#1 and Resident #2. She was not sure what happened. There was a lot going on that day and a lot of confusion. The staff are not supposed to be using bleach on the floor at the nursing home. She was not sure where CNA A got the bleach from . In an interview on [DATE] at 5:13 PM, the interim ADON stated she found out the following day about the bleach bath incident with CR#1. CNA A was then placed on suspension and taken off the schedule until further notice. There had been a lack of communication between her and the interim DON due to turmoil at the facility. She had not seen CR#1 the day the incident happened. She knew he passed during the night shift on [DATE]. She said the interim DON exited the facility yesterday, there was a lot of things going on with her which was an issue. She said she was not aware of the incident with Resident #2. The interimADON said the interim DON was notified and was supposed to do an assessment on CR#1 and Resident #2 and the physician should have been notified. The interim DON would refuse to work the floor. The Administrator was in a tough position, the interim DON could not complete a task, she had short focus, she was the cause of a lot of issues at the facility. In an interview on [DATE] at 5:30 PM the Administrator stated on [DATE] he was notified by the interim DON that CNA A bathed CR#1 with bleach. CNA A was placed on suspension . He started interviewing staff. The interviews did not produce anything. The situation had been a confusing mess. CNA A said she did not bathe CR#1 in bleach, and he was not sure if he believed her . He was made aware of this incident Wednesday ([DATE]) afternoon. Supposedly this occurred on Wednesday morning. He did not have an incident report for the incident. He was not aware of the allegation that Resident #2 was given a bed bath in bleach. The interim DON said she did an assessment, but she did not document the assessment. He was not sure if she contacted the physician. The assessment should have been documented and physician notified. The interim DON was a loose cannon and caused a lot of turmoil in the facility. He did not report this to the state agency because it was discussed at the corporate level and since it was just a bath in bleach, they were going to take any disciplinary action. This was not considered abuse. Staff are not supposed to use bleach to clean in the facility. The bleach was taken from CNA A and the staff were informed that they were to use sanitation wipes and not bleach to clean. The nurse aide reported she got the bleach from kitchen, but the kitchen denied that. CNA A had been a troublemaker at the facility, he was not sure who she got the bleach from. In an interview on [DATE] at 11:51 AM, Dietary Manager stated CNA A came to the kitchen about two weeks ago asking for bleach to clean the rooms with because they were smelling foul. She told her the kitchen did not keep bleach. The bottle of bleach that was taken from CNA A was from a company that did not service the facility . She spoke to the Administrator and told him the kitchen did not keep bleach or give it to CNA A. The facility was not supposed to have bleach on the premises. In an interview on [DATE] at 4:45 PM, the Maintenance Director stated he believed CNA A got the bleach from the container connected to the washing machine. It's called Liquid Destainer 8%. It is an industrial type of bleach and can burn the skin and needs to be handled with gloves. A special tool is needed to open the container, but the CNA A may have a straw or tool to pour it into a smaller container. In an interview on [DATE] at 12:13 PM, the ADON stated she was not privy to the incident regarding the bleach with CR#1. CR#1 passed away that same night. She had not seen CR#1 the day of the incident. She saw Resident #2 the next day, she assessed the resident because someone came to her and asked her to assess her due to possible bleach exposure the previous day. She checked her all her vitals and they were within normal limits. She assessed Resident #2 on Thursday [DATE]. She did not document the assessment of Resident #2. She just did the assessment due to the mention of the exposure. She had only been at the facility for three weeks. She overhead talk about the incident but the Administrator had not shared any information with her. If it was reported to her that a resident was exposed to bleach, she would have completed an assessment, reported this to the physician and notify the Administrator who was the abuse coordinator. In an interview on [DATE] at 4:00 PM, the DON stated Resident #2's family came and picked up her belongings. The resident was at the hospital and did not have more than two weeks to live, she was terminally ill. Resident #2 was going to another facility on hospice. In an interview on [DATE] at 1:40 PM, the Administrator stated he did suspend CNA A and take the bleach once he found out on Wednesday. He could not remember what day or time CNA A was suspended. In a follow up telephone interview on [DATE] at 7:37 AM, CNA B stated she was called and placed on suspension. She did not understand because she told the nurse on duty, RN B about the incident with the bleach and the interim DON was aware. CNA A was sent to the office and spoke with the DON and Administrator, the day of the incident. CNA A was sent back to the unit. The next day she had to write a statement. In an interview on [DATE] at 2:12 PM, the DON stated it was important for staff to assess residents and report changes of condition so the physician can follow up on the issues which could cause death. This was a resident's rights issue and could lead to neglect. The Administrator needed to be notified so an investigation could be completed. In an interview on [DATE] at 2:56 PM, the Administrator stated it was important for staff to immediately notify him of allegations of abuse and neglect so he can start his investigation and immediately initiate the abuse protocol and guidelines. Record review of the facility timeline attached to the Provider Investigation Report dated [DATE] provided by the Administrator revealed Notified of incident around 3:00 PM on [DATE]. I sent [interim] DON for the C.N.A. [CNA A] at that time. Apx. 3:20 pm the C.N.A. [CNA A] came to the office where she was questioned. I told the C.N.A. [CNA A] to bring any bleach she was using to me. She explained that she was only using the bleach to clean and disinfected. I instructed her to use authorized sanitary wipes only for sanitation (purple top). Apx. 3:30 pm the C.N.A. [CNA A] brought the bottle to me. I confiscated the bottle and instructed the employee that she could not use unapproved substances in the facility. I directed the [interim] D.O.N to start an in-service of the use of non-approved chemicals in the facility (in-services not located). Apx. 8pm or 8:30 pm I instructed the interim ADON to take the employee off the schedule until further notice. [DATE] Apx 10 am during the morning shift I interviewed other employees that work in that area about the use of bleach for any purposes. I interviewed [CNA B] who admitted to this writer that she smelled bleach when she was in the resident's room (#220A). [CNA B] stated she was in the room when the alleged performed a bed bath. I asked [CNA B] to write a statement. Two housekeeping personnel reported that they smelled bleach in the hallway but did not see it in use. One additional C.N.A. indicated she smelled bleach but did not see it being used. Apx. 11 am I consulted with [Regional Nurse Consultant] regarding the use of bleach by the C.N.A. [CNA A] for sanitation purposes. She consulted with [Director of Clinical Operations] regarding the use of bleach for sanitation. The result was to educate the staff members on what chemicals are appropriate for use in the Nursing center for cleaning and sanitation purposes. Apx. 3:00 pm an additional 2 C.N.A.'s was interviewed and had not smelled the bleach on their shift. [interim] DON did not return on the 11th. On [DATE] Apx. 5:15 pm I was provided a written statement from [CNA B] and it indicated the resident [CR#1] was having difficulty breathing because the aide put bleach in her bath water, but later recovered. At that time, I escalated this to a reportable event. I consulted with [Regional Nurse Consultant] who agreed to report the event to HHS. Record review of the facility Abuse Prevention Program dated ,d+[DATE] revealed 1. The Administrator is responsible for the overall coordination and implementation of our Center's abuse prevention program policies and procedures Identification Assessment and Recognition of Abuse: 1. The nurse will assess the individual and document related findings 2. The nurse will report findings to the physician. As needed, the physical will assess the resident/patient to verify or clarify such findings, especially if the cause or source of the problem is unclear. Investigation Role of the Administrator: 1. The Administrator has the overall responsibility for the coordination and implementation of our Center's abuse prevention program policies and procedures. The Administrator is the Abuse Prevention Coordinator. In absence of the Administrator the Director of Nursing will serve in this capacity. 6. The Administrator will suspend immediately any employee who has been accused of resident abuse, pending the outcome of the investigation. 7. The Administrator will ensure that any further potential abuse, neglect exploitation or mistreatment is prevented. Reporting 1. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the Center Administrator, or his/her designee, to the following person or agency's required: a. The State licensing/certification agency responsible for surveying/licensing Center 2. An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than: 3. Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury; or Twenty-four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury . Review of Clorox Regular-Bleach1 JW [DATE] at https://www.osha.gov/sites/default/files/,d+[DATE]/Sample%20SDS%20Handout.pdf accessed [DATE] indicated Precautionary Statements - Response Immediately call a poison center or doctor . If on skin (or hair): Take off immediately all contaminated clothing. Rinse skin with water .If inhaled: Remove person to fresh air and keep comfortable for breathing. Specific treatment (see supplemental first aid instructions on this label . Hazards not otherwise classified (HNOC) Although not expected, heart conditions or chronic respiratory problems may be aggravated by exposure to high concentrations of vapor or mist such as irate respiratory tract and cause coughing. Inhalation high concentrations may cause pulmonary [CONDITION(S)]. Skin contact may cause [NAME] skin irritations and [CONDITION(S)]. This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 1:30 PM. The Administrator and DON were notified. The Administrator was provided the Immediate Jeopardy template on [DATE] at 1:43 PM. The following Plan of Removal was submitted and accepted on [DATE] at 10:20 PM: [Facility Name] [Facility Address] [DATE] PLAN OF REMOVAL OF IMMEDIATE JEOPARDY STAFF WILL NOT BE ALLOWED TO WORK UNLESS THEY HAVE RECEIVED TRAINING AND REEDUCATION. Abuse & Neglect Issue: The facility failed to prevent and stop abuse of CR# 1 on [DATE] when CNA B witnessed CNA A provide bed bath to CR#1 using bleach and water. o On [DATE], CR #1 transferred to the hospital from the facility at 1:31am and expired at the hospital. o On [DATE], (Resident #2 was transferred to the hospital after assessment by the physician. Resident #2 was hyper salivating, her respiratory rate was increased, and her skin was flush. o On [DATE] the Administrator, will conduct safe surveys with the cognitive residents and will follow up with any unusual findings. o On [DATE] the Director of Nurses, will educate all staff on notifying the Licensed Nurse on any residents they've identified to have had a change in condition and alleged abuse and neglect. o [DATE] the Director of Nurses re-educated all staff on the importance of reporting all allegations of abuse to their immediate supervisor as well as to the Abuse Coordinator. If a staff member feels that nothing is being done related to an allegation of abuse, they have been instructed to report to the next person in charge immediately which is the Director of Nurses. o On [DATE], the Regional Director of Operations educated the Administrator, and Director of Nurses on the State of Texas Provider letter ,d+[DATE], and the SLP Abuse and Neglect Policy that specifically states when and what to report to HHS and the required time frame. o Upon discovery of an alleged abuse or neglect incident involving a resident, staff are expected to stop immediately ensure the resident is safe, which includes not leaving the resident alone, and calling immediately for help. It is expected the staff member to yell for immediate assistance and pull the resident's call light if in a resident's room. Issue: the facility failed to implement their abuse policy by allowing alleged perpetrator CNA A and CNA B to continue working their shifts. CNA A then worked a double shift that day and was not suspended until the next day o CNA A was suspended on [DATE] o CNA B was suspended on [DATE] o On [DATE] the Administrator, will educate all staff on abuse and neglect, protecting the resident, reporting, abuse prevention and who is the abuse coordinator. o On [DATE], the Regional Director of Operations educated the Administrator, and Director of Nurses on the State of Texas Provider letter ,d+[DATE], and SLP Abuse and Neglect Policy that specifically states when and what to report to HHS and the required time frame.

Based on observation, interview, and record review the facility failed to, based on the comprehensive assessment of a resident, ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and the resident's choices for 2 of 12 residents (CR #1, Resident #2) reviewed for quality of care. The facility failed to promptly assess and monitor CR#1 and Resident #2 for changes in conditions following incident of chemical (Bleach) exposure. CR#1 was found unresponsive hours after the exposure to bleach and sent to the hospital on [DATE] where he died an hour later. Resident #2 was found hyper salivating, her respiratory rate was increased, and her skin was flushed following assessment by the physician. Resident #2 died afterwards. An Immediate Jeopardy (IJ) was identified on [DATE] at 1:30 PM. While the IJ was removed on [DATE] at 8:00 AM, the facility remained out of compliance at a scope of isolated and severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk for inadequate care, infections, decline in health, and/or death. Findings included: In an interview on [DATE] at 1:00 PM, the Physician stated CR#1 potentially died from bleach intoxication. She said once she got to the facility today ([DATE]), she was told by several staff that CR#1 was given a bath in bleach. CR#1 was given a bath on [DATE] around 10 AM. She was told it was a strong pervasive bleach smell in the room and was reported that throughout the day CR#1 declined. A staff member witnessed CR#1 gasping for air and he was very upset. CR#1 was assessed by one of the nursing staff, and was found unresponsive, CPR was initiated, the resident was sent to the hospital and he passed away. The staff was upset and afraid of losing their jobs but was concerned because the Administrator was not addressing the issue, and felt the interim DON and Administrator covered up the incident. The physician said it was also reported to her hat Resident #2 was bathed in bleach also on [DATE]. She had not got a chance to assess Resident #2 yet. She stated from what was reported Resident #2 was assessed by nursing staff as well. She was not called or notified of either incident. She said if she was told that the residents were bathed in bleach, she would have ordered vital signs every two hours, stat labs, increased monitoring based on the resident's vitals and condition and they would have been sent out to the hospital. She said this could have contributed or caused CR#1's demise. The DON was interim and just left yesterday. She had not determined a cause of death and had not certified the death certificate. In an interview on [DATE] at 3:23 PM, the Administrator stated the facility called the incident to the state on [DATE] because he heard that CR#1was killed due to the bleach. The police were notified as well. 1. Record review of CR#1's face sheet revealed CR#1 was a [AGE] year old male that was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . CR#1 was discharged on [DATE]. Record review of CR#1's MDS dated [DATE] revealed CR#1 did not have a BIMS. CR#1 required extensive assistance with two-person assistance for personal hygiene. CR#1 required physical help in part of bathing activity with two-person assistance. Record review of CR#1's Care Plan dated [DATE] revealed CR#1 required total dependence with bathing with one-person assistance. Staff are to set up, assist, give shower, shave, oral, hair, nail care per schedule and PRN. Record review of [CR#1] Progress Notes revealed .Nursing [RN A] RN [DATE] 01:31 AM Transfer to Hospital Progress Note (Nursing) Received Order from Medical Provider to Transfer Resident to: Hospital ER (Name of Hospital) Transfer Order Obtained from: Nurse Practitioner (Name) [NP name] Transfer Order Entered in Resident Record.: Yes Primary Reason for Transfer: Unresponsive Responsible Representative Notified of Transfer: Yes (Name) [RP Name] Time Responsible Representative Notified of Transfer: [DATE] 01:24 AM Transportation notified of Transport: EMS (911) called Report Called to Hospital, spoke with: Name: na, Department: na, Phone Number: na CPR (Check all that apply): CPR Initiated before transport / EMS arrival, AED Used , Time CPR Initiated (Time) 0110, EMS Took Over CPR upon arrival , Emergency Cart / AED Arrived at Site of CODE, Oxygen Applied (liters) 2 Documentation Sent to Hospital (Check all that apply): Face Sheet Resident Condition at time of Transfer: Unresponsive Resident left facility at: [DATE] Disposition of Medication:: Medications Remain Secured on Medication Cart. Disposition of Belongings: Personal Belongings Remain at Facility. Bed Hold Notification: Resident / Responsible Representative will be Notified of Bed Hold Notification Information within 24 hours of Transfer Record review of CR#1's hospital records dated [DATE] revealed Chief Complaint Cardiac Arrest, found down Patient expired at 0152, informed patients' guardian .Clinical Impression Primary Impression: Cardiopulmonary arrest . 