Every finding on record at Avir at Boerne

Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals used in the facility were stored and labeled in accordance with currently accepted professional principles for 4 of 6 carts (the C/D hall treatment cart, the A/B hall treatment cart, the B hall medication cart, and the C hall medication cart) reviewed for medication storage and labeling. The facility failed to ensure all insulins located inside the C/D hall treatment cart and the A/B hall treatment cart were properly labeled with opened dates. The facility failed to ensure all medications located inside the B hall medication cart and the C hall medication cart were stored in labeled containers. These failures could place residents at risk of receiving inadequate treatments or ingesting medications for which they were not prescribed.The findings included:During an observation of the C/D hall treatment cart on [DATE] at 8:45 AM, 3 of 8 insulins in the cart did not contain an opened date indicating when they were removed from refrigeration. During an interview with the ADON on [DATE] at 8:46 AM, the ADON stated insulins should be dated as soon as they were removed from the refrigerator to know if the medication was still potent. The ADON stated if the insulins had lost their potency, residents might not receive the intended effect of their medication.During an observation of the A/B hall treatment cart on [DATE] at 8:54 AM, 1 of 7 insulins in the cart did not contain an opened date indicating when they were removed from refrigeration. During an interview with LVN B on [DATE] at 8:55 AM, LVN B stated it was important to date the insulins when they come out of the refrigerator, so they would know when to dispose of them. LVN B stated if the medications were not dated, they could be past their expiration date. LVN B stated the insulin could be less effective if it was expired, and residents might not get a therapeutic dose of their medication.During an observation of the B hall medication cart on [DATE] at 9:05 AM, 9 loose pills were discovered lying in the bottom of the second drawer of the cart.During an interview with CMA C on [DATE] at 9:06 AM, CMA C stated if there were loose pills in the cart, a resident might not have received their medication. CMA C stated if a resident had a condition like high blood pressure, anxiety, or acid reflux, and they missed a dose of their medication, they could experience an elevation in their blood pressure or an increase in anxiety or discomfort. CMA C stated that when found, loose pills should be discarded, and the nurse should be informed. During an observation of the C hall medication cart on [DATE] at 9:15 AM, 3 loose pills were discovered lying in the bottom of the second drawer of the cart. During an interview with CMA A on [DATE] at 9:16 AM, CMA A stated there should not be loose pills in the cart, because they could be picked up from the drawer and given to a resident causing cross contamination. CMA A stated there could be a delay in therapy if a resident is missing a dose of their medication. During an interview with the DON on [DATE] at 1:33 PM, the DON stated her expectation for insulins was that they be labeled with the date as soon as they came out of the refrigerator so they would know when the medication would expire. The DON stated she expected her staff to clean and inspect their carts for loose pills regularly during any down time. The DON stated if loose pills were administered to residents, they could be expired and less effective, or if given to the incorrect person, the resident could be exposed to an adverse effect like an allergic reaction. Record review of the facility policy titled Medication Labeling and Storage, revised 02/2023, noted Medication Storage 1. Medications and biologicals are stored in the packaging, containers, or other dispensing systems in which they are received. 5. Medications are stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. Medication Labeling 1. Labeling of medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices. 2. The medication label includes, at a minimum: d. expiration date.

Based on observation and interview, the facility failed to provide a safe, clean, comfortable, and homelike environment with maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for 1 of 4 units (Unit B), reviewed for physical environment. The facility failed to ensure the door jamb, strike plate, and latch hole of the women's secure unit B shower room was not covered with black duct tape which prevented the door from latching and locking and the push buttons 5, 6, 7, and 9 on the electronic door lock were not missing. The facility failed to ensure the shower floor drain had a drain cover over it. This failure could place residents at risk of being exposed to others while being provided with care and showers, an unsanitary environment, accidents, and could result in embarrassment and being uncomfortable. The findings were: Review of the facility women's secure unit B resident roster on 5/5/25 at 9:45am revealed there were 17 female residents residing on the unit. In an observation on 5/5/26 at 10:35 a.m. the unit B shower room door was pulled to but not fully closed and latched and there was an area of solid black that could be seen between the wall and the door where it would latch. There was an electronic lock with numbered push buttons sticking out and numbered buttons missing were 5, 6, 7, and 9. After knocking and ensuring it was not occupied the door was pushed opened. The door jamb, strike plate, and latch hole were covered with black duct tape approximately 12 inches in length and it was pulling away from the door jamb in an area approximately 6 inches long and in that area was what appeared to be sheetrock or part of the frame that had gotten stuck to the duct tape. There was another piece of duct tape going crossways across this area from the outside of the door frame to the inside of the door frame and wrapping around to the inside wall. Inside the shower room there were two linen carts, a toilet, sink and shower area behind a partial tiled wall. There were no razors or chemicals observed. In the shower area the drain hole in the floor was observed to be open and not covered with what looked to be hair and debris in the drain and a shower chair was inside. The shower chair and floor were damp but not wet and the room smelled of fresh soap. In an observation and interview on 5/5/26 at 10:53 a.m. in the secure women's unit B shower room, MA C stated she was unsure of how long the shower room door jamb had black duct tape on it, or how long the buttons on the lock had been missing and she was unsure of how long the drain cover had been missing on the shower room drain. MA C stated there had been no accidents or issues that she was aware of with residents walking in on other residents or of residents or staff stepping in the drain hole. MA C stated they did not keep shampoo, body washes, razors, or anything the resident could injure themselves with, out in the open in the shower room. The shower room was observed to be exactly as observed at 10:35 a.m In an interview on 5/5/26 at 11:02 a.m. LVN E stated the shower room door and lock had not been like that for long but unable to state how long it had been like that. LVN E stated there had been no issues with the residents wandering into the room while another resident was being showered and provided care as the door was pulled shut and the residents did not try to open closed doors and just walk past them. LVN E stated residents pulled the buttons off of the electronic lock and she was unsure if it had been reported to maintenance. In an interview on 5/5/26 at 11:05 a.m. the DON stated she was unaware of the shower room door in the women's secure unit B having tape on it or the buttons on the lock missing. An unknown staff member in the DON's office stated it was being fixed by maintenance already. In an observation and interview on 5/8/26 at 11:30 a.m. in the secure women's unit B shower room, the black duct tape was removed, the electronic lock had been replaced with a new working lock. CNA G demonstrated the lock worked and let the surveyor into the shower room. Observation revealed there was still no drain cover over the shower floor drain and all four of the shower chair wheels would fit into the first upper ring of the drain but only tilted the shower chair slightly and was not enough to tilt the chair significantly. The shower chair was wet as was the shower floor and CNA G stated they had been showering residents and had not had any issues or concerns with the floor drain cover missing. CNA G stated she was unsure of how long the drain cover had been missing or if it had been reported to maintenance but that there had been no issues with the shower chair wheels going into the top of the drain or any staff stepping or tripping on the drain while showering residents. CNA G grabbed the shower chair and pushed it back and forth to demonstrate the drain hole was not near the shower chair wheels and stated there had been no issues or concerns with the drain cover missing. Debris that was dark in color remained in the uncovered drain of the shower floor. In an interview on 5/8/26 at 11:50 a.m. the Maintenance Director stated he was not aware the women's secured unit B shower room floor drain cover was missing and he would fix it right now. The Maintenance Director stated there was an online computer reporting system for all staff to report maintenance issues, anything reported went directly to his notifications, and nothing had been entered in the system for the shower room floor drain cover. In a joint interview on 5/8/26 at 1:35 p.m. with the Administrator and DON, the Administrator stated the door to the women's secure unit B shower room should not have had duct tape on it, the lock should work and have no missing buttons, and the drain cover should be in place. The Administrator stated there could possibly be a dignity issue with the door not being able to be locked and a possible accident with the drain cover missing but there had been no negative occurrences and all of the issues with the door, lock, and drain had already been resolved and the Administrator had a picture of the drain cover in place. Review of the facility policy on maintenance service revised December 2009 indicated Maintenance service shall be provided to all areas of the building, grounds, and equipment. 1. The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. 2. Functions of maintenance personnel include but are not limited to: a. maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines. b. maintaining the building in good repair and free from hazards.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for 1 of 1 kitchen reviewed for food service safety. 1. A bag of waffles was undated in the refrigerator. 2. A container of orange juice was undated in the refrigerator. 3. A bag of pita bread was in an unsealed plastic bag in the refrigerator. 4. Three boxes of gluten free items were opened and undated in the refrigerator. 5. Two bags of cereal and four prepared bowls of cereals were undated in the pantry. 6. A package of quick oats was in an unsealed and undated bag in the pantry. 7. A package of gravy mix was in an undated bag in the pantry. 8. Scoops were left in the bulk sugar and bulk rice bins in the pantry. 9. A package of corn starch was in an undated bag on the counter. 10. The bean puree was not held at a temperature of at least 135 degrees Fahrenheit before serving. 11. The corn puree was not held at a temperature of at least 135 degrees Fahrenheit before serving. These failures could place residents who consume meals and snacks from the kitchen at risk for food borne illness.The findings included: During an observation of the facility kitchen on 5/05/2026 at 9:12 AM, a bag of waffles was discovered undated in the refrigerator, a container of orange juice was discovered undated in the refrigerator, a bag of pita bread was discovered in an unsealed plastic bag in the refrigerator, three boxes of gluten free items were discovered opened and undated in the refrigerator, two bags of cereal and four prepared bowls of cereal were discovered undated in the pantry, a package of quick oats was discovered in an unsealed and undated bag in the pantry, a package of gravy mix was discovered in an undated bag in the pantry, scoops were discovered inside the bulk sugar and bulk rice bins in the pantry, and a package of corn starch was discovered in an undated bag on the counter. During an interview with the Dietary Manager on 5/05/2026 at 9:13 AM, the Dietary Manager stated there should not be undated or opened items in the kitchen, and scoops should not be left inside bulk food bins. The Dietary Manager stated if items are opened or undated, or if scoops are left in bulk bins, residents could consume contaminated or expired items. During a second observation of the facility kitchen on 5/05/2026 at 11:37 AM, two items on the warming table were not held at the safe holding temperature of 135 degrees Fahrenheit before serving. The bean puree was measured at 120 degrees Fahrenheit. The corn puree was measured at 132 degrees Fahrenheit. During a second interview with the Dietary Manager on 5/05/2026 at 11:38 AM, the Dietary Manager stated if food is not held at the proper holding temperature of 135 degrees Fahrenheit, it could cause bacteria to grow and illness to residents who consume the items. During an interview with the DON on 5/05/2026 at 2:05 PM, the DON stated it was important to keep bags sealed and dated, and to make sure the food is at the minimum holding temperature before serving to ensure food safety for the residents. Record review of the facility policy titled Refrigerators and Freezers, revised 11/2022, noted This facility will ensure safe refrigerator and freezer maintenance, temperature, and sanitation, and will observe food expiration guidelines. 7. All food is appropriately dated to ensure proper rotation by expiration dates . 'Use by' dates are completed with expiration dates on all prepared food in refrigerators. Expiration dates on unopened food are observed and 'use by' dates are indicated once a food is opened. 9. Supervisors are responsible for ensuring food items in pantry, refrigerators, and freezers are not past 'use by' or expiration dates. Record review of the facility policy titled Food Receiving and Storage, revised 11/2022, noted Foods shall be received and stored in a manner that complies with safe food handling practices. 2. 'Danger Zone' means temperatures above 41 degrees Fahrenheit (F) and below 135 degrees F that allow the rapid growth of pathogenic microorganisms that can cause foodborne illness. Dry Food Storage 3. Dry foods are handled and stored in a manner that maintains the integrity of the packaging until they are ready to use. 4. Dry foods that are stored in bins are removed from original packaging, labeled and dated ('use by' date). Refrigerated/Frozen Storage 1. All foods stored in the refrigerator or freezer are covered, labeled and dated ('use by' date).