2. Record review of Resident #2's face sheet revealed Resident #2 was an [AGE] year old female that was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #2 was discharged on [DATE]. Record review of Resident #2's MDS dated [DATE] revealed she did not have a BIMS. Resident #2 required extensive assistance with two-person assistance with personal hygiene. Resident #2 required total dependence with bathing. Resident #2 was at risk for pressure ulcers, she had no pressure ulcers or skin issues documented. Record review of Resident #2's Physician Orders dated [DATE] revealed .Cleanse wound to right lower buttock with normal saline, apply Santyl and calcium alginate and skin prep to periwound and apply gauze island w/BDR dressing Q Day start date [DATE] . Record review of Resident #2's Care Plan dated [DATE] revealed Resident #2 required extensive assistance with bathing with one-person assistance. Staff were to set up, assist, give-shower, shave, oral care, hair, nail care per schedule and PRN. Record review of Resident #2's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . There was a verbal report to me that this patient may have been bathed during the bath with water with bleach in it. State is present at the building at this time, incident under investigation. Family member, [person], at the bedside, states patient has been sweaty, less responsive, appears to be flushed. He stated that patient looks like she is warm but appears to be cold, has been shaking a lot. Patient had a lower blood pressure documented yesterday, blood pressure reported as normal today. Due to dementia, I am unable to obtain history from the patient. Patient will be sent to the ER due to concern for progressive respiratory symptoms and changes from baseline . Note written by Physician. Observation on [DATE] at 1:28 PM, revealed Resident #2 was lying in bed, resident shaking, crying, labored breathing, saliva coming from her mouth. Resident #2 was non-verbal. In an interview on [DATE] at 1:42 PM the Physician stated she was sending Resident #2 to the hospital because she was shaking, and cold. She was hyper salivating, her respiratory rate was up , her skin was flush. She could not rely on the staff at the facility. She did not want to chance it. A family member also complained Resident #2 was shaking and could not get warm. She was looking for a nurse but could not find one, she did not want to wait another minute, especially knowing she had this exposure to bleach. In an interview on [DATE] at 3:15 PM Housekeeper A stated, she was coming down hallway with the housekeeping cart, when she smelled a loud bleach odor. CNA A opened the door to CR#1's room and the smell got stronger. Housekeeper A asked CNA A what was going on and CNA A said she bathed CR#1 with bleach, soap and water. She reported the incident to her supervisor Housekeeper B. They went to look at him, CR#1 was lying in the bed, he was wrapped up and his hair was wet, he was shivering and lying on his side. Housekeeper B went and told the interim DON. She was called in for an interview with DON and the Administrator . She told them she smelled bleach with the door closed, and she asked CNA A what was going on, and CNA A told her she used bleach with soap and water to clean CR#1. In an interview on [DATE] at 1:32 PM, Housekeeper B stated on [DATE] Housekeeper A reported to him that CNA A used bleach and water to bathe CR#1. Housekeeper B w ent into CR#1's room and the resident was shaking and gasping for air. He immediately got the interim DON and she assessed him. She said he looked to be okay. The room door was closed during the bed bath and the fumes were strong. He heard that CNA B said that she asked CNA A to stop the bath . Later that night he was sent out with breathing problems. Later that same morning Resident #2 was given a bath and the staff noticed her wound was bubbling. CR#1 and Resident #2 were non-verbal. Resident #2 had a big open wound. Staff are not supposed to use bleach to clean at the facility. Bleach was not supposed to be in the building. CNA A continued to work that day and was not placed on suspension. The Administrator did not report this incident to the state agency. CNA A had bleach because it was taken by the Administrator after he found out about the incident. In a interview on [DATE] at 2:55 PM, Housekeeper B stated when he got to duty Housekeeper A reported to him that CNA A bathed CR#1 in bleach this was around 10 AM. He ran immediately and got the interim DON. The interim DON assessed CR#1 said he was okay. The agency nurse RN B was aware of the situation, but he was not sure if she reported this to anyone. RN B said she smelled the bleach on the hallway but was not sure where it came from or who had the bleach. In an interview on [DATE] at 2:37 PM, CNA B stated on [DATE] CNA A asked her to assist with giving CR#1 a bed bath. When she walked into the room there was a strong bleach odor. CNA A reported to her that she put a little bleach in the water. CNA B said she told CNA A that those chemicals were strong and should not be used on the resident's skin. CNA A then told her she did it all the time and she used it to wash CR#1's hair. CNA B said she asked CNA A to stop the bath. CNA A replied to her lets just hurry up and finish . During the bed bath CR#1 started having difficulty breathing. After the bath he was dressed and put in the wheelchair. She reported this incident to the nurse on duty RN B that CR#1 had a reaction to the bleach. During the bed bath Housekeeper A walked in and asked had they been using bleach in the room. The staff are not supposed to use bleach in the facility. CNA A told her she got the bleach from the kitchen. CNA A was interviewed by the Administrator and she lied and said she was using the bleach to clean the room. The Administrator did take the bottle of bleach from CNA A and she was not suspended immediately after the incident. CNA A had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . She later found out CR#1 passed away and this hurt her. Later that morning RN B walked into Resident #2's room and noticed the bleach odor in her room. She helped CNA A reposition Resident #2 but she did not help with the bath. CNA A used bleach and water to clean that resident as well. She reported this to RN B. RN B looked at Resident #2's wound and it was bubbling. She reported to the nurse that CNA A used bleach to clean Resident #2. RN B did not want to do anything about the situation and said she did not want anyone to lose their job. Interview on [DATE] at 12:55 PM, CNA B stated she was called to CR#1's room to assist with his bath. She smelled and witnessed CNA A had bleach in a small pan with water during CR#1's bath. CNA A only used a small amount of water, just enough to wipe residents down. During the bed bath CR#1 was gasping for air but after CNA A finished, he started breathing normal. She asked CNA A to stop during the bath but was told by her just hurry. CNA A washed CR#1's hair as well. She reported this to RN B. She was not interviewed about the incident until the next day. She did not assist with Resident #2's bath but helped dry her off. She noticed Resident #2's wound was bubbling she reported to RN B that CNA A used bleach to clean Resident #2. In an interview on [DATE] at 3:55 PM, RN B stated Resident #2 had a pressure sore. She asked the aides to contact her when they finished the bath so she could treat the wound. On [DATE] CNA A yelled down the hallway she was finished bathing Resident #2 and when she got to the room, she could smell the bleach in the hallway, it was very strong. When she opened the door, the odor was strong in the room. The wound was bubbling , CNA A then stated the wound was cleaned with soap and water very well. CNA A told her she used the bleach to clean the room. This incident occurred around 11:15 AM. CNA B made an off-hand comment about bleach , but she was not sure what was going on that day. Later she figured out what was going on. The next day CNA B told her about the bleach and that CNA A put bleach in Resident #2's bath water . She was not sure who assessed Resident #2. She asked the interim DON what happened, and she told her she was not supposed to know about the incident and asked her who reported this to her. The interim DON was aware and was supposed to do an assessment and contact the physician. Resident #2 looked bug-eyed and was moaning during the wound treatment, she had pain in her wound. She cleaned and packed the wound. Resident #2 was alert. She was not sure about CR#1 she was told he had some trouble breathing and he had been moved to another side of the facility but that was it. In an interview on [DATE] at 12:31 PM, RN A stated when she got to her shift at 10:30 PM CR#1 was asleep. She usually checks to make sure residents were breathing, she was not too familiar with the resident he had just moved to her side. She said at 1:00 AM it was reported to her that CR#1 was gasping for air, so she went to assess him. She could not palpate a pulse, his pupils were fixed and he was unresponsive. She started CPR and 911 was notified. 10 minutes later the paramedics showed up and they took over. CR#1 was transferred to the hospital. During that night Resident #2 was fine, she was sleeping, she took her morning medication and had no issues. She heard that a staff member was cleaning residents with bleach. She had never witnessed anything like that, if that was reported to her she would had done something right away. She would have assessed the patient, took their vital signs and notified the physician, the family, and sent the residents out more than likely. That was a chemical, something poison control may have to deal with. In an interview on [DATE] at 4:29 PM, CNA A stated she did not give CR#1 a bath with bleach, she used bleach to clean the room and she was not aware it could not be used in the facility. She got the bleach from the kitchen, and a former Administrator allowed the staff to use bleach. She also used bleach to clean around the unit. She said there was a lot of misunderstandings and jealousy in the facility. She said she would not harm anyone. Staff were going around the facility accusing her of murdering residents. She only used the bleach to clean the resident's mattress and mop the rooms. She said she mopped the floors and cleaned the mattresses with bleach because housekeeping does not clean, and the night shift do not change the residents so they beds are soaked with urine. Housekeeping uses bleach as well but they will not report on themselves. She bathed CR#1 and CNA B helped put on his brief. CNA B told her she was going to tell the Administrator that she did not use bleach to bathe CR#1. CNA A said Resident #2 had a wound and she would not use bleach to clean the resident She was not sure if they were assessed. She worked a double that day because the facility had nobody to work. The residents were moved away from the memory care unit. She was later placed on suspension pending the investigation. In an interview on [DATE] at 3:39 PM, the Interim DON, stated on [DATE] it was reported to her by Housekeeper B that CNA A was washing CR#1 with bleach and water. CNA A reported she was just cleaning out the bed pan with the bleach cleanser. The resident did not have any issue or trouble breathing. None of the staff reported they actually saw her put bleach in CR#1's bath water. She assessed CR#1 and he was fine . She fed CR#1 in the dining room due to staffing challenges that day. She reported this to the Administrator, and he was still investigating. She said did not document the assessment and she was sorry; she said she was doing a number of things that day. The physician was not notified. The Interim DON said staff were saying two different things and there was confusion about what happened between CR#1 and Resident #2. She was not sure what happened. There was a lot going on that day and a lot of confusion. The staff are not supposed to be using bleach on the floor at the nursing home. She was not sure where CNA A got the bleach from . In an interview on [DATE] at 5:13 PM, the interim ADON stated she found out the following day about the bleach bath incident with CR#1. CNA A was then placed on suspension and taken off the schedule until further notice. There had been a lack of communication between her and the interim DON due to turmoil at the facility. She had not seen CR#1 the day the incident happened. She knew he passed during the night shift on [DATE]. She said the interim DON exited the facility yesterday, there was a lot of things going on with her which was an issue. She said she was not aware of the incident with Resident #2. The interimADON said the interim DON was notified and was supposed to do an assessment on CR#1 and Resident #2 and the physician should have been notified. The interim DON would refuse to work the floor. The Administrator was in a tough position, the interim DON could not complete a task, she had short focus, she was the cause of a lot of issues at the facility. In an interview on [DATE] at 5:30 PM the Administrator stated on [DATE] he was notified by the interim DON that CNA A bathed CR#1 with bleach. CNA A was placed on suspension . He started interviewing staff. The interviews did not produce anything. The situation had been a confusing mess. CNA A said she did not bathe CR#1 in bleach, and he was not sure if he believed her . He was made aware of this incident Wednesday ([DATE]) afternoon. Supposedly this occurred on Wednesday morning. He did not have an incident report for the incident. He was not aware of the allegation that Resident #2 was given a bed bath in bleach. The interim DON said she did an assessment, but she did not document the assessment. He was not sure if she contacted the physician. The assessment should have been documented and physician notified. The interim DON was a loose cannon and caused a lot of turmoil in the facility. He did not report this to the state agency because it was discussed at the corporate level and since it was just a bath in bleach, they were going to take any disciplinary action. This was not considered abuse. Staff are not supposed to use bleach to clean in the facility. The bleach was taken from CNA A and the staff were informed that they were to use sanitation wipes and not bleach to clean. The nurse aide reported she got the bleach from kitchen, but the kitchen denied that. CNA A had been a troublemaker at the facility, he was not sure who she got the bleach from. In an interview on [DATE] at 11:51 AM, Dietary Manager stated CNA A came to the kitchen about two weeks ago asking for bleach to clean the rooms with because they were smelling foul. She told her the kitchen did not keep bleach. The bottle of bleach that was taken from CNA A was from a company that did not service the facility . She spoke to the Administrator and told him the kitchen did not keep bleach or give it to CNA A. The facility was not supposed to have bleach on the premises. In an interview on [DATE] at 4:45 PM, the Maintenance Director stated he believed CNA A got the bleach from the container connected to the washing machine. It's called Liquid Destainer 8%. It is an industrial type of bleach and can burn the skin and needs to be handled with gloves. A special tool is needed to open the container, but the CNA A may have a straw or tool to pour it into a smaller container. In an interview on [DATE] at 12:13 PM, the ADON stated she was not privy to the incident regarding the bleach with CR#1. CR#1 passed away that same night. She had not seen CR#1 the day of the incident. She saw Resident #2 the next day, she assessed the resident because someone came to her and asked her to assess her due to possible bleach exposure the previous day. She checked her all her vitals and they were within normal limits. She assessed Resident #2 on Thursday [DATE]. She did not document the assessment of Resident #2. She just did the assessment due to the mention of the exposure. She had only been at the facility for three weeks. She overhead talk about the incident but the Administrator had not shared any information with her. If it was reported to her that a resident was exposed to bleach, she would have completed an assessment, reported this to the physician and notify the Administrator who was the abuse coordinator. In an interview on [DATE] at 4:00 PM, the DON stated Resident #2's family came and picked up her belongings. The resident was at the hospital and did not have more than two weeks to live, she was terminally ill. Resident #2 was going to another facility on hospice. In an interview on [DATE] at 1:40 PM, the Administrator stated he did suspend CNA A and take the bleach once he found out on Wednesday. He could not remember what day or time CNA A was suspended. In a follow up telephone interview on [DATE] at 7:37 AM, CNA B stated she was called and placed on suspension. She did not understand because she told the nurse on duty, RN B about the incident with the bleach and the interim DON was aware. CNA A was sent to the office and spoke with the DON and Administrator, the day of the incident. CNA A was sent back to the unit. The next day she had to write a statement. In an interview on [DATE] at 2:12 PM, the DON stated it was important for staff to assess residents and report changes of condition so the physician can follow up on the issues which could cause death. This was a resident's rights issue and could lead to neglect. The Administrator needed to be notified so an investigation could be completed. In an interview on [DATE] at 2:56 PM, the Administrator stated it was important for staff to immediately notify him of allegations of abuse and neglect so he can start his investigation and immediately initiate the abuse protocol and guidelines. Record review of the facility Abuse Prevention Program dated ,d+[DATE] revealed 1. The Administrator is responsible for the overall coordination and implementation of our Center's abuse prevention program policies and procedures Identification Assessment and Recognition of Abuse: 1. The nurse will assess the individual and document related findings 2. The nurse will report findings to the physician. As needed, the physical will assess the resident/patient to verify or clarify such findings, especially if the cause or source of the problem is unclear. Investigation Role of the Administrator: 1. The Administrator has the overall responsibility for the coordination and implementation of our Center's abuse prevention program policies and procedures. The Administrator is the Abuse Prevention Coordinator. In absence of the Administrator the Director of Nursing will serve in this capacity. 6. The Administrator will suspend immediately any employee who has been accused of resident abuse, pending the outcome of the investigation. 7. The Administrator will ensure that any further potential abuse, neglect exploitation or mistreatment is prevented. Reporting 1. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the Center Administrator, or his/her designee, to the following person or agency's required: a. The State licensing/certification agency responsible for surveying/licensing Center 2. An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than: 3. Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury; or Twenty-four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury . Review of Clorox Regular-Bleach1 JW [DATE] at https://www.osha.gov/sites/default/files/,d+[DATE]/Sample%20SDS%20Handout.pdf accessed [DATE] indicated Precautionary Statements - Response Immediately call a poison center or doctor . If on skin (or hair): Take off immediately all contaminated clothing. Rinse skin with water .If inhaled: Remove person to fresh air and keep comfortable for breathing. Specific treatment (see supplemental first aid instructions on this label . Hazards not otherwise classified (HNOC) Although not expected, heart conditions or chronic respiratory problems may be aggravated by exposure to high concentrations of vapor or mist such as irate respiratory tract and cause coughing. Inhalation high concentrations may cause pulmonary [CONDITION(S)]. Skin contact may cause [NAME] skin irritations and [CONDITION(S)]. Record review of the Safety Data Sheet for Liquid Destainer 8% dated [DATE] revealed .4. First Aid Measures EYES: Immediately flush eyes with plenty of water for at least 15 minutes. Get medical attention, if irritation persists. SKIN: Wash with soap and water. Get medical attention if irritation develops or persists .INHALATION: Remove from area to fresh air. Seek medical attention if respiratory irritation develops or if breathing becomes difficult. SIGNS AND SYMPTOMS OF OVEREXPOSURE ACUTE EFFECTS: Irritation or [CONDITION(S)] to eyes, skin, mouth and throat. Inhaling this product may cause irritation, [CONDITION(S)], and pulmonary [CONDITION(S)]. CHRONIC