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program so that the facility is free of pests for 1 of 8 resident rooms (Resident #43) reviewed for physical environment.The facility failed to ensure there were no roaches in Resident #43's room and other areas of the facility.This failure could place residents at risk of unsanitary conditions, feelings of fear, irritation, embarrassment, depression, and an overall decline in quality of life.The findings were:Record review of Resident #43's face sheet dated 5/6/26 revealed the resident was an [AGE] year-old male resident admitted to the facility on [DATE]. Resident #43's diagnoses included encephalopathy unspecified (general, non-specific brain disease or damage where the exact cause is not yet determined), major depressive disorder recurrent and moderate (recurring mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life moderate in severity), and PTSD (mental health condition that's caused by being a part of or witnessing an extremely stressful or terrifying event and symptoms may include flashbacks, nightmares, severe anxiety and uncontrollable thoughts about the event).Record review of Resident #43's quarterly MDS assessment dated [DATE] revealed the resident had clear speech, understands and was understood by others. The resident had a BIMS score of 9 out of 15 indicating the resident had moderate cognitive impairment. The resident had rejected care daily and used a walker. The resident was frequently incontinent of urine and bowel.Record review of Resident #43's undated care plan revealed a focus initiated on 11/28/25 with revision on 2/4/26 for a potential behavior problem related to his diagnoses the resident refused care and assistance to include allowing sheets to be placed on mattress, bathing or to receive personal hygiene refusing nursing care, medications, labs, and preferring to eat in his room in the dark at times. This focus had multiple interventions to include psych services, family involvement, and encouragement. Another focus initiated on 9/24/25 with revision on 5/5/26 for verbal aggression towards staff and refusing showers and medications at times. Multiple interventions included on 4/26/26 an off-cycle care conference with family, Administrator, Activities Director, DON, Social worker, and the Ombudsman to address resident's refusal of showers, clean clothing, and medications. Family member will start coming in at least once a week to get the resident to shower, family will get a hamper for his room so they can keep track of his clothing and will encourage him to take his medications. A nurse will sign off on the shower so day staff will know it has been done. The team agreedto follow up in about three weeks.Record review of an anonymous visitor complaint received by HHSC (Health and Human Services Commission) revealed roaches were seen crawling on the visitor's belongings while in the facility.In an observation on 5/5/26 at 11:10 a.m. Resident #43 was not in his room, a sign on the door indicated there was video surveillance in his room. The resident's bed was stripped and was against the hallway wall, a recliner was across the room, the blinds were open, the room had an odor of cleaner and slight urine and looked to be recently mopped and was sticky. A large approximately 2-inch X 3/4 inch roach was observed on the same wall as the bed near the ceiling facing head down towards the bed. An unknown staff member was notified of the roach and stated he would report it and stated Resident #43 was most likely in the courtyard.In an observation and interview on 5/6/26 at 10:35 a.m. Resident #43 was sitting on the side of his bed, no linens on mattress and his walker next to him. The resident was looking out the window. The resident was dressed in a t-shirt, jogging style pants, and croc style shoes. The resident stated he was irritated and raised his voice slightly while stating no one here at the facility knows what they are doing and that he should not be here and wants the facility to show him one physician's note or piece of paper stating that he belongs here. While interviewing the resident, I was standing at the end of his bed at the door with the door closed and a large roach approximately 1 inch X 1/2 inch ran into my shoe and then went under the resident's bed. The resident asked me what kind of bug it was, and I stated it was a roach and the resident stated, oh yeah, there are thousands of them around here. The resident further stated the roaches get on all his belongings and the roach came out from under the resident's bed and was crossing in front of the resident's feet and he pointed down and stated, there's another one. The resident was calm and was no longer raising his voice. The roach then went across the room and under the resident's recliner. The resident stated someone came and sprayed today but it never helps. The resident stated he was used to the roaches and had served in Vietnam and those bugs were worse. The resident started talking about the bugs in Vietnam and I did not ask any more questions due to his PTSD. The resident was calm and heading outside to smoke.In a resident group meeting on 5/6/26 at 9:19 a.m. two other facility residents reported seeing small roaches in the facility on 5/5/26 at different times and the facility needed to address roach issues. The residents did state the facility does have pest control come.Review of the facility pest control invoices revealed Pest control visits were completed on 11/11/25, 12/5/25, 1/6/26, 2/6/26, 2/13/26, 3/6/26, 3/12/26, 3/20/26, 3/27/26, 4/3/26, 4/10/26, 4/24/26, 5/1/26, and an emergency visit on 5/6/26. At each visit American and or German cockroaches were targeted pests and on each visit different areas throughout the facility were targeted. Pest control time spent treating the facility on each visit varied from 1 hour to 3 hours. On the 5/6/26 visit per the pest control invoice the time in was recorded as 9:51 a.m. and time out was 10:53 a.m. and the only room treated was Resident #43's room and bathroom as that was where the roach was observed on 5/5/26 by surveyor and no other rooms or halls were treated at that time. In a joint interview on 5/8/26 at 1:35 p.m. with the Administrator and DON. The Administrator stated they notify pest control anytime there were reported issues with pests and have pest control come out. The DON stated part of the issue with roaches in Resident #43's room was the resident had a documented history of crumbs on himself and the floor and general uncleanliness but that was addressed in his care plan meeting and was much improved from previously. The Administrator and DON stated the roach problem was much better not only in Resident #43's room but facility wide and pest control continues to address the issues. Review of the facility pest control policy revised May 2008 indicated Our facility shall maintain an effective pest control program. 1. This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents. 6. Maintenance services assist, when appropriate and necessary, in providing pest control services.

Based on observation, interview and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality and to protect and promote the rights of the resident for 1 of 8 residents (Resident #59) reviewed for resident rights. The facility staff failed to ensure Resident #59's lunch meal tray was not placed in front of her, uncovered when they were not ready to assist her with eating and after having access to her meal tray that it was not pushed away from her and out of her reach while her tablemate continued eating her lunch. This failure could place residents at risk of feelings of embarrassment, humiliation, depression, and an overall decline in quality of life.The findings were: Record review of Resident #59's face sheet dated 5/6/26 revealed the resident was an [AGE] year-old female admitted to the facility on [DATE] with readmission on [DATE]. Resident #59's diagnoses included alcohol dependence with alcohol-induced persisting amnestic disorder (associated with chronic ethanol abuse (alcoholism) and nutritional deficiencies characterized by short term memory loss, confabulations, and disturbances of attention), alcohol dependence with alcohol-induced persisting dementia (alcohol-related brain damage), and unspecified lack of coordination (inability to control voluntary movements and manifests as clumsiness, difficulty with fine motor skills, and balance issues). Record review of Resident #59's quarterly MDS assessment dated [DATE] revealed the resident had unclear speech, was rarely or never understood, and usually understands others. The resident was unable to complete the BIMS and staff assessment of mental status indicated the resident was severely impaired cognitively. The resident for eating (the ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident) was marked a 3 indicating Partial/moderate assistance - helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort and was a risk for malnutrition. Record review of Resident #59's undated care plan revealed a focus initiated on 2/11/26 for risk for potential nutrition problem related to impaired cognition, mechanically altered diet, use of psychotropic medications with interventions that included to provide and serve diet as ordered. Another focus initiated on 2/19/26 for self-care deficit requires assistance related to muscle weakness, lack of coordination muscle weakness, and cognitive impairment/loss with interventions that included partial to moderate assistance with eating. Record review of Resident #59's documentation for the resident's meal intake percentage revealed from 4/9/26 to 5/7/26 the resident ate 25-50 percent of her meal for 10 meals, 51-75 percent of her meal for 19 meals, and 76-100 percent of her meal for 56 meals. In an observation and interview on 5/5/26 at 12:20 p.m. Resident #59 was seated in the tv room in her wheelchair. The resident answered uh huh when asked if she was ready for lunch as it was almost time. The resident was asked if she was hungry and she stated yes and nodded her head. The resident continued to answer all questions with a yes or nodding her head and was not able to answer questions appropriately. In an observation and interview on 5/5/26 at 12:27 p.m. LVN I was checking the meal trays on the cart prior to CNAs's and other staff delivering them to the residents that were in the dining room. Resident #59 was seated at a small table across from an unknown resident who was eating her lunch. Resident #59's lunch tray was delivered and the dome covering removed. The plastic wrap remained over the 3 glasses of fluids on her tray. Resident #59 was observed to pick up her bread and turn it over and set it back down on the plate. The resident then picked up one of her drinking glasses but as she was lifting it her hand was shaking and she set it back down. The resident looked around and continued picking things up off her tray then setting them back down. The last tray was delivered to another resident at a different table and CNA H went over to Resident #59 and pushed her meal tray away from her towards the center of the small table out of the resident's reach. The resident looked directly at CNA H's face after she pushed the tray away and CNA H lightly touched the resident's arm and smiled at her. CNA H then started to push the cart out of the dining room and Resident #59 was sitting at the table while her table mate ate her lunch and the resident was looking at her tray. At 12:28 p.m. CNA H stated Resident #59 had to be assisted with her meals when asked why she pushed the resident's tray away from her and out of her reach. CNA H further elaborated the resident spilled and mixed her food unless assisted. CNA H and other unknown staff pushed the cart into the hall to deliver to the resident rooms. LVN I stated he was going to feed the resident her meal and sat down and asked the resident if she was ready to eat and she nodded her head that she was and he moved the tray within reach and began feeding the resident. In an interview on 5/5/26 at 3:05 p.m. LVN I stated Resident #59 ate 100% of her lunch meal without issues. LVN I stated he had always planned to feed the resident and had checked all the trays so they could finish delivering them on the halls but understood the resident's tray being moved away and out of her reach after being provided to her was a problem. In a joint interview on 5/5/26 at 3:30 p.m. with CNA H and CNA G, CNA H stated Resident #59 poured her drinks into her food and spilled it on the front of her and that was why she had pushed the tray away until someone was feeding the resident, so she did not spill her food and that someone else was going to feed the resident but she was not sure who. In a joint interview on 5/8/26 at 1:35 p.m. with the Administrator and the DON, the DON stated a resident's meal tray should never be pushed away or out of their reach once delivered to the resident, and the resident should immediately be assisted with eating when their meal tray was delivered and staff were being re-trained on the issue. The DON stated LVN I did immediately feed the resident when the CNAs were leaving the room. Review of the facility policy on dignity revised February 2021 indicated Each resident will be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. 5. When assisting with care, residents are supported in exercising their rights, for example, residents are:. e. Provided with a dignified dining experience.

Based on observation, interview, and record review, the facility failed to ensure the environment was free from accidents and hazards for 3 of 17 residents (R# 23, # 38 and # 12) in the Men's Secure Unit, in that: Resident # 23 had 3 unsecured bottles (shampoo/conditioner, moisturizer, and hand cream) in his room. Resident # 38 had an unsecured disposable razor and an unsecured electric shaving razor in his bathroom. Resident # 12 was wandering in and out of rooms. This failure could result in residents in the Men's secure unit experiencing accidents, injuries and/or a diminished quality of life.The findings were: Record review of R #23 's face sheet, dated 5/7/26, reflected a -[AGE] year-old male who was admitted to the facility on [DATE]. Resident #23 had diagnoses which included: metabolic encephalopathy (brain dysfunction), dementia (a decline in mental ability), bi-polar disorder (mental illness) and schizoaffective disorder bi-polar type (hallucination/delusions and mood disorder) The RP was listed as: a Guardian.Record review of R#23's quarterly MDS, dated [DATE], reflected a BIMS score of 6, indicative of moderate impairment in cognition. In Section GG, the ADLs were documented as: resident needing supervision with bowel and bladder, transfer, and mobility. The resident had no impairments to range of motion. Record review of R#23's CP, undated, reflected the resident had the behavior of removing personal items and bringing them back to his room. An intervention included: removing items and storing items in safe storage. Record review of R #38 's face sheet, dated 5/7/26, reflected an [AGE] year-old male who was admitted to the facility on [DATE]. R#38 had diagnoses which included: myocardial infarction (blood blockage in the heart), lack of coordination, dementia (decline in cognition), anxiety, and Alzheimer's disease (irreversible brain disorder). The RP was listed as: a family member.Record review of R#38's quarterly MDS, dated [DATE], reflected a BIMS score of 5, indicative of severe impairment in cognition. Section GG revealed the ADLs were documented as: resident required supervision for bowel and bladder. R#38 was independent in ambulation but required some partial to moderated assistance in mobility and transfer. R#38 required partial/moderate assistance in toilet hygiene. The resident had no impairments in ROM and had no assistive devices. Record review of R#38's CP, undated, reflected the resident lack safety awareness and had confusion. An intervention listed in the CP was to Keep environment free from possible hazards. Record review of R#12's face sheet dated 5/7/26, revealed the resident was admitted on [DATE] with diagnoses that included dementia (decline in cognition), schizoaffective disorder (mental illness), anxiety, and Alzheimer's disease (irreversible brain disorder). The RP was listed as the resident. Record review of R#12's quarterly MDS dated [DATE] revealed (Section C), the resident's BIMS score was 5 indicative of severe impairment in cognition. The resident was ambulatory and only required supervision in mobility and transfer (Section GG). Record review of R#12's CP, undated, reflected the resident was a wanderer and at risk for elopement. Intervention included close monitoring of the resident and re-direction. Observation on 5/6/26 at 10:46 a.m. of room [ROOM NUMBER] in the secure Men's Unit revealed on the overhead shelf near R# ]23's bed were 3 unsecured bottles (1 bottle of shampoo/conditioner, 1 bottle of moisturizer, and one bottle of hand cream). Further observation and interview on 5/6/26 at 11:25 a.m. of room [ROOM NUMBER]'s bathroom, in the secure Men's Unit, revealed a disposable razor and an electric shaving razor in the resident's bathroom. R#38 stated the items belong to him. Further observation revealed R#12 wandering in an out of room [ROOM NUMBER]. During an attempted interview on 5/6/26 at 10:25 a.m., R #23 refused the interview and did not want to answer any questions about the 3 unsecured bottles of personal items in his room. During an interview on 5/6/26 at 10:30 a.m., LVN A stated it was not okay for R#23 to have lotions and shampoos because: the resident or wanderers could swallow the shampoo or lotions and lead to stomach issues. LVN A stated the family brought the bottles into the secure unit. LVN A stated the staff should have been aware of the bottles and stored them in the locked shower room in the cabinet. During an interview on 5/6/26 at 10:36 a.m., CNA C stated he worked at the Men's Unit 2 days per week. CNA C stated R#23 tended to hide the 3 unsecured bottles. CNA C stated he did not see the 3 unsecured bottles on 5/5/26 and 5/6/26. CNA C stated the resident should not have the unsecured bottles because it posed a poisoning danger to residents. During an interview on 5/6/26 at 10:39 a.m., CNA D stated she worked in the Men's Unit about 4-5 days per week. CNA D stated that she had not seen the 3 unsecured bottles belonging to R#23 on 5/5/26 and 5/6/26. CNA D stated she removed the 3 bottles after being directed by LVN A because the bottles posed a danger to the residents. CNA D stated the family gave the bottles to the resident, but she was not certain when the bottles were given to the resident. During an interview on 5/6/26 at 10:53 a.m., LVN B stated she worked in the Men's Unit 2 days per week. LVN B stated, part of working in the secure unit was to check for accidents and hazards and unsecured items. LVN B stated she did not notice the 3 of liquids in R#23 on 5/5/26 or 5/6/26. LVN B stated that it was not safe for residents in the secure unit to have lotions or moistening cream in the room because of the hazard of poisoning. During an interview on 5/6/26 at 11:03 a.m., the DON stated residents in a secure unit were not allowed to have unsecured bottles of shampoo/conditioner, moisturizer, and/or lotions in their room because it could present a poisoning hazard to residents. The DON stated that family members did not know that items brought into the secure unit had to be checked and locked. The DON stated that the staff working the secure unit may have failed to see the products that should have been secured in a locked cabinet. During an interview on 5/6/26 at 11:26 a.m., R #38 stated he had a disposable razor in his room to shave with, and an electric razor and the staff were not aware of the items. stated he kept the disposable razor and electric razor in the bathroom. The resident stated he did not know how or where the disposable razor and shaving electric razor where [NAME] into his bathroom. The resident stated he did not know the razor and the electric razor had to be stored in a secure cabinet outside of his room. During an interview on 5/6/26 at 11:41 a.m., CNA D confirmed the existence of the disposable razor blade and electric shaving razor in R#38's bathroom. CNA D stated the said items were not permitted in the Men's Unit. CNA D stated she did not know how the resident got the disposable razor blade and electric shaver; and would request approval from LVN A to remove the items and stored them in a secure cabinet. During a joint interview on 5/6/26 at 11:46 a.m., CNA C stated and LVN A confirmed the existence of the disposable razor blade and an electric razor in R#38's bathroom. Both stated it was unsafe for R#38 to have an unsecured disposable razor and electric shaver because it posed a danger to the resident and other residents that could wander into R#38's bathrrom. LVN A and CNA D stated they had not seen the razor or shaving electric razor on 5/5/26 and 5/6/26. During an interview on 5/6/26 at 11:50 a.m., LVN B stated she did not see the disposable razor blade or the electric razor on 5/5/26 during her shift. LVN B stated that housekeeping and CNAs needed to be aware of the environmental hazards and inform her. LVN B stated that she constantly educated staff in the secure unit on maintaining environmental visibility for potential accidents and hazards. Attempted interview on 5/6/26 at 11:55 a.m., R #12 had severe cognition issues and could not answer any direct questions. [Also, R#12 was observed wandering throughout the Men's Unit.] During an interview on 5/6/26 at 12:05 p.m., the ADON stated a resident in the secure unit with t a disposable razor and electric shaver needed for the items to be secured in a locked cabinet when not in use. The ADON stated the unsecured razor, or electric razor could present harm. The ADON stated she did not know how R#38 got the disposable razor and electric shaver in the room. The ADON stated every staff member in the Men's Unit should have checked the room for safety hazards. During an interview on 5/8/26 at 10:15 a.m., the Administrator stated the items in room [ROOM NUMBER] and room [ROOM NUMBER] should not have been present because the items posed potential harm to residents in the secure unit. The Administrator stated that the staff (nursing, housekeeping, maintenance, and laundry) entering and exiting Rooms #4 and #8 should have seen the prohibited items and should have secured the items in a locked cabinet. The Administrator stated she had no explanation why the staff did not see the prohibited items and had them locked in a cabinet. Record review of Facility's Non-Allowable Items policy dated 4/2025, revealed: For the safety of yourself and others the following is not allowed to be brought in or kept at the facility.7. Razors.Sharp Objects [electric razor] . [checklist did not include shampoos/conditioner, moisturizers, and/or body creams].

Based on observation, interview, and record review, the facility failed to ensure drug records were in order and that an account of all controlled drugs was maintained and periodically reconciled for 2 of 6 carts (D hall medication cart and C hall medication cart) reviewed for pharmacy services. The facility failed to ensure the controlled substance reconciliation logs were signed for accuracy of medication quantities during shift change. This failure could place residents at risk of not receiving their prescribed medications, experiencing untreated pain and anxiety, and a decreased quality of life.The findings included: During an observation of the D hall medication cart on 5/07/2026 at 8:32 AM, one signature was discovered missing from the controlled medication reconciliation log used to audit the inventory of the cart during shift change on 5/07/2026. During an interview with CMA A on 5/07/2026 at 8:33 AM, CMA A stated it was important to sign the controlled medication reconciliation log at the time of cart exchange, because they need to realize if there was a missing medication as soon as possible. CMA A stated it was important for the log to be accurate to make sure all medications were accounted for. CMA A stated residents might not get the therapeutic benefit of their medications if their pills were missing. During an observation of the C hall medication cart on 5/07/2026 at 9:15 AM, the controlled medication reconciliation log had one signature signed in advance of the next cart exchange audit on 5/07/2026. During an interview with CMA A on 5/07/2026 at 9:16 AM, CMA A stated the controlled medication reconciliation log should not be signed in advance of the cart exchange. CMA A stated to ensure accuracy of the inventory, the log should be signed at the time of the audit conducted with the staff member taking control of the cart. CMA A stated a medication error could occur if the log was signed in advance. During an interview with the DON on 5/07/2026 at 1:33 PM, the DON stated her expectation for the controlled medication reconciliation logs was that medications should be counted at shift change, and the logs should be signed at the time of the audit. The DON stated if the logs are signed in advance, the count of the controlled medications could be off causing residents to miss a dose of medication or increase the risk of drug diversion. Review of the facility policy titled Controlled Substances, revised 11/2022, noted Dispensing and Reconciling Controlled Substances. 1. Controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow-up. 2. The system of reconciling the receipt, dispensing and disposition of controlled substances includes the following: a. Records of personnel access and usage; b. Medication administration records; c. Declining inventory records; and d. Destruction, waste and return to pharmacy records. 3. Nursing staff count controlled medication inventory at the end of each shift, using these records to reconcile the inventory count. 4. The nurse coming on duty and the nurse [NAME] off duty make the count together and document and report any discrepancies to the director of nursing services.

Based on observation, interview, and record review, the facility failed to dispose of garbage and refuse properly for 1 of 1 trash disposal areas that was reviewed for disposal of garbage. The doors on the left and right sides of the dumpster were open, and trash was on the ground outside of the dumpster. These failures could place residents at risk for exposure to germs and diseases carried by vermin and rodents.The findings included: During an observation of the trash disposal area on 5/05/2026 at 9:12 AM, both the left and right dumpster doors were open, and two disposable gloves were lying on the ground outside of the dumpster. During an interview with the Dietary Manager on 5/05/2026 at 9:13 AM, the Dietary Manager stated the dumpster doors should be closed, and no trash should be left on the ground. The Dietary Manager further stated if the dumpster doors were open or trash was left on the ground, rodents could come to the facility and expose residents to contamination or other illness. During an interview with the DON on 5/05/2026 at 2:05 PM, the DON stated her expectation for the trash disposal area, was that the dumpster should be closed and the grounds should be free of litter, so residents were not exposed to rodents or contaminated trash. During an interview with the Maintenance Director on 5/08/2026 at 11:43 AM, the Maintenance Director stated it was the responsibility of management to educate staff on proper garbage disposal and use of the dumpster. The Maintenance Director stated his expectation for staff was to pick up any debris and throw it in the dumpster and to make sure the dumpster doors were closed. The Maintenance Director stated residents could get an illness from exposure to trash left on the floor, and that the dumpster doors should be closed so that trash could not get out. Record review of the facility policy titled Grounds, revised 5/2008, noted Facility grounds shall be maintained in a safe and attractive manner. 1. Maintenance shall be responsible for keeping the grounds free of litter.