EFFECTS: The effects of long term exposure to this product have not been determined. Safe handling of this product on a long term basis should emphasize the avoidance of all effects from repetitive acute exposure . Record review of the facility policy Change in a Resident's Condition or Status dated ,d+[DATE] revealed 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): a. accident or incident involving the resident .d. significant change in the resident's physical/emotional/mental condition; e. need to alter the resident's medical treatment significantly; g. need to transfer the resident to a hospital/treatment center; .i specific instruction to notify the physician of changes in the resident's condition . This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 1:30 PM. The Administrator and DON were notified. The Administrator was provided the Immediate Jeopardy template on [DATE] at 1:43 PM. The following Plan of Removal was submitted and accepted on [DATE] at 10:20 PM: PLAN OF REMOVAL OF IMMEDIATE JEOPARDY STAFF WILL NOT BE ALLOWED TO WORK UNLESS THEY HAVE RECEIVED TRAINING AND REEDUCATION. Abuse & Neglect Issue: The facility failed to prevent and stop abuse of CR# 1 on [DATE] when CNA B witnessed CNA A provide bed bath to CR#1 using bleach and water. o On [DATE], CR #1 transferred to the hospital from the facility at 1:31am and expired at the hospital. o On [DATE], (Resident #2 was transferred to the hospital after assessment by the physician. Resident #2 was hyper salivating, her respiratory rate was increased, and her skin was flush. o On [DATE] the Administrator, will conduct safe surveys with the cognitive residents and will follow up with any unusual findings. o On [DATE] the Director of Nurses, will educate all staff on notifying the Licensed Nurse on any residents they've identified to have had a change in condition and alleged abuse and neglect. o [DATE] the Director of Nurses re-educated all staff on the importance of reporting all allegations of abuse to their immediate supervisor as well as to the Abuse Coordinator. If a staff member feels that nothing is being done related to an allegation of abuse, they have been instructed to report to the next person in charge immediately which is the Director of Nurses. o On [DATE], the Regional Director of Operations educated the Administrator, and Director of Nurses on the State of Texas Provider letter ,d+[DATE], and the SLP Abuse and Neglect Policy that specifically states when and what to report to HHS and the required time frame. o Upon discovery of an alleged abuse or neglect incident involving a resident, staff are expected to stop immediately ensure the resident is safe, which includes not leaving the resident alone, and calling immediately for help. It is expected the staff member to yell for immediate assistance and pull the resident's call light if in a resident's room. Issue: the facility failed to implement their abuse policy by allowing alleged perpetrator CNA A and CNA B to continue working their shifts. CNA A then worked a double shift that day and was not suspended until the next day o CNA A was suspended on [DATE] o CNA B was suspended on [DATE] o On [DATE] the Administrator, will educate all staff on abuse and neglect, protecting the resident, reporting, abuse prevention and who is the abuse coordinator. o On [DATE], the Regional Director of Operations educated the Administrator, and Director of Nurses on the State of Texas Provider letter ,d+[DATE], and SLP Abuse and Neglect Policy that specifically states when and what to report to HHS and the required time frame. o On [DATE], the Regional Director of Operations educated the Regional Nurse Manager, Administrator, and Director of Nurses, on suspension of involved staff immediately with all allegations of abuse and neglect and the first course of action which is to protect the resident and make sure he/she is safe. o [DATE] the Director of Nurses re-educated all staff on the importance of reporting all allegations of abuse to their immediate supervisor as well as to the Abuse Coordinator. If a staff member feels that nothing is being done related to an allegation of abuse, they have been instructed to report to the next person in charge immediately which is the Director of Nurses. Anytime an allegation of abuse is made, the staff is

Based on observation, interview, and record review, the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 12 residents (Resident #3) reviewed for accidents and supervision. The facility did not prevent Resident #3 from eloping from the facility on 11/02/21. Resident #3 was found by a stranger near a busy intersection (IH-45 and FM 1764 ), the resident was given beer by the stranger and then later returned to the facility. The facility was not aware Resident #3 had eloped until a family member called another resident of the facility, due to not being able to reach anyone via the facility phone. Resident #3 was last seen at the facility between 2-3 p.m., he was noted missing at approximately 6:54 pm, approximately 3 hours and 54 minutes before staff was aware. Resident #3 was not wearing his wander guard bracelet. Facility staff failed to intervene when RA A saw Resident #3 standing outside in the parking lot prior to her shift. Facility staff failed to put Resident #3's wander guard on after his return from a home visit . Facility staff failed to obtain a physician's order for Resident #3's wander guard which would have triggered monitoring of the wander guard. An Immediate Jeopardy (IJ) was identified on 12/10/21 at 6:10 PM. While the IJ was removed on 12/13/21 at 9:07 AM, the facility remained out of compliance at a scope of isolated and severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed residents at risk of serious harm, injury or death. Findings Included: Record review of Resident #3's face sheet revealed he was a [AGE] year-old male that was admitted to the facility on [DATE] with diagnoses of delusional disorders, idiopathic gout, anxiety disorder, alcohol dependence, alcohol use, and Wernicke's [CONDITION(S)] ( disorder that primarily affects the memory system in the brain that control balance and movement.). Resident #3 was discharged from the facility on 11/13/21. Resident #3 was discharged from the facility on 11/13/21 due to testing positive for COVID- 19. Record review of Resident #3's MDS dated [DATE] revealed he had a BIMS of 12 which meant he had moderate cognitive impairment and independent with walking in and off unit. Record review of Resident #3's clinical record revealed he did not have a care plan. Record review of Resident #3's Elopement Risk assessment dated [DATE] revealed Resident #3 was at Risk for Elopement. Record review of Resident #3's Progress Note dated 11/02/21 revealed Missing Resident Progress Note [interim ADON]: Resident was noted missing at: 11/02/2021 06:54 PM Resident was last seen by: (Name) CNA Resident was last seen in: (Location) Hallway Reviewed Facility Sign Out Log and: Resident Was Not Signed Out Notified: Facility Administrator of CODE PINK Activation, Facility Director of Nursing of CODE PINK ( elopement/missing person alert) Activation After the Initial Search, the Resident: Resident was Located and Code Pink Cancelled. The Following Individuals were Notified of Resident's Return to Facility: Resident's Responsible Representative, Facility Administrator, Facility Director of Nursing , Resident's Medical Provider Upon Return to the Facility;: A Physical Evaluation was Performed to Evaluate for Injury (See Focused Observation) , Resident Offered Nutrition and Fluids , Updated Medical Provider of on Resident's Status, Referral for Secure Unit Evaluation, Received New Orders (See Orders Section) , Updated Resident's Responsible Representative on Resident's Plan of Care , Elopement Risk Observation Completed 11/02/2021 09:10 PM Completed assessment completed with no signs of injury. Resident denies pain or injury. [interim ADON] Observation on 11/12/21 at 6:27 PM, revealed Resident #3 was sitting in his wheelchair in the secure unit hallway. In an interview on 11/19/21 at 1:46 PM, CNA F stated Resident #3 went on a home visit and his wander guard was taken off and not put back on, aide could not recall the date. She said Resident #3 was gone for several hours before anyone knew where he was at. Resident #3 told staff he had a few beers while he was away from the facility. A truck driver brought him back to the facility. The truck driver said he found him off of Interstate-45 and F.M. 1764 . He returned to the facility around 9 pm. In an interview on 11/19/21 at 2:01 PM, LVN D stated Resident #3 went on a home visit and when he returned his wander guard was not put on. On 11/02/21 she started her shift at 2pm, she said one of the aides told her they could not find the resident; she did not remember which one. She was not sure what time Resident #3 went missing. He was found by a truck driver off the freeway and was the one that brought him back to the facility. Resident #3 was moved to memory care. Resident #3 was brought back to the facility around 8 pm. He was assessed, moved to memory care unit, the physician was notified. Resident #3 did not have any injuries. In an interview on 11/19/21 at 2:35 PM, MA B stated during dinner time staff brought him his tray but he was not here. She just figured he was walking around the facility somewhere. MA B said the last time she saw Resident #3 was around 3 pm that day. A staff member saw him standing outside but thought a family member was coming to pick him up. She said around 6pm a family member of Resident #3 called another resident (Resident #16) at the facility because they received a call that Resident #3 left the facility. The family member gave the staff the phone number of the person Resident #3 was with. Resident #3 was in a town approximately with the person who picked