Based on interviews and record reviews the facility failed to ensure a comprehensive care plan was developed within 7 days after completion of the comprehensive assessment and reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for 4 of 9 (#20, #28, #33, #35) residents reviewed for IDT meetings/ care plans in that: 1. The facility failed to review and revise Resident #28's care plan after the MDS assessment on 2/17/25. 2. The facility failed to review and revise Resident #35's care plan after the MDS assessment on 2/25/25 3.The facility failed to review and revise Resident #33's care plan after each assessment in 2023. 4. The facility failed to review and revise Resident #20 care plan after the MDS assessment on 3/3/24, 6/1/24, 9/1/24, 10/9/24 and 1/9/25. This could result in residents not receiving necessary care. The Finding were: Record review of the list of Residents that still required a care plan conference with the end date of 3/6/2025 reflected 22 residents, and included Residents #20, #28, #33, #35. 1. Record review of Resident #28's Admission Record dated 3/6/2025 reflected he was admitted on [DATE] and readmitted on [DATE] with diagnoses of Human immune deficiency virus, respiratory disease, herpes viral infection, muscle wasting, bipolar disorder, dementia, cognitive communication deficit , diabetes II, altered mental status, and acquired absence of right and left leg below the knee. Record review of Resident #28's Quarterly MDS assessment dated on 2/17/25 reflected his BIMS score was 10/15 (moderately cognitively impaired), he had no impairment to upper extremity, had impairment to both sides of lower extremity, and he used a wheelchair for mobility. Record review of Resident #28's care plan dated 10/15/2024 and there was no care plan conference after the MDS assessment on 2/17/25. Record review of Resident #28's assessments revealed two care plan conferences were held dated 8/20/2024 and 10/15/2024. There is no no evidence the IDT met to review/revise the care plan after the MDS assessment on 2/17/25. In an interview on 3/05/2025 at 11:41 AM, Resident # 28 stated he had not been invited to a care plan conference in a while. 2. Record review of Resident #35's Admission Record dated 3/6/2025 reflected she was admitted on [DATE] and readmitted on [DATE] with diagnoses of cerebral infarction (stroke), hemiplegia and hemiparesis (paralysis or weakness), diabetes II (a chronic disease that affects how the body uses glucose (sugar) for energy), psychotic disorder with delusions. and chronic pain. Record review of Resident #35's significant change MDS assessment dated on 2/25/2025 reflected her BIMS score was 13/15 (cognitively intact), she had impairment on upper and lower extremity, and she used a wheelchair for mobility. Record review of Resident #35's care plan dated 2/22/2025 . Record review of Resident #35's three care plan conference were dated 11/16/2022, 8/14/2024 and 11/15/2024. No other evidence of care plan conferences / IDT met after these dates for Resident #35. In an interview on 3/05/2025 at 12:04 PM, Resident #35 stated she had not had a care plan conference every 3 months and does not remember when she had the meeting. 3. Record review of Resident #33's Admission Record dated 3/7/2025, reflected he was admitted on [DATE], and readmitted on [DATE] with diagnoses of Parkinson's disease (a progressive neurodegenerative disorder that affects movement, balance, and coordination) schizoaffective disorder (a mental health condition that combines symptoms of schizophrenia and a mood disorder, such as depression or bipolar disorder ), anxiety, and delusional disorders. Record review of Resident #33's Quarterly MDS assessment dated [DATE] reflected his BIMs score was 14/15 (cognitively intact), he had 2 impairments to lower extremity and used a wheelchair/walker for mobility. Record review of Resident #33's care plan was dated 2/7/2025. Record review of the MDS Assessments for 2023 the care plan should have been reviewed/revised by IDT/care plan conference. Record review of Resident #33 had three care plan conferences dated 12/20/2022, 4/12/2024 and 2/7/2025. No IDT/care plan conferences for year 2023. 4. Record review of Resident #20's Admission Record dated 3/7/25 revealed Resident #20 admitted to the facility on [DATE] and readmitted [DATE]. Diagnoses listing revealed diagnosis of encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition), schizoaffective disorder bipolar type (a mental health condition that combines symptoms of schizophrenia (a chronic mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interacitons) and bipolar disorder (a mental condition characterized by extreme mood swings, including perioeds of intense hights and lows)), Major depression disorder, hypotension (low blood pressure), EPS (a group of movement disorders caused by certain medications), Vit. D deficiency, anxiety, age related nuclear cataracts, orthostatic hypotension (a condition in which blood pressure drops significantly when a person stands up from a sitting or lying position), hypothyroidism (a condition in which the thyroid gland does not produce enough thyroid hormone). Record review of Resident #20's Quarterly MDS assessment dated [DATE] revealed she has a BIMs score of 6/15 indicating severe cognitive impairment and she required set up assistance with self-feeding, upper body dressing, supervision with toilet hygiene, lower body dressing and moderate assistance in bathing, personal hygiene. Record review of Resident #20's MDS schedule revealed Annual MDS dated [DATE], Quarterly MDS completed 6/1/24, Quarterly MDS dated [DATE], Significant change in status MDS dated [DATE], and Quarterly MDS dated [DATE]. Based on completed Conference Reports, facility failed to review and revise care plan after a comprehensive and quarterly review assessments completed 3/3/24, 6/1/24, 9/1/24, 10/9/24 and 1/9/25. Record review revealed a Care Conferences were completed 7/24/24 and 10/25/24. No evidence of care plan conferences and care plan revision for 2023. No evidence of care plan revision completed within 21 days of MDS assessments. Care plan revision date 1/23/25. In an interview on 3/07/2025 4:07 PM the SW stated she had just started working and was catching up on resident care plan conferences. The SW stated she had a plan to finish the care plan conference and be up to date on 3/28/2025. In an interview on 3/07/2025 at 10:12 AM, the MDS Nurse stated they missed the care plan conferences, but they do have a plan and know they are late on care plan conferences. The MDS Nurse stated they will include care plan conferences as part of their routine audits and a complete audit will be done by 3/28/2025 for all residents. In an interview on 3/07/2025 at 11:30 AM, the ADM stated he was not aware the resident care plan conferences were not being done as scheduled. The ADM stated the resident care plan conferences would need to be done timely, and devise a plan and start over with a new rotation. Review of facility policy named Care Plans, Comprehensive Person-Centered, Comprehensive Assessments and comprehensive Care Plans, revised March 2022 reflected 12. The interdisciplinary team reviews and updates the care plan: d. where there has been a significant changein the resident's condition, a. when the resident has been readmitted to the facility from a hospital stay; and b. at least quarterly.

Based on observations, interviews 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 in that: 1. Food containers in the storage room, rice container lid was open and had a smaller container. The flour container lid was not tightly closed. The flour container was on a shelf, underneath the shelf of the flour container was on had a rat trap box. 2. DM Q was not wearing a hairnet while in the kitchen. 3. Dietary aide L was not wearing gloves while placing chicken patties in the deep fryer oil. These failures could place residents at risk for food borne illness. The Findings were: 1. Observation on 3/05/2025 at 9:25AM in the kitchen revealed in the storage room, a rice container on a shelf. The lid was open and there was a smaller container in the rice container. The lid of the flour container on the shelf was not tightly closed. Under the shelf was a rat trap box. Interview on 3/05/2025 at 9:25AM with DM R confirmed the rice container was open with a smaller container in it. , The flour container lid was not tight, and the rat trap at the bottom of shelf above the flour container . DM R stated the containers need to be closed to keep pests away and containers cannot be in the food buckets due to contamination. DM R stated he was not sure why the rat trap box was under the food storage containers, after observation. 2. Observation on 3/5/2025 at 4:30 PM revealed DM Q was in the kitchen about to take food temperatures. DM Q was not wearing a hairnet in the kitchen. Interview on 3/5/2025 at 4:32 PM with DM Q confirmed she was not wearing a hairnet in the kitchen; she had just come in from outside . 3. Observation on 3/5/2025 at 11 AM revealed Dietary aide L was not wearing gloves while putting chicken patties in the deep fryer. Interview on 3/5/2025 at 10:59 AM with Dietary L had no response to not wearing gloves while handling food in the kitchen. In an interview on 03/06/2025 at 1:42 PM, the Dietician consultant stated she would educate staff on wearing gloves while handling food, wearing hairnets, keeping containers closed, and that no containers should have containers in them. Record review of Policy dated November 2022, Food Receiving and Storage, Foods shall be received and stored in a manner that complies with safe food handling practices. Dry Food Storage 1. Non-refrigerated foods, .are stored in a designated dry storage unit which is temperature and humidity controlled, free of insects and rodents and kept clean. 5. Other opened containers are dated and sealed or covered during storage. Record review of Policy dated November 2002, Food Preparation and Service, Food and nutrition services employees prepare, distribute and serve food in a manner that complies with safe food handling practices. General Guidelines 3. Food preparation staff adhere to proper hygiene and sanitary practices to prevent the spread of foodborne illness. Food Distribution and Services 7. Bare hand with food is prohibited. gloves are worn when handling food directly and changed between task. 8. Food and nutrition service staff wear hair restraints, so that hair does not contact food.

Based on observations and interviews the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition, for 1 of 1 facility's reviewed for maintenance and operation of essential equipment. 1. Laundry facility essential equipment was not operational. a. 2 of the 3 commercial clothing dryers were not operational. b. 1 of the 2 commercial clothing washers was not operational. c. 1 of the 1 Heating, ventilation, and air-conditioning (HVAC) system for the laundry facility was not operational. 2. The stove and deep fryer were not restrained. Deep fryer back right-side leg was propped up by wood. These failures could place residents at risk for neglect and not having their needs met. The findings included. During an observation 3/06/25 at 1:20 PM of the facility's laundry department revealed the departments HVAC system not operational, 2 of the 3 dryers were not operational, and 1 of the 2 washers was not operational. During an interview 3/06/25 at 1:24 PM with LA K stated she had been an employed as the laundry aide for the last year. LA K stated the laundry department has installed 3 commercial dryers, 2 commercial washers and 1 HVAC system. LA K stated the HVAC system was inoperative for the winter and has malfunctioned again after a recent repair. LA K stated of the 3 dryers only 1 was operational and of the 2 washers only worked. LA K stated her ability to produce clean clothes was challenging with only 1 dryer and washer. LA K stated the Maintenance Director was aware of the equipment failure and had provided a small window air-conditioner for the dryer room but not the washer room. LA K stated the dryers and washer were broken for longer than 4-5 months. During an observation and interview on 3/06/25 at 1:55 PM the Maintenance Director toured the Laundry Department and stated the dryers were not operational and recently the 1 dryer was repaired and now functions. The maintenance director stated the HVAC system could not be maintained due to excessive coolant gas leaks. The Maintenance Director stated only 1 of the 2 commercial washers was operational. During an interview on 3/07/25 at 11:43 AM the Administrator stated he was aware of the malfunctioning laundry equipment and has not been able to replace the equipment. 2. Observation on 3/5/2025 at 4:35 PM in the kitchen, revealed the deep fryer next to the stove was missing a leg on the far-right side. The Deep fryer far right-side leg had a piece of wood under it. Observation of the stove and deep fryer were not restrained. Interview and Observation on 3/5/2025 at 11 AM with dietary aide L was at the deep fryer cooking chicken Pattie, he said the piece of wood was under the deep fryer to keep it balanced. Interview on 3/06/2025 at 11:23 AM with kitchen vendor M stated the piece of wood under the deep fryer, between the stove, should not be there. The vendor stated the piece of wood was not a good conductor and could cause fire if grease spilled on the piece of wood. Interview and Observation on 3/6/2025 at 10:54 AM with Maintenance Director stated he stated he placed the piece of wood under one of the legs of the deep fryer to keep it balanced and he knows he should have used a brick, instead of wood. The Maintenance Director stated the piece of wood placed under leg of deep fryer could cause a fire. The Maintenance Director stated the stove and deep fryer were not restrained and should have been. This could cause the stove and deep fryer to move forward causing an accident with kitchen staff. Interview on 3/06/25 at 12:11 PM with ADM stated he was not aware of the piece of wood under the deep fryer leg and could cause fire. Record review of Sanitation policy dated November 2022 documented 2. All .equipment are maintained in good repair. A policy for maintenance and operation of essential equipment was requested on 3/6/2025 and was not provided.

Based on observations and interviews, the facility failed to provide a safe, functioning, and comfortable environment for residents, staff and public for A wind and B wing in that: 1. The window blinds in three windows in the A Wing common room were broken. 2. The B wing shower tile on ground had mold and the shower curtain had mold spots. This failure could affect residents by placing them at risk for diminished quality of life due to the lack of a well-kept environment. Findings included: 1. Observation Rounds on 3/4/25 at 9:35 AM of A Wing common area revealed three windows with missing, broken, or bent window blind slats. During an interview on 3/5/25 at 10:30 AM, LVN B stated he would put the concern in the maintenance logbook. During an interview on 3/6/25 at 1:40 PM, Administrator stated, we routinely purchase window blinds due to the male unit frequently breaking blinds and replace them at each occurrence. 2. Observation on 3/04/25 at 10:24 AM in the secure B wing revealed the tile floor had mold and the shower curtain had spots of mold. Interview on 3/4/2025 at 10:25 AM in the B wing shower room, with CMA/CNA N stated black substance along the tile floor and black spots on the curtain in multiple areas. Interview on03/04/2025 at 10:32 AM with Housekeeper O stated the B wing shower was cleaned yesterday. The Housekeeper O stated he was not aware of mold on the tile floor and on the shower curtain. Housekeeper stated he cleaned mold with bleach, HSK O stated the black substance on tile and shower was mold. HSK O stated mold can cause illness to residents. Record review of policy, Cleaning and Disinfecting of Environmental Surfaces, dated August 2019 was documented Environmental surfaces will be cleaned and disinfected according to current CDC recommendations for disinfection of healthcare facilities and the OSHA bloodborne pathogens standards. C non-critical items are those that come in contact with the intact of skin but not mucous membranes. 1, Non environmental surface include furniture and floors. 1, most non c-critical items cand be decontaminated where they are used. 11. Walls, blinds and window curtains in resident areas will be cleaned when these surfaces are visibly contaminated or soiled. Facility maintenance policy was not provided at time of exit.