him up . He walked away from the facility and was found off F.M. 1764 by someone he met. Resident #3 said he hung out with the person and drank some alcohol. She told the person that had him that Resident #3 needs to be brought back to the facility because he was a resident and they could get in trouble. She notified the interim DON, the Administrator, and the interim ADON. Resident #3 had a wander guard, but it was not on him. In an interview on 11/19/21 at 2:49 PM, the interim ADON (LVN) stated the interim DON, called her and said they had an elopement. When she got to the building, Resident #3 had returned, she notified the Administrator but was not aware of the incident . She said she completed an assessment and documented what she did and called the physician and family. The interim ADON said Resident #3 was moved to the memory care unit (a secure unit). She said a family member reported a staff member had taken off his wander-guard for a home visit, and when Resident #3 returned it was not put back on. The family member reported Resident #3 had gotten to Interstate-45, someone stopped to help him, and they brought him back. She was not sure when he left. From what she understood Resident #3 used the man's phone and called his family member; the family member notified the facility. After the incident Resident #3 was moved to the memory care unit per family consent and physician order. In an interview on 11/19/21 at 2:56 PM, the Administrator stated Resident #3 left the facility and was picked up by someone that brought him back to the facility. He said Resident #3 was attempting to get to his family when he left . The facility did not consider Resident #3 missing because they knew where he was . The administrator said Resident #3 did not have a risk for elopement . In an interview on 11/19/21 at 3:14 PM, LVN E stated he was told Resident #3 was missing around 5pm. Staff went to look for him but could not find him. That was his first day at the facility and he did not know what Resident #3 looked like. He started his shift at 2pm and had not seen the resident. In an interview on 11/20/21 at 7:58 AM, LVN D stated she was not sure who took off the wander guard or when Resident #3's last home visit was . In an interview on 11/22/21 at 9:30 AM, Restorative Aide A stated she saw Resident #3 standing outside sometimes between 2-3pm during shift change and did not tell anyone. Resident #3 was fully dressed, had his cane, and was walking through the parking lot. She did not speak with him; she thought the staff knew he left out of the facility. He had never left out of the door before. She was not sure if he had a wander guard. She was leaving the facility to go on break. When she came back the facility, Resident #3 was not outside. She was not sure what time he returned. When she left her shift at 6pm the resident had not returned. She was not sure when he went missing. In an interview on 11/22/21 at 11:00 AM, the DON stated if she was at the facility at the time of the elopement with Resident #3 she would have instructed the staff members to find out the location of the resident and go to that location to make sure the resident was okay. The facility did not have transportation staff, but they could have got a non-emergency EMS company to pick him up and bring him back safely to the facility. Since she was notified about this incident all the residents at the facility had been assessed and reviewed for elopement risk. The wander guard system was tested and assessed by the facility monthly . In an interview on 11/22/21 at 12:35 PM, the DON stated she was informed that Resident #3's wander guard was taken off during one of his home visits and it was never put back on. She said she could not find a care plan for Resident #3. In an interview on 11/22/21 at 3:00 PM, the Administrator stated the facility did not know where Resident #3 was at the time so he could not have staff go pick him up. Normally the facility would have picked up Resident #3 if they knew where he was. In an interview on 11/22/21 at 4:30 PM, the DON stated the facility did not have a policy on supervision or wander guards. Resident #3 did not have an order for a wander guard . The staff should have obtained a physician order for the wander guard. When nursing staff put in an order it will trigger documentation for the monitoring of the wander guard. The nursing staff were responsible for testing monitoring resident wander guards to make sure they were on residents. In an interview on 12/10/21 at 3:35 PM, MA B stated the staff did not know Resident #3 was gone. A family member called her ex roommate at the facility Resident #16, and Resident #16 came to the nurses station and told the staff Resident #3 left the premises, she said this was after dinner between 6pm-7pm . In an interview on 12/10/21 at 3:45 PM, Resident #16 stated she got a call from her ex roommate around 6:55 PM but she missed the call because she was smoking. She returned the call to Resident #3's family member around 7:06 PM. She said she was told that Resident #3 had left the facility and a good Samaritan picked him up off the side of the highway and took him to find his old home. She said they could not find the home, so he (Resident #3) called his family member to try and come to her house. The family member tried to get in contact with the facility, but nobody was answering the phone. Resident #16 said she told the facility staff that Resident #3 was off the premises and staff went looking for him. She said Resident #3 had gone on a home visit a week or so before he eloped, and staff did not put on his wander guard when he returned. Resident #16 was given information by Resident #3's family member who was Resident #16 previous roommate at the facility. She said the facility staff do not answer the phone. She said she got calls from other family members to report things to the staff because nobody answers the phones. Record review of Resident #16's MDS dated [DATE] revealed she had a BIMS of 12 indicating moderate cognition impairment. Record review of the facility policy Wandering and Elopements dated 03/2019 revealed Policy Statement The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents .1. If identified as a risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. 2. If an employee observes a resident leaving the premises, he/she should; a. Attempt to prevent the resident from leaving in a courteous manner; b. Get help from other staff members in the immediate vicinity, if necessary; and c. Instruct another staff member to inform the Charge Nurse or Director of Nursing Services that a resident is attempting to leave or has left the premises . This was determined to be an Immediate Jeopardy (IJ) on 12/10/21 at 6:10 PM. The interim Administrator was notified. The interim Administrator was provided the Immediate Jeopardy template on 12/10/21 at 6:12 PM. The following Plan of Removal was submitted and accepted on 12/11/21 at 3:32 PM: Plan of Removal Please accept this Plan of Removal as a credible allegation of compliance for immediate jeopardy initiated on December 10, 2021, for failing to ensure resident #3 received adequate supervision to prevent accidents-elopement. Issue: The facility failed to ensure Resident #3 received adequate supervision to prevent elopement. The administrator will conduct in-services elopement with all clinical staff on elopement risk. STAFF WILL NOT BE ALLOWED TO WORK UNLESS THEY HAVE RECEIVED TRAINING AND RE-EDUCATION. Action: Administration conducting education with all direct care staff regarding residents to effectively supervise and monitor residents and ensure their safety at all times including risk for elopement and intervening when a resident is found outside the facility. To ensure awareness of other residents who may be prone or exhibiting exit seeking behaviors to include residents with these diagnosis or characteristics of the following: Alzheimer's disease, anxiety disorder, restlessness, [CONDITION(S)] disorder, delusional thinking, generalized dementia, and depression. All direct care staff, nursing management, IDT team, and administrator will be educated on the following protocol: 1. Self report 2. Resident who eloped assessed and assessment documented in clinical record 3. Physician notification and RP notification documented in resident clinical record 4. Incident report completed 5. Incident will be reported to DOH. Investigation initiated. 6. Conduct head count to ensure all residents are accounted for 7. Complete/update elopement/BIMS assessments for ALL residents in the building. All elopement assessment of facility residents to be completed by 12/12/2021 to identify those who are risk of elopement and or exit seeking. The Regional Nurse manager or designee will be training all licensed nurses on how to complete elopement risk assessments and the Regional Nurse Manager will assist with the completion of the elopement risk assessment. Residents found to be at risk for elopement will have their care plan updated to address at risk for elopement. All at risk for elopement will have care plans updated by the IDT team by 12/12/2021 8. The Administrator and Regional Nurse Manager will identify from the completion of elopement risk assessment # of wander guard bracelets required by 12/11/2021. There are 6 residents that require wander guards, physician orders for use of the wander guards will be verified by the Regional Nurse Manager on 12/11/2022. The Administrator or designee will check to ensure all residents with wander guard bracelets have been checked and are functional by 12/12/2021 and document in the wander guard book located at the nurses station. 9. The charge nurse will be responsible for checking wander guard bracelet per physician orders. The Charge Nurse will document on the resident's MAR/TAR have wander guard orders to include monitoring. 