Based on interviews and record reviews the facility failed to ensure allegations neglect were reported immediately, but not later than 24 hours if the events that caused the allegation do not involve abuse and did not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures, for 1 of 1 facility's reviewed for reporting allegations of abuse, neglect, exploitation. On 1/21/2025 the facility's exhaust fan, located in the women's memory care unit's pantry closet, began to produce large amounts of smoke, which caused staff to engage the fire alarm system, alerted the fire department, and staff used a fire extinguisher to extinguish the smoke from the exhaust fan. This failure could place residents at risk for not reporting allegations of ANE. The findings included: A record review of the Texas Unified Licensure Information Portal accessed 3/5/2025 revealed no report and or investigation for the 1/21/2025 incident. A record review of the facility's Facility Assessment for (the facility) dated 1/14/2025 revealed, Information About Our Physical Resources . fire alarm and sprinkler system: one system, fully functional, including fire extinguishers. During an interview on 3/06/25 at 6:44 AM CNA A stated she has worked at the facility for the past 6 months during the 6 AM to 6 PM shift in the Memory Care Unit (MCU). CNA A stated one day in January 2025, a fan caught fire in a closet in the women's MCU. CNA A stated she immediately alerted staff to include the ADON of the fire. CNA A stated she organized the 14 residents from the MCU to the MCU secured courtyard and took a census count to ensure all residents were evacuated. CNA A stated the MCU became filled with smoke, the fire alarm was sounding, and the fire department arrived and assisted staff to relocate residents back indoors to the safe lobby due to the cold winter weather. During an interview on 3/06/25 at 9:55 AM CNA B stated she had worked in the facility for the past 6 months in the men's MCU and recalled an evacuation event for the women's MCU due to a fire in the women's MCU in January 2025. CNA B advised surveyor to speak with CNA A due to her direct witness of the fire. During an interview on 3/06/25 at 10:04 AM CNA C stated she worked the women's MCU for the past 2 years and she was not on duty the day of the fire but did learn the women's MCU had a ceiling exhaust fan which caught fire and the fire department was dispatched. CNA C stated the fan was replaced and the closet repainted. During an observation on 3/6/2025 at 10:05 AM revealed the pantry closet in the women's MCU to have an exhaust fan. The fan appeared new and was running. During an interview on 3/06/25 at 10:32 AM LVN D, stated he was on duty from 6:00 AM to 6:00 PM the day the fire was in the women's MCU unit. LVN D stated he understood the ADON used the fire extinguisher on the exhaust fan and the residents were evacuated to the facility's lobby. LVN D stated the fire alarm sounded and the fire department arrived. LVN D stated the staff received an in-service for fire prevention and control and all women's MCU residents were assessed for safety. During a joint interview on 3/06/25 at 10:33 AM with the Administrator and the DON, the administrator stated he was on vacation the week when the fan smoked. The Administrator stated the Regional Director of Operations and the DON were on duty in the facility while he was away. The Administrator stated he learned the smoke incident was 1/21/2025 in the women's MCU. The Administrator stated the fire department was dispatched and used fans to evacuate the facility of smoke and checked the exhaust fan for a fire. The administrator stated the fire department cleared the building for safety and left. The administrator stated the DON and the RDO decided the incident was not eligible for a report to the state agency due the lack of any flames. The DON stated the incident was 1/21/2025, during the day. The DON stated she heard CNA A alert for a fire in the women's MCU and the ADON ran and used the fire extinguisher in the women's MCU's pantry. The DON stated she reviewed and ensured the 14 residents of the MCU were assessed for safety and reviewed and ensured 46 of the 46 staff received in-services, which included, the fire dept responded to the fire alarm, During an interview on 3/06/25 at 10:46 AM the RDO stated he had reviewed the smoke incident with his leadership and the decision was made the incident was not eligible to be reported to the state agency due to the lack of any flames. The RDO stated all the exhaust fans were inspected by the maintenance director, the local physical maintenance contractor, and the fire department. The RDO stated the fire suppression contractor inspected the fire suppression and alarm system, and the maintenance director replaced the exhaust fan. A record review of the facility's policy titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating dated September 2022, revealed, Policy Statement: All reports of Resident abuse (including injuries of unknown origin), neglect, exploitation, or theft / misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations arc documented and reported. Policy Interpretation and Implementation: Reporting Allegations to the Administrator and Authorities: l. If resident abuse, neglect. exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law and HHSC reporting guidelines. 2. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility; b. The local/state ombudsman; . 3. Immediately is defined as: a. within two hours of an allegation involving abuse or result in serious bodily injury: or b. within 24 hours of an allegation that does not involve abuse or result in serious bodily injury.

Based on interviews and record reviews the facility failed to report the results of all investigations in response to allegations of abuse, neglect, exploitation (ANE), or mistreatment to the State Survey Agency, within 5 working days of the incident, for 1 of 1 facility's reviewed for investigating an alleged fire. On 1/21/2025 the facility investigated an alleged fire in the facility without a report to the state agency, when an exhaust fan in the women's Memory Care unit (MCU) produced a large amount of smoke, causing the fire alarm to activate and the local fire department response. This failure could place residents at risk for ANE. The findings included. A record review of the Texas Unified Licensure Information Portal accessed 3/5/2025 revealed no report and or investigation for the 1/21/2025 incident. A record review of the facility's Facility Assessment for (the facility) dated 1/14/2025 revealed, Information About Our Physical Resources . fire alarm and sprinkler system: one system, fully functional, including fire extinguishers. A record review of the facility's Quality Assessment and Performance Improvement Plan dated 1/21/2025 revealed the facility held an ad hoc Quality Assurance Improvement Plan (QAPI) meeting which included attendees: the Administrator, the Medical Director, the Director of nursing (DON), the Assistant Director of Nursing (ADON), the Minimum Data Set nurse (MDS) the Business Office Manager (BOM), the Human Resources Manager (HRM), the Director of Rehab (DOR), and the Activities Director (AD). Further review revealed, facility review; one to one in service with maintenance director on cleaning and checking exhaust fans, maintenance checklist daily. Inservice staff on fire safety and storage of items on top of fridge. Code drill followed. Residents on B hall were assessed for any respiratory issues 1/21/2025. (name of contractor) Fire inspection on 1/21/2025. (name of contractor for equipment) inspection on 1/21/2025. Ad hoc with the medical director. A record review of the facility's Training In-Service Form dated 1/21/2025 revealed 45 of 45 employees received the in-service training Fire Safety and Prevention which included, Policy Statement; All personnel must learn methods of fire prevention and must report condition(s) that could result in a potential fire hazard. Policy Interpretation and Implementation 1. Fire prevention is the responsibility of all personnel, residents, visitors, and the general public. 2. Whoever identifies a fire hazard, or other conditions that could develop into a fire hazard, must report the situation to the department director or maintenance director as soon as practical. 3. The following fire safety precautions must be followed in the facility at all times: Electrical Precautions: . 1. h. Do not use defective equipment. Overheating: . b. Keep filters on heating systems, dryers, etc., free of lint. All personnel must report observations of: . a. unusual odors or conditions; . b. malfunctioning equipment and supplies; c. any unusual incidents; d. sounding of false alarms A record review of the facility's Training In-Service Form dated 1/21/2025 revealed the ADON provided training for the Maintenance Director for Cleaning / Checking Exhaust Fans; Maintenance Checklist which included a form worksheet for monthly checking exhaust fans in the facility, A record review of the women's MCU census for 1/21/2025 revealed 14 residents, Further review revealed all 14 residents were assessed for respiratory distress which included Shortness of Breath (SOB). A record review of Resident #3s post incident safety assessment dated [DATE] revealed, 1/21/2025 5:25 PM, assessment performed resident with no SOB, cough or change from baseline. T 97.8, P 60, R 18, 106 / 67, 98% oxygen on room air. Resident denies pain or discomfort. Monitoring for safety. MD / RP aware. During an interview on 3/06/25 at 6:44 AM CNA A stated she has worked at the facility for the past 6 months during the 6 AM to 6 PM shift in the Memory Care Unit (MCU). CNA A stated one day in January 2025, a fan caught fire in a closet in the women's MCU. CNA A stated she immediately alerted staff to include the ADON of the fire. CNA A stated she organized the 14 residents from the MCU to the MCU secured courtyard and took a census count to ensure all residents were evacuated. CNA A stated the MCU became filled with smoke, the fire alarm was sounding, and the fire department arrived and assisted staff to relocate residents back indoors to the safe lobby due to the cold winter weather. During an interview on 3/06/25 at 10:32 AM LVN D, stated he was on duty from 6:00 AM to 6:00 PM the day the fire was in the women's MCU unit. LVN D stated he understood the ADON used the fire extinguisher on the exhaust fan and the residents were evacuated to the facility's lobby. LVN D stated the fire alarm sounded and the fire department arrived. LVN D stated the staff received an in-service for fire prevention and control and all women's MCU residents were assessed for safety. During a joint interview on 3/06/25 at 10:33 AM with the Administrator and the DON, the Administrator stated he was on vacation the week when the fan smoked. The Administrator stated the Regional Director of Operations and the DON were on duty in the facility while he was away. The Administrator stated he learned the smoke incident was 1/21/2025 in the women's MCU. The Administrator stated the fire department was dispatched and used fans to evacuate the facility of smoke and checked the exhaust fan for a fire. The administrator stated the fire department cleared the building for safety and left. The administrator stated the DON and the RDO decided the incident was not eligible for a report to the state agency due the lack of any flames. The DON stated the incident was 1/21/2025, during the day. The DON stated she heard CNA A alert for a fire in the women's MCU and the ADON ran and used the fire extinguisher in the women's MCU's pantry. The DON stated she reviewed and ensured the 14 residents of the MCU were assessed for safety and reviewed and ensured 46 of the 46 staff received in-services, which included, the fire dept responded to the fire alarm, During an interview on 3/06/25 at 10:46 AM the RDO stated he had reviewed the smoke incident with his leadership and the decision was made the incident was not eligible to be reported to the state agency due to the lack of any flames. The RDO stated all the exhaust fans were inspected by the maintenance director, the local physical maintenance contractor, and the fire department. The RDO stated the fire suppression contractor inspected the fire suppression and alarm system, and the maintenance director replaced the exhaust fan. A record review of the facility's policy titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating dated September 2022, revealed, Policy Statement: All reports of Resident abuse (including injuries of unknown origin), neglect, exploitation, or theft / misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations arc documented and reported. Policy Interpretation and Implementation: Reporting Allegations to the Administrator and Authorities: l. If resident abuse, neglect. exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law and HHSC reporting guidelines. 2. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility; b. The local/state ombudsman; . 3. Immediately is defined as: a. within two hours of an allegation involving abuse or result in serious bodily injury: or b. within 24 hours of an allegation that does not involve abuse or result in serious bodily injury.