10. The facility administrator or designee will educate all clinical staff on the sign in and out process. This will include those with a wander guard. The wander guard bracelet should not be removed from the resident unless authorized by the director of nurses or the administrator. The Charge nurse will be responsible for checking for wander guard placement upon a resident's return from an outing or pass. The administrator or designee will educate all clinical staff to checking for wander guard placement on each resident by facility resident listing and document in wander guard book and resident clinical record. All staff present on the day of the incident are being educated on elopement protocol and expectations. Staff RA will receive one on one education with the Interim Administrator on 12/11/2021. 11. The administrator or designee will educate all staff on what to do when a resident is outside the facility. The staff will be educated on the following: 1) promptly respond to the doorbell ringing located in the front lobby of the facility. 2) identify the resident located outside the facility by reviewing the facility resident listing and the resident photo locate in the Electronic Medical Record. 3) Once the resident's identity has been verified by the staff member, notify the charge nurse to assessed the resident for any issues or injury and document in the resident's clinical record 4) resident located outside the facility : the staff member should identify the resident from the facility resident listings; notify the administrator immediately to go retrieve the resident; upon return to the facility, the resident would need to be assessed for injury, RP and Physician notified. This education will be completed by 12/12/2021. On/or before 12/10/2021, The Regional Director of Operations will reeducate the Interim Administrator on elopement protocols, reporting elopement to DOH, and investigating accidents and incidents. On/or before 12/12/2021, The Regional Nurse Manager will reeducate the Director of Nursing on elopement protocols, investigating accidents and incidents, ensuring physician orders are in place for wander guards. Completion Timeline: December 10, 2021, and going forward to include staff not working at time of in-service (FT, PT, agency, PRN) Training will be conducted by the administrator or designee. Completed on 12/12/2021. Responsible: Administrator, Regional Nurse Manager, CCM, and, Charge nurses 2. Action: 1. Residents who have been identified at risk for elopement need to be placed in the elopement risk book located at each nurse's station (to include picture, and face sheet) to locate wander guard notebook with the resident photo and resident profile) 2. Direct care staff should respond when a missing resident is alleged to include: conducting room to room and all areas of the center search; conduct a search outside of the center on the building perimeter and grounds; if the resident is not located in these search contact law enforcement will be notified by the charge nurse or designee. Beginning December 10, 2021, direct care staff (agency, PRN, new hires) who have not received the above stated education will be educated by Nursing Administration prior to providing resident direct care. Administrator or designee will be responsible for conducting training. Completion Timeline: Beginning December 10, 2021, and going forward to include staff not working at time of in-service (FT, PT, agency, PRN). Training will be completed 12/12/2021. Responsible: Administrator, Regional Nurse manager, CCM, and, Charge nurses 3.Action: Administrator or designee will audit the following to ensure residents that are prone to elopement and exit seeking on the following: 1. Residents at risk of elopement will have wander guards in place with physician order to ensure accurate assessment. 2. Wander guard system door checks are to be conducted each day to ensure functionality every weekday and documented by the Director of Maintenance. 3. Wander guard system door checks are to be conducted each weekend day to ensure functionality by Weekend Nurse Supervisor. These checks must be documented on the log sheet. 4. Testing The Signaling Device is completed as required. 5. The facility will ensure residents at risk of elopement have wander guards functional especially after they return form outgoings or passes. Completion Timeline: December 10, 2021, and going forward to include staff not working at time of in-service (FT, PT, agency, PRN). Completion date 12/12/21. Responsible: Administrator, Maintenance Director, Charge nurses, Nurse manager Quality Assurance Performance Improvement o Conduct and document Ad Hoc PI (include MD telephonically) to be completed December 12, 2021. o Ensure doors continue to be checked daily- document in TELS-----Proactive measure o Ensure all wander guards are documented with no omissions on the TAR's. Proactive measure o Audit elopement risk assessments/books/care plans 3 times per week for 1 month and monthly for 2 months; subsequent audits per the advisement of the QAPI committee. o Review audit information monthly in PI for one quarter. Please review and accept this Plan of Removal. All items above have been completed and or initiated with completion date and time of December 12, 2021, at 5pm. After this time, any staff that have not completed their in-service will not be allowed to work until in-service is completed. Surveyor Monitored the plan of removal as follows: Observations were started on 12/11/21 at 12:20 PM and continued through 12/13/21 at 7:44 AM. Observations of Resident #11, Resident #12, Resident #13, Resident #14, Resident #15 revealed Residents had wander guard bracelets on. Resident #3 was out on pass. Observation of the facility wander guard system revealed no concerns the system was working properly. Interviews were started on 12/12/21 at 12:52 PM and continued through 12/13/21 at 8:31 AM with 25 staff across all three shifts, including weekdays, weekends, and multiple departments. The staff interviewed regarding the plan of removal: RN A, LVN G, LVN J, Housekeeper B, CNA Q, LVN H, Regional Nurse Consultant, CNA R, CNA M, CNA S, TNA, CNA T, CNA U, CNA H, CNA K, CNA V, LVN K, RN C, MA B, LVN C, CNA C, CNA D, Maintenance Director, Rehabilitation Coordinator, and OTA. All staff interviewed verbalized adequate understanding of plan of removal training received on need to supervise residents and have residents within sight at all times. Record review of Resident #11, Resident #12, Resident #13, Resident #14, and Resident #15, Physician Orders dated 12/2021 revealed residents had physician orders for wander guards. Resident #3 was on the secure unit and no longer had a wander guard. Resident #3 was reported to be out on pass on 12/13/21. Record review of Resident #11, Resident #12, Resident #13, Resident #14, and Resident #15, Medication Administration Record dated 12/2021 revealed residents had documentation of monitoring for wander guard system by nursing staff. Record review of Resident #3, Resident #11, Resident #12, Resident #13, Resident #14, Resident #15, electronic medical record revealed each resident had an up to date elopement risk assessment completed. Record review of Resident #3, Resident #11, Resident #12, Resident #13, Resident #14, Resident #15 care plans dated 12/2021 revealed each resident had a care plan to address elopement risk. Record review revealed the facility had a binder on the South and North Nurse Stations for wander guard residents, at risk for wandering residents, and a sign in/out book for residents out on pass. Record review of facility POR binder dated 12/2021 revealed the facility had maintenance check of the wander guard system weekly. Record review of the facility in-services dated 12/10/21 and 12/11/21 revealed staff were in-serviced on elopement protocols, elopement templates, completing nursing documentation, missing resident Code Pink protocols, wandering and elopements, wander guard placement, wander guard function, wander guard monitoring, documentation on MAR/TAR, incident/accident reports, sign in/out book, and RA A was in-serviced 1;1. The Regional Nurse Consultant was informed the Immediate Jeopardy was removed on 12/13/21 at 9:07 AM. The facility remained out of compliance at a scope of isolated and severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on Observation, interview, and record review, the facility failed to consult the physician for changes in condition for 1 of 10 residents (Resident #5) reviewed for changes in condition as evidenced by: -Resident #5 had significant weight loss in 1 month; the physician was not consulted; -Resident #5's physician was not consulted on the continuous decline in weekly weight; -Resident #5 ' s physician was not consulted on the Speech Therapy (ST) - progress and discharge summary. This failure affected 1 resident and placed an additional 38 residents at risk for weight loss and a decline in health status related to poor nutrition. Findings include: Review of the medical record face sheet for Resident #5 revealed he was admitted to the facility on [DATE] and re-admitted on [DATE]; he was [AGE] years old. His admission [DIAGNOSES REDACTED]. Record review of Resident #5's weight loss care plan, dated 2/4/15, revealed a goal of I will gain 2 lbs per month.health shakes with lunch. Record review of the ST - Therapist Progress & Discharge Summary dated 4/24/2015 read in part . Start of Goal Status as of 4/17/15 . the patient consumes mechanical soft consistency while facilitating no compensatory safe swallow strategies exhibiting intermittent signs and symptoms (s/s) aspiration and a moderate swallow impairment for solids. - Analysis of functional Outcome/Clinical Impression -patient has made minimal progress, minimal effort. - Impact on Burden of Care/Daily Life - patient continues to demonstrate signs and