Based on observation, record review and interview, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for 1 of 8 residents (Resident 35) reviewed for nursing services. The facility failed to follow physicians' orders to monitor for edema (swelling caused by fluid building up in body tissue) for Resident #5 as ordered on 4/30/24. This failure could place residents at risk for not receiving appropriate care and treatment and/or a decline in their health. Findings included: Record review of Resident #5's Admission Record dated 3/7/25 revealed a [AGE] year-old male admitted to the facility on [DATE] and readmitted [DATE]. Diagnoses listing revealed DMII (Diabetes Type 2, a chornic metabolic disorder characterized by high blood sugar levels due to insulin resistance and/or deficiency), COPD (a group of lung diseases that cause ongoing breathing problems), MDD (Major Depressive Disorder), Anxiety, Hyperlipidemia (elevated lipid levels in the blood which can increase the risk of heart disease), Heart Disease, Dysphagia (difficulty swallowing), Seizures, (temporary disruptions in brain electrical activity), Bilateral age-related cataracts, Myopia (nearsightedness), Dementia (a decline in mental ability severe enough to interfere with daily life) , Alzheimer's Disease (progressive, neurodegenerative disorder tha primarily affects memory, leading to a decline in cognitive function and eventually impacting daily activities). Record review of Resident #5's current Quarterly MDS dated [DATE] revealed a BIMS Score of 4 indicating severe cognitive impairment. Resident #5 required set up assistance in self-feeding, supervision with upper and lower body dressing, moderate assistance in bathing, personal hygiene, and maximum assistance in toilet hygiene. Record review of Resident #5's care plan last reviewed/revised 2/19/25 revealed problem identification of potential for complications, s/sx related to diagnosis of COPD. Approaches included administer medications as ordered and monitor for side effects, administer oxygen as ordered, assess/record/report to MD prn: anxiety, restlessness, SOB, wheezing, dyspnea (difficulty breathing), respiration rapid or shallow, cough cyanosis (coughing resulting in a bluish discoloration of the skin around lips and fingertips indicating there is not enough oxygen in the blood to support the body's tissues), confusion, altered mental status, fatigue, headache, encourage adequate fluid intake, provide extra fluid on meals trays, encourage physical mobility, exercise as tolerated, monitor V/S as ordered, nebulizer treatments and/or inhalers as ordered, obtain and monitor lab / diagnostic work as ordered. Record review of Resident #5's physicians order dated 4/30/24 revealed order for edema checks: Check extremities Q shift and report to MD any abnormalities. Observation of Resident #5 on 3/5/25 at 10:00 AM, 3/5/25 at 3:35 PM and 3/6/25 at 10:45 AM revealed no noted edema. Resident #5 is alert, pleasantly confused and a poor historian. Unable to conduct interview regarding edema. Record review of Resident #5's March 2025 MAR revealed resident was not being monitored for edema. During an interview on 3/6/25 at 1:30 PM, LVN D stated that he used to monitor edema on the MAR for this resident but has not done it in a long time. LVN D stated he checks for edema but does not document it on a MAR or in progress notes. LVN D stated, sudden increase in edema could cause problems. During an interview on 3/6/25 at 2:00 PM, the ADON revealed order was put in the EMR system inaccurately and should have been linked to the HCTZ order. ADON stated order has been corrected and is now on the nurse's MAR to monitor. During an interview on 3/6/25 at 2:15 PM, the DON stated failure to monitor edema could result in exacerbation of disease process with shortness of breath, elevated heart rate or possibly death if left unmonitored. The DON said the expectation of nursing staff is to monitor this resident for edema and follow physicians orders. Requested Policy &Procedures for following physicians orders on 3/7/25 at 10:45 a.m., did not receive.

Based on observations, interviews, and record review the facility failed to provide food that was palatable, and at a safe and appetizing temprature for 1 of 1 test tray. 1. Test tray was not hot and lukewarm. 2. No food temperatures were logged for lunch. These failures could affect all residents who ate their meals prepared by the facility kitchen by placing them at risk of weight loss, altered nutritional status, and diminished quality of life. The findings were: 1. In an observation on 3/06/2025 at 1:17 PM of a lunch test tray, revealed the chicken patty melt was not hot, but lukewarm. 2.In an interview on 3/06/2025 at 1:33 PM, DM U stated the test tray was taken from staff and went directly to the conference room, near the kitchen. DM U said to write down the food temperature on the food temperature log for lunch to Dietary Aide L. In an interview on 3/6/2025 at 1:35 PM, Dietary aide L stated he did take the food temperatures for lunch and wrote them on a piece of paper. Dietary aide L stated he was washing dishes and the piece of paper got wet and he misplaced it. Dietary aide L stated were at a good temperature and he did not document on the food temperature log. In an interview on 03/06/2025 at 1:42 PM, the Dietician consultant stated she would educate staff on keep food temperatures in a food log for every meal, in the kitchen. In an interview on 3/06/2025 at 1:16 PM, Resident #28 stated his food was not hot, but he just ate because he was hungry. In an interview on 3/06/2025 at 2:43 PM, Resident #44 stated his food was not hot. Record review of the Food temperature log was blank for lunch meal dated 3/6/2204. Record review of Policy dated November 2002, Food Preparation and Service, Food and nutrition services employees prepare, distribute and serve food in a manner that complies with safe food handling practices. General Guidelines 3. Food preparation staff adhere to proper hygiene and sanitary practices to prevent the spread of foodborne illness. Food Distribution and Services 2. The temperature for foods held in steam tables are monitored throughout the meal service by food and nutrition services staff.

Based on observation, interview and record review the facility failed to ensure storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption 1 of 1 (#35) residents' personal refrigerator in that: Resident #35's personal refrigerator had 3-4 Styrofoam empty cups with mold in them. This failure could affect residents by placing them at risk for food borne illness. Findings included: Observation on 3/04/2025 at 10:36 AM in Resident #35, revealed her personal refrigerator had 3-4 Styrofoam empty cups with mold in them. Resident #35 was asleep at the time and had just came back from the hospital. Interview on 3/4/2025 at 10:37 AM with the DON stated Resident #35's personal refrigerator had 3-4 Styrofoam empty cups with mold in them. The DON stated the resident personal refrigerators were cleaned periodically by staff. asked for policy. Interview on 3/06/2025 at 12:01 PM with ADM stated he was aware of Residents #25's personal refrigerate had empty cups with mold in them. The ADM stated the cups were thrown away. Record review of policy, Foods brought by Family/Visitors, dated March 2022 was documented Food [NAME] to the facility by visitors and family is permitted. Facility staff will strive to balance resident choice and a homelike environment with the nutritional and safety needs of residents. 6. The nursing staff will discard perishable foods on or before the use by date. 7. Potentially hazardous foods that are left out for resident without a source of refrigeration longer than 2 hours are discarded.

Based on observations, interviews, and record reviews the facility failed to ensure the establishment and maintenance of an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections to include standard and transmission-based precautions to be followed to prevent spread of infections, for 2 of 8 residents (Residents #16 and #162) reviewed for Enhanced Barrier Precautions (EBP). 1. On 3/6/2025 CNA I provided catheter care to Resident #16 while not donning Personal Protection Equipment (PPE). 2. On 3/5/2025 CNA J provided incontinent care for Resident #162 while not donning PPE. These failures could place residents at risk for cross contamination and spread of communicable diseases. The findings included: 1. A record review of Resident #16's Face Sheet record dated 3/6/2025 revealed an admitted [DATE] with diagnoses which included obstructive uropathy (a blockage that prevents urine from flowing naturally through the urinary system). A record review of Resident #16's quarterly MDS assessment dated [DATE] revealed Resident #16 was a [AGE] year-old male admitted for long term care and was assessed with a BIMS score of 11 out of a possible 15 which indicated mild cognitive impairment. further review revealed Resident #16 could make himself understood and could understand others, had adequate vision to see large print and had adequate hearing. Further review revealed Resident #16 needed assistance with his urinary catheter (an indwelling tube into the bladder through the urethra), Toileting hygiene: the ability to maintain perineal hygiene, adjust close before and after using the toilet, commode, bedpan, or urinal. substantial maximal assistance - helper does more than half the effort. does the resident use a wheelchair . yes . bladder and bowel indwelling catheter, yes . urinary continence - resident had a catheter A record review of Resident #16's physicians' orders dated 3/6/2025 revealed the physician ordered for Resident #16 to receive EBP care. A record review of Resident #16's care plan dated 3/7/2025 revealed, Resident has a DX of Urinary Tract Infection & is at risk for complications. Perform catheter care as indicated. (See Indwelling Urinary Catheter Care Plan) . Report signs of UTI (acute confusion, urgency, frequency, bladder spasms, nocturia, burning, pain, difficulty urinating, low back/flank pain, malaise, nausea/vomiting, chills, fever, foul odor, concentrated urine, blood in urine). Infection - There is risk for developing and/or spreading infection related to: Indwelling Urinary Catheter . Enhanced Barrier Precautions will reduce risk of the spread of organisms . Utilize enhanced barrier precautions as ordered Every Shift; Created: 08/01/2024 During an observation and interview on 03/06/25 05:50 AM CNA I assisted Resident #16 seated in his wheelchair into the shower room, where CNA I performed hand hygiene and donned gloves. CNA I handled Resident #16's urine collection bag and drained the bag of urine. CNA I measured 1300ml of urine. CNA stated Resident #16 had an indwelling urinary catheter and Resident #16 needed assistance to drain the urine. CNA I stated he was not aware of Resident #16's EBP and believed the use of gloves was sufficient for infection control. 2. A record review of Resident #162's face sheet dated 3/6/2025 revealed an admitted [DATE] with diagnoses which included malignant neoplasm of sigmoid colon (colon cancer, and colostomy status (a surgical opening on the belly, needed because a problem is causing the colon to not work properly, or a disease is affecting a part of the colon and it needs to be removed. The end of the colon (large intestine) is brought through this opening in the skin to form an opening.) further review revealed Resident #162 was a [AGE] year-old female. A record review of Resident #162's physicians' orders dated 3/6/2025 revealed the physician ordered for Resident #162 to receive EBP care. A record review of Resident #162's care plan dated 3/6/2025 revealed, Infection - There is risk for developing and/or spreading infection related to: Colostomy Status - Created: 03/03/2025 . Enhanced Barrier Precautions will reduce risk of the spread of organisms . Utilize enhanced barrier precautions as ordered During an observation and interview on 3/06/25 at 2:10 PM revealed Resident #162's door to her room presented without signage to indicate any EBP precautions. Observation in the room revealed CNA J with Resident #162, Resident #162 laid in bed while CNA J wore gloves and assisted with Resident #162's incontinent care. CNA J had not donned a gown for PPE. CNA J stated resident #162 had a colonoscopy. CNA J stated she was confused on resident #162's status because she had not seen any EBP signage on the door. CNA J stated she had been trained to wear EBP PPE to include the use of gloves and a gown during check and change for a resident with EBP precautions. CNA J stated the risk for residents was cross-contamination of infectious diseases. During an interview on 3/06/25 at 1:10 PM the DON stated the expectation was for residents with colostomy bags and or indwelling urinary catheters to be cared for under EBPs, specifically, at a minimum, for staff to DON PPE to include a gown and gloves. A record review of the United States of America's Centers for Disease Prevention and Control's website titled Enhanced Barrier Precautions in Skilled Nursing Facilities https://www.cdc.gov/infection-control/media/pdfs/Webinar-EBPinNH-Nov2022-Slides-508.pdf accessed 3/6/2025, revealed, What are Enhanced Barrier Precautions (EBP)? A risk-based approach to PPE use designed to reduce the spread of multidrug-resistant organisms (MDROs). The use of a gown and gloves during high-contact Resident care activities for residents at high risk of colonization* with an MDRO to disrupt spread. Expands the use of PPE beyond situations in which exposure to blood and body fluids is anticipated. Used in coordination with good infection prevention and control measures. What are High-Contact Resident Care Activities? . Changing Briefs or Assisting with Toileting . When Should I Use Enhanced Barrier Precautions? . Residents with any of the following: . Indwelling medical devices (e.g., ., urinary catheter, .)