symptoms (s/s) aspiration; refuses to incorporate any compensatory safe swallow strategies into mealtime. - Precautions - falls, aspiration. Record review of the MDS assessment screening section on Swallowing/Nutritional Status dated 5/6/2015 revealed Resident #5 weighed 149 lbs. Record review of Resident #5's facility weekly weight records revealed the following weights/dates: -5/18/2015 of 142 lbs. -5/25/2015 of 137 lbs. -6/1/2015 of 130 lbs. -6/15/2015 of 129 lbs -6/23/2015 of 127 lbs Record review of the facilities most recent entry in the Nursing Documentation Record dated 5/14/2015 @ 2:30 pm revealed an entry NP in facility making rounds - please see new order to d/c [MEDICATION NAME] . No further documentation was noted referencing weight loss. Record review of Resident #5's physician order [REDACTED].snacks three times a day. Further review revealed an order for [REDACTED]. Observation on 6/23/15 at 12 noon revealed Resident #5 was in his room eating his lunch alone. Observation revealed the resident's right hand was slightly contracted and his right arm was contracted. Further observation revealed he ate approximately 1/2 of a meat patty, 1/4 of his potatoes and a few carrots. He was unassisted during this meal. Observation and interview on 6/24/15 at 11:45 am revealed Resident #5's lunch tray was delivered to him. At that time he was asked if he took the pill to increase his appetite and he responded yes, he takes that. In an interview on 6/25/2015 @ 3:30 pm, the DON stated if there are no doctor's orders addressing the weight loss then it appears that he has not been notified. When asked about Resident #5's diet as noted on the Speech Therapy Summary dated 4/24/2105 of a mechanical soft diet, the DON replied that nursing wasn't aware of the diet recommendations and she would call the doctor as soon as we were done and notify her of the 10 lb weight loss in 1 month and the dietary recommendation for a mechanical soft diet. She stated, There must be a breakdown in communications, nursing was not aware of the Speech Therapist Progress & Discharge Summary noting Resident #5 consuming a mechanical soft diet. Record review of the facility's policy and procedures for Change of Condition - Observing, Reporting and Recording, revised March 2012, read in part .it is the policy of this home to inform the resident, the residents physician and if indicated the residents responsible party of the following: .2. A significant change in the resident ' s physical, mental or psychosocial status, such as a deterioration in health, mental, or psychosocial status, in life-threatening conditions or clinical complications . Record review of the facility's policy and procedures for Weight System, revised March 2012, read in part .It is the policy of this home to ensure resident ' s weights and heights are monitored in a timely manner, to identify residents with significant weight change and provide nutritional intervention to stabilize weights, unless otherwise indicated. A significant weight change is defined as a weight loss or gain of 5% in 30 days (1 month), 7.5% in 90 days (3 months) and 10% in 180 days (6 months). Procedure. 7. The Director of Nursing/Designee will ensure that the Physician, Responsible Party, and Dietitian will be notified in a timely manner and documented in the clinical record. According to CMS 672 the facility census was 39.

Based on interview and record review, the facility failed to prevent unplanned weight loss for 1 of 11 residents (Resident #5) reviewed for nutrition and necessary care, as evidenced by: -Resident #5 had significant weight loss in 1 month; These failures affected 1 residents and could place an additional 38 residents at risk for weight loss and a decline in health status related to poor nutrition. Findings include: Record review of the medical record face sheet revealed Resident #5 was [AGE] years old. He had been admitted to the facility on [DATE] and re-admitted on [DATE]. His admission [DIAGNOSES REDACTED]. Record review of the quarterly MDS assessment screening section on Swallowing/Nutritional Status dated 5/6/1015 revealed Resident #5 weighed 149 lbs. Resident #5 required supervision of 1 person for assistance with eating. Record review of Resident #5's weight loss care plan, dated 2/4/15, revealed a goal of I will gain 2 lbs per month.health shakes with lunch. Record review of Resident #5's weekly weight records revealed the following weights/dates: -5/18/2015 of 142 lbs. 5/25/2015 of 137 lbs 6/1/2015 of 130 lbs. -6/15/2015 of 129 lbs. -6/23/2015 of 127 lbs. Observation on 6/23/15 at 12:01 pm of the lunch meal revealed there were no red napkins being utilized for the residents. All napkins were white. Record review of the facilities most recent entry in the Nursing Documentation Record dated 5/14/2015 @ 2:30 pm revealed an entry NP in facility making rounds - please see new order to d/c [MEDICATION NAME] . No further documentation was noted referencing weight loss. Record review of the ST - Therapist Progress & Discharge Summary dated 4/24/2015 read in part . Start of Goal Status as of 4/17/15 . the patient consumes mechanical soft consistency while facilitating no compensatory safe swallow strategies exhibiting intermittent signs and symptoms (s/s) aspiration and a moderate swallow impairment for solids. - Analysis of functional Outcome/Clinical Impression -patient has made minimal progress, minimal effort. - Impact on Burden of Care/Daily Life - patient continues to demonstrate signs and symptoms (s/s) aspiration; refuses to incorporate any compensatory safe swallow strategies into mealtime. - Precautions - falls, aspiration. Record review of Resident #5's physician order [REDACTED].snacks three times a day. Further review revealed an order for [REDACTED]. Observation on 6/23/15 at 12 noon revealed Resident #5 was in his room eating his lunch alone. Observation revealed the resident's right hand was slightly contracted and his right arm was contracted. Further observation revealed he ate approximately 1/2 of a meat patty, 1/4 of his potatoes and a few carrots. He was unassisted during this meal. Observation and interview on 6/24/15 at 11:45 am revealed Resident #5' lunch tray was delivered to him. At that time he was asked if he took the pill to increase his appetite and he responded yes, he takes that. Observation on 6/24/15 at 11:55 am of the lunch meal revealed there were no red napkins being utilized for the residents. All napkins were white. During an interview on 6/25/15 at 2:48 p.m. the Dietary Manager said dietary staff would put red napkins on trays for those who were on the list. She said the Dietician did assessments and then the residents were discussed in the risk meetings at the facility, and that was how the list was generated for the Red Napkin program. The Dietary Manager said they were currently out of red napkins and that was why they did not have them this week. When asked how long they had been out she said about two weeks. She said she was responsible for ordering the napkins and she needed to check on her order. When asked if someone could buy them locally the Dietary Manager said yes, and that she could go out and get some today for meal service that evening and the next day. Interview on 6/25/15 @ 3:30 pm the DON stated if there are no doctor's orders addressing the weight loss then it appears that he has not been notified . When ask about Resident #5 's diet as noted on the Speech Therapy Summary dated 4/24/2105 of a mechanical soft diet, the DON replied that nursing wasn't aware of the diet recommendations and she would call the doctor as soon as we were done and notify her of the 10 lb weight loss in 1 month and the dietary recommendation for a mechanical soft diet. There must be a breakdown in communications, nursing was not aware of the Speech Therapist Progress & Discharge Summary noting Resident #5 consuming a mechanical soft diet During an interview on 6/25/15 at 3:47 p.m. the DON and Administrator said they were unaware the facility did not have red napkins for the last two weeks. When asked if anyone had noticed there was no answer. The DON said they probably needed to train staff periodically about the program. Record review of the facility's policy and procedures for Weight System, revised March 2012, read in part .It is the policy of this home to ensure resident ' s weights and heights are monitored in a timely manner, to identify residents with significant weight change and provide nutritional intervention to stabilize weights, unless otherwise indicated. A significant weight change is defined as a weight loss or gain of 5% in 30 days (1 month), 7.5% in 90 days (3 months) and 10% in 180 days (6 months). Procedure. 7. The Director of Nursing/Designee will ensure that the Physician, Responsible Party, and Dietitian will be notified in a timely manner and documented in the clinical record. Review of the Policy and Procedure Subject Weight - Red Napkin Program revised 3/2012 read: It is the policy of the home to initiate a red napkin program to identify residents with significant weight loss for staff and procedures to improve these residents (sic) food intake. 1. The Resident-at-Risk Committee will notify the Dietary Service Manager of which residents with significant weight loss will be placed on the Red Napkin Program. A list should be developed and assessable (sic) for staff to review. A copy of this list should be given to the Dietary Staff. 2. Upon notification, the Dietary Manager will purchase red dinner napkins and train staff of who should receive them. 4. The Dietary Aide/designee will roll silverware in the red napkin and place on the tray for all residents with significant weight loss. 5. Each resident with a red dinner (sic) will receive extra attention and coaching in eating their meal. According to CMS 672 36 residents ate food prepared by the kitchen.