Based on observations, interviews and record review the facility failed to ensure the Dispose of garbage and refuse properly for 1 of 1 facility in that: The dumpster door on the left side was open. This deficient practice could place residents at risk for exposure to germs and diseases carried by vermin and rodents. The findings were: Observation on 3/6/2025 at 10:50 AM revealed the door on the left side, was open on the dumpster. Interview on 3/6/2025 at 10:54 AM Maintenance Director stated the the dumpster outside side, door was open. The Maintenance Director stated he told staff all the time to make sure the dumpster doors were closed, and stated he posted the staff need to close the doors to dumpster. The Maintenance Director stated if the door to dumpster were left open and can create more pest coming around. Interview on 3/06/25 at 12:11 PM ADM stated he was not aware the dumpster door was left opened. The ADM stated this could lead to lead to pest/rodents. Record review of policy dated November 2022 Sanitization, . 14. Garbage and refuse containers are in good condition, without leaks, and waste is properly contained in dumpster with lids. 15. Areas used for garbage disposal are free from odors and waste fats, and maintained to prevent pest. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed, 5-501.113 Covering Receptacles. Receptacles and waste handling units for refuse, recyclables, and returnables shall be kept covered: (B) With tight-fitting lids or doors if kept outside the food establishment. 5-501.114 Using Drain Plugs. Drains in receptacles and waste handling units for refuse, recyclables, and returnables shall have drain plugs in place.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 3 of 7 residents (Resident #4, #42, and #38) and 1 of 1 medication room reviewed for pharmacy services. 1. Resident #4 received milk of magnesia for gastro-esophageal reflux disease (stomach contents leak back into the esophagus) on 10/17/2024 at 8:14 a.m., but the resident's physician order said Geri-Lanta (alum-mag hydroxide-simeth) for gastro-esophageal reflux disease. 2. There was Resident #42's insulin flex pen (Aspart) for diabetes with open dated 09/17/2024 found inside the A and B hall nursing cart on 10/16/2024. It should have been discarded 28 days (10/15/2024) after opening. 3. There was Resident #38's insulin flex pen (Lantus) for diabetes with open dated 09/08/2024 found inside the A and B hall nursing cart on 10/16/2024. It should have been discarded 28 days (10/06/2024) after opening. 4. There was one medication (Cherry Flavor Sore Throat Spray for sore throat) expired on 07/2024 found inside the medication room on 10/16/2024. This failure could place residents at risk of inaccurate drug administration and not having appropriate therapeutic effects. The findings included: 1. Record review of Resident #4's face sheet, dated 10/18/2024, revealed Resident #4 was [AGE] years old male and admitted to the facility 11/24/2003 and readmitted to the facility 04/25/2017 with diagnoses of cerebral infarction (blood flow to the brain is blocked), gastro-esophageal reflux disease (stomach contents leak back into the esophagus), hemiplegia and hemiparesis (weakness and paralysis on one side of the body), muscle wasting and atrophy (loss of muscle tissue and strength), constipation (infrequent bowel movement), and ataxia (lack of coordination in muscle movement). Record review of Resident #4's Quarterly MDS assessment, dated 09/17/2024, revealed the resident's BIMS score was 12, which indicated moderately cognitive impairment. The Quarterly MDS assessment further revealed Resident #4 required setup or clean-up assistance (helper sets up or cleans up) to eating, chair/bed-to-chair transfer, and toilet transfer, and partial/moderate assistance (helper does less than half the efforts) to shower and personal hygiene. Record review of Resident #4's physician order, dated 06/10/2024, revealed the resident had the order of Geri-Lanta (alum-mag hydroxide-simeth) over the counter suspension 200-200-20 mg per 5 ml give 300 ml by mouth once a day at 8:00 AM for gastro-esophageal reflux disease (stomach contents leak back into the esophagus). Observation on 10/17/2024 at 8:14 a.m. revealed MA-C administered 30 ml of milk of magnesia to Resident #4, and the resident took it by mouth. Interview on 10/17/2024 at 1:10 p.m. with MA-C acknowledged she administered 30 ml of milk of magnesia to Resident #4, but the resident's physician order said, Geri-Lanta (alum-mag hydroxide-simeth) over the counter suspension 200-200-20 mg per 5 ml give 300 ml by mouth once a day at 8:00 AM for gastro-esophageal reflux disease (stomach contents leak back into the esophagus). Further interview with the MA-C stated she thought milk of magnesia and Geri-Lanta (alum-mag hydroxide-simeth) was the same medication for gastro-esophageal reflux disease (stomach contents leak back into the esophagus). That was why MA-C administered milk of magnesia to Resident #4, instead of Geri-Lanta (alum-mag hydroxide-simeth). Interview on 10/17/2024 at 1:07 p.m. with the DON said milk of magnesia and Geri-Lanta (alum-mag hydroxide-simeth) was not the same medication. A milk of magnesia was used for constipation, and it was laxative. However, Geri-Lanta was used for gastro-esophageal reflux disease or heartburn, and it was acid reducer. If MA-C was confused if the two medications were the same or not, MA-C should have asked the charge nurse before giving the medication to Resident #4. DON was responsible for overseeing for medication administrations. The potential harm was the resident might have allergy to milk of magnesia and not have therapeutic effect. Record review of the facility policy, titled Administering Medications, revised 12/2012, revealed . 3. Medications must be administered in accordance with the orders, including any required time frame. 5. If a dosage is believed to be inappropriate or excessive for a resident or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication shall contact the resident's attending physician or the facility's medical director to discuss the concerns. 2. Record review of Resident #42's face sheet, dated 10/18/2024, reflected the resident was [AGE] years old male and initially admitted to the facility on [DATE] with diagnoses included: cerebral infarction (blood flow to the brain is blocked), dysphagia (difficulty finding words and speaking slowly), type 2 diabetes mellitus (body does not insulin properly, resulting in high blood sugar levels), heart failure (heart cannot pump enough blood and oxygen), dementia (decline in cognitive abilities), and hypertension (high blood pressure). Record review of Resident #42's admission MDS, dated [DATE], reflected his BIMS score was 7 of 15 reflecting he had severe cognitive impairment. Further record review of Resident #42's admission MDS, dated [DATE], indicated the resident required set up or clean-up assistance (helper sets up or cleans up) to eating, chair/bed-to-chair transfer, and toilet transfer. Record review of Resident #42's physician order, dated 07/03/2024, revealed the resident had the order of Insulin aspart pen 100 unit/ml per sliding scale; if blood sugar is less than 70 call medical doctor; if blood sugar is 150 to 200 give 3 units; if blood sugar is 201 to 250 give 6 units; if blood sugar is 251 to 300 give 9 units; if blood sugar is 301 to 350 give 12 units; if blood sugar is 351 to 400 give 15 units; if blood sugar is 401 to 800 give 18 units; if blood sugar is greater than 800 give 18 units and call medical doctor. Observation on 10/16/2024 at 3:37 p.m. revealed inside the A and B hall nursing cart, there was Resident #42's insulin flex pen (Aspart) for diabetes with open dated 09/17/2024. Interview on 10/16/2024 at 3:44 p.m. with ADON stated the ADON saw there was Resident #42's insulin flex pen (Aspart) for diabetes with open dated 09/17/2024 inside the A and B hall nursing cart. The ADON said nurses should have discarded Resident #42's insulin flex pen (Aspart) on 10/15/2024, which was 28 day because nurses opened it on 09/17/2024. Record review of Medline Plus for National Library for Medicine (https://medlineplus.gov/druginfo/meds/a605013.html#:~:text=Unrefrigerated%20unopened%20vials%20of%20insulin,time%20they%20must%20be%20discarded), dated 10/16/2024, revealed Insulin aspart can be used within 28 days once it was opened; after that time it must be discarded. 3. Record review of Resident #38's face sheet, dated 10/18/2024, reflected the resident was [AGE] years old female and initially admitted to the facility on [DATE] with diagnoses included: lack of coordination (difficulty walking and maintain balance), type 2 diabetes mellitus (body does not insulin properly, resulting in high blood sugar levels), hyperglycemia (too much glucose in the blood), muscle wasting and atrophy (loss of muscle tissue and strength), and schizophrenia (mental condition affects how to think, feel and behave). Record review of Resident #38's annual MDS, dated [DATE], reflected her BIMS score was 12 of 15 reflecting she had moderate cognitive impairment. Further record review of Resident #38's annual MDS, dated [DATE], indicated the resident required set up or clean-up assistance (helper sets up or cleans up) to eating, chair/bed-to-chair transfer, and toilet transfer. Record review of Resident #38's physician order, dated 06/03/2024, revealed the resident had the order of Lantus Solostar insulin pen; 100 unit/ml give 5 units subcutaneous for diabetes. Observation on 10/16/2024 at 3:37 p.m. revealed inside the A and B hall nursing cart, there was Resident #38's insulin flex pen (Lantus) for diabetes with open dated 09/08/2024. Interview on 10/16/2024 at 3:44 p.m. with ADON stated the ADON saw there was Resident #38's insulin flex pen (Lantus) for diabetes with open dated 09/08/2024 inside the A and B hall nursing cart. The ADON said nurses should have discarded Resident #38's insulin flex pen (Lantus) on 10/06/2024, which was 28 day because nurses opened it on 09/08/2024. Interview on 10/16/2024 at 3:56 p.m. with DON said that nurses should have discarded Resident #42's insulin flex pen (Aspart) on 10/15/2024, which was 28 day because nurses opened it on 09/17/2024 and Resident #38's insulin flex pen (Lantus) on 10/06/2024, which was 28 day because nurses opened it on 09/08/2024. The facility did not have specific policy for that but following the standard of care. DON was responsible to oversee. The potential harm was the residents might not have therapeutic effects. Record review of Cleveland Clinic (https://my.clevelandclinic.org/health/drugs/19802-insulin-glargine-injection), dated 10/16/2024, revealed if stored at room temperature, the pen must be discarded after 28 days. 4. Observation on 10/16/2024 at 3:00 p.m. revealed one of Cherry Flavor Sore Throat Spray for sore throat was found inside the medication room, and it was expired 07/2024. Interview on 10/16/2024 at 3:13 p.m. with LVN-E acknowledged one of Cherry Flavor Sore Throat Spray for sore throat was found inside the medication room, and it was expired 07/2024. Further interview with the LVN-E said she did not know why the medication was in the medication room because nurses usually checked the medication room and should discard all expired medications from the medication room as the facility policy. Potential harm was nurses might use the expired medication, and the expired medication might not have therapeutic effects. Record review of the facility policy, titled Medication Labeling and Storage, revised 02/2023, reflected 3. If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items.

Based on observation, interview and record review revealed the facility failed to ensure the resident environment remained as free of accident hazards as is possible for 1 of 12 Residents (Resident #1) whose records were reviewed for smoking. 1. The facility staff failed to ensure Residents did not have access to smoking paraphernalia. Resident #1 obtained a lighter, set a piece of paper on fire in his room while his oxygen concentrator was on. An Immediate Jeopardy (IJ) was identified on 08/17/2024. The IJ template was provided to the facility on [DATE] at 04:59 P.M While the IJ was removed on 08/19/2024, the facility remained out of compliance at a scope of Isolated and a severity level of no actual harm with the potential for more than minimal harm because all staff had not been trained on smoking policies. 2. The facility staff failed to have a smoking sign identifying the designated smoking area and failed to have metal ashtrays resulting in residents disposing of the cigarette butts on the ground. These deficient practices could affect any resident who smoked and other residents in the near vicinity by exposing them to a fire which could have resulted in injury and or death. The findings were: Review of Resident #1's face sheet, dated 8/17/24, revealed he was admitted to the facility on [DATE] with diagnoses including Chronic obstructive pulmonary disease with (acute) exacerbation (Primary), Pneumonia, unspecified organism (Admission), Heart failure, unspecified, Hypertensive heart disease with heart failure, and Unspecified right bundle-branch block. Further review revealed Resident #1 was discharged from the facility on 8/13/24, Review of Resident #1's smoking assessment completed on 6/12/24 revealed he smoked cigarettes and was assessed as being a safe smoker. Review of Resident #1's quarterly MDS assessment, dated 6/27/24, revealed his BIMS was 13 indicating he had minimal cognitive impairment, he did not have behavior or mood indicators, used a walker for ambulation and he was receiving an antidepressant and hypnotic medications. Further review revealed he was not receiving oxygen during this assessment period. Review of Resident #1's Care Plan, updated on 8/8/24, revealed he had potential for complications related to: Pneumonia. An approach was to Administer oxygen as ordered. Observe oxygen precautions.; Resident had episodes of anxiety and was at riskor fluctuations in moods. An approach was to monitor and record any abnormal behaviors and or moods. Review of Resident #1's consolidated physician orders revealed he had an order for oxygen, 2-5 Liters per minute for shortness of breath/SATs below 90% as needed. Review of SBAR report for Resident #1, dated 8/1/24, revealed there was concern for mental status changes related to Resident #1 stating he doesn't feel right. The summary read, Resident had been complaining of not feeling well. He reported that he had some SOB concentrator hooked up at 2l per min and resident reported feeling much better. After a few minutes resident was seen running to front office where he fell . DON/ADON and regional nurse at his side. At later time this Ln called 911. Resident was then admitted to hospital for further eval. Review of Resident #1's hospital discharge report, dated 8/8/24, revealed Resident #1 was discharged with an order for Nicotine patch 7 mg/24 hr. 1 patch for smoking cessation. Review of Resident #1's admission nursing assessment dated , 8/8/24, completed by LVN A revealed Resident #1 was readmitted to the facility. The document included he returned as a non-smoker, used a walker for ambulation and would receive oxygen. Further review revealed there was no indication LVN A asked Resident #1 if he had smoking materials in his possession. Review of incident/accident report, dated, 8/13/2024, revealed at 6:15 PM Resident #1 told LVN A he started a fire in his room with his oxygen. He told LVN A that he was hearing voices that told him to burn down the building and he could not control himself. Interview on 8/16/24 at 10:20 AM with the ADON, who assessed Resident #1 after the incident on 8/13/24, stated she did not know where Resident #1 obtained a lighter. Resident #1 did not tell her, and she did not ask him. The ADON stated upon Resident #1's return from the hospital on 8/8/24, he had orders for a nicotine patch to help him quit smoking. Interview on 8/16/24 at 10:45 AM with the ADM and ADON revealed prior to the incident with Resident #1, nursing staff would review the smoking policy with residents during the admission process but would not have them sign the policy. The ADM stated they did not have a process in place to ensure smoking residents returning from the hospital did not have smoking materials on their possession. Nursing staff would not ask the residents if they had smoking items. Interview on 8/16/24 at 11:15 AM with the ADON revealed she had a conversation with Resident #1's family member about the incident but did not think to ask if she knew how Resident #1 obtained a lighter. She did not ask the Resident #1 either. Interview on 8/16/24 at 12:42 PM with the DON revealed the ADM called her and told her about the incident involving Resident #1. She stated she was in shock because Resident #1 did not have a history of mental illness. She stated she was grateful nothing major happened because Resident #1's oxygen was on. Interview on 8/16/24 at 2:06 PM with Resident #2 revealed residents were not able to have cigarettes or lighters but his roommate would have a cigarette in his possession during smoke breaks. He also stated staff would not stay with them for the entire smoke break like they were supposed to stay. Resident #2 presented as being alert and oriented to person, place and time. Review of Resident #2's smoking assessment dated , 8/14/24, revealed his General Awareness and Orientation- Including Ability to Understand the Facility Safe Smoking Policy was rated as no problem. Further review revealed Resident #2 was a safe smoker. Telephone interview on 8/16/24 at 2:20 PM with LVN A revealed Resident #1 walked up to the nurse's station and told her he did not know what he was doing and started a fire in his room. She stated she was walking down the hall towards Resident #1's room as a CNA was walking up the hall yelling out fire. She stated when she arrived, to Resident #1's room, there was a burnt piece of paper on the floor in front of the nightstand. It was smoldering and the front of the nightstand was black in color but not burned through the wood. She stated she and the CNA stomped the embers out without the use of an extinguisher. LVN A stated she turned Resident #1's oxygen tank off at this time. LVN A stated the CNA did not pull the alarm. She stated they immediately put the fire out, but protocol required he pull the alarm when there was a fire. LVN A stated Resident #1 did not have a history of behaviors and had never done anything similar. She stated Resident #1's behavior was new onset and totally out of character. LVN A stated Resident #1 was discharged from the facility on the same date on an emergency detainment. Telephone interview on 8/16/24 at 4:33 PM with LVN A revealed she readmitted Resident #1 on 8/8/24 and did not ask him about having smoking paraphernalia because he returned as a non-smoker with orders for a nicotine patch even though he had been a daily smoker up to the date of discharge to the hospital, 8/1/24. LVN A stated she did not usually receive residents after being out on pass and had not been instructed to ask residents upon their return if they had smoking paraphernalia. Interview on 8/16/24 at 5 PM with the ADM and ADON revealed they reiterated they did not know where or when Resident #1 obtained a lighter. They stated he had not been out on pass, was hospitalized from 8/1/24 to 8/8/24 and then he started the fire on 8/13/24. The ADM and ADON were asked about safeguards in place to prevent families/residents from bringing paraphernalia into the facility. The ADON stated staff reviewed the smoking policy with residents and family members upon the resident's admission and as needed and they had never had a problem. The ADM stated staff was not asking the residents or family members upon re-entering the facility if the resident had smoking paraphernalia on them. The ADON stated family members were also allowed to visit, sit outside and smoke with residents at any time during their visit. She stated again they had not had a problem. The ADM and ADON stated they did not have a process in place to ensure residents did not have smoking paraphernalia during readmissions and upon returns from being out on pass. The ADM stated Staff could not [NAME] the residents upon their return to the facility, but stated staff was not required to ask residents if they had paraphernalia in their possession either. Interview on 8/17/24 at 11:19 AM with agency RN B revealed the charge nurse would provide her with the resident's status during shift change. However, stated she was new to the facility and not familiar with smokers. RN B stated after outings families would sign residents back into the facility in the sign on their Out on Pass Log and would return medications to the charge nurse. She stated she was not instructed to ask the families and residents if they had smoking paraphernalia on them. Interview on 8/17/24 at 11:32 AM agency LVN C revealed she had worked at the facility twice including on this date. She stated she received an in-service on this same date regarding the facility smoking policy but was not provided with a list of smokers. She stated she did not know who they were and had not seen a list anywhere. LVN C stated she had not supervised residents during a smoking break and had not completed documentation for a new admission. LVN C stated she had not received any residents coming back in from an outing and had not received any instructions related to the processes in place. She had not been instructed to ask residents if they had smoking paraphernalia on their possession. Interview on 8/17/24 at 12:08 PM with RN D revealed he provided RN weekend coverage but was not a supervisor. He stated he was not in charge of orienting agency nurses to the facility and not been involved in admitting a resident to the facility. He stated he had supervised residents during smoke breaks. He commented, You can tell them all you want but residents will not always give up their cigarettes or lighters. He stated he did not ask residents if they had paraphernalia on them and had not asked families or residents about having paraphernalia upon returning from pass. RN D stated he was not sure if there was a list of smokers. Interview on 8/17/24 at 12:44 PM with Resident #1's family member revealed Resident #1 had been out on pass with her multiple times. She had bought Resident #1 cigarettes and offered to buy him a lighter in the past, but he declined. She stated she did not know about the facility's smoking policy and staff had never talked with her about it. The family member stated she did not provide Resident #1 with a lighter while he was hospitalized , 8/1/24 to 8/8/24. She stated she did not know how he obtained the lighter and had not talked to Resident #1 since his discharge from the facility. Resident #1's family member stated facility staff was also still trying to figure out how Resident #1 obtained the lighter. She stated a staff member called her earlier on this date. 2. Observation and interview during a walk through the smoking area outside on 8/16/24 at 12:29 PM with the MS revealed there was not a smoking sign or ashtrays. There were three visible aluminum trash cans: two under the eve upon exiting the facility and one in the covered patio area. Interview with the MS revealed the SW would supervise the residents during smoke breaks and would store the ashtrays in her office after smoke breaks. She would then bring them back out for smoke breaks. Observation and interview on 8/16/24 at 3 PM revealed about 8 Residents smoking outside in the courtyard. There was not a smoking sign leading to the courtyard and there was not a sign outside in the smoking area. There were also no ashtrays. The ADON was supervising the smoke break and stated someone went inside to get the ashtrays because they also noticed there were no ashtrays. The ADON stated she did not notice there was not a smoking sign. Further observation revealed a staff member brought 2 glass ashtrays for the smokers to use. Interview on 8/16/24 at 3:10 PM with the ADM and Regional Consultant revealed they had not noticed there was not a smoking sign. The ADM stated he had never taken the residents out for smoke breaks and did not know what type of ash trays were available but knew they should be metal. Observation and interview on 8/16/24 at 3:20 PM revealed a glass ashtray on top of a small table under the eve right outside the door and a second glass ashtray on top of a picnic table under the covered patio. Further observation revealed a cigarette butt on the ground between a chair and the cigarette butt trash can under the eve. Interview with the ADM revealed he stated there was a cigarette butt on the ground and should be disposed in the cigarette butt trash can for safety precautions. He stated he understood if the cigarette butt was not completely turned off it could start a fire. Interview on 8/16/24 at 3:38 PM with the SW revealed she would take residents out for a smoke break on M, W, F at 11 AM. The SW stated she was not sure about what type of ashtrays the residents used. She stated there were metal trash cans available for the residents' use. Review of facility Smoking Policy, dated October 2022, read 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 smoking areas, and the extent to which the facility can accommodate their smoking or non-smoking preferences. 2. Smoking is not allowed inside the facility under any circumstances. Smoking is only permitted in designated resident smoking areas, which are located outside of the building. 7. The resident will be evaluated on admission to determine if he or she is a smoker or non-smoker. 13. Lighters, including matches are prohibited to be kept in patients' rooms. Review of facility policy, [ Code Red], dated July 2024 read: POLICY: To ensure the safety of the residents, this policy provides instructions for staff to know and follow in the event of a fire. RESPONSIBLE PERSONS: Every employee is responsible to understand and to follow these procedures. PROCEDURE: Upon finding a fire staff must: 1) Yell CODE RED and the location of the fire, remove any residents from immediate danger. 2) Remove any residents in immediate danger. 3) Pull the alarm. 4) Use the overhead paging system and announce, 'CODE RED, and give a brief description of the location of the fire. 5) Contain the fire by closing doors, and/or windows. 6) Extinguish Fire if possible. 7) Close all doors in the area, checking bathrooms. 8) Close remaining windows and doors on the floor. 9) Do Not cross the fire area. 10) Visitors will not be permitted to enter floors. They will be permitted to remain in the lobby until the fire emergency is cleared. Remember RACE >>> R = Rescue/Remove resident from fire location and yell out CODE RED. A = Alarm: pull the fire alarm and tell someone to overhead page CODE RED. C = Contain: close all doors in the area. E = Extinguish: while removing residents from the area. This was determined to be an Immediate Jeopardy (IJ) on 08/17/2024 at 4:59 PM and the Administrator was notified. The Administrator was provided with the IJ template on 08/17/2024 at 4:59 PM. The following Plan of Removal was accepted on 08/18/2024 at 12:20 PM and it included: 8/13/2024 Residents #1 was assessed by ADON and resident was not a smoker and had a nicotine patch in place, police were notified and in building at this time. Resident was Emergency discharged to [hospital]. MD notified and aware of ED. There were no new orders obtained. Affected resident responsible party was notified by ADON of the alleged incident and plan of correction. 8/13/2024 ADON in serviced staff on smoking policy and reporting fire. On 8/13/2024 the Social worker, ADON, and Administrator interviewed all residents in the facility to determine if any other residents experienced any psychosocial harm from the alleged incident. There was no concern identified. The interviews were completed before midnight on 8/16/2024. On 8/14/2024 Administrator reported alleged incident to THHS and initiated an investigation immediately. 8/14/2024 Administrator/designee re-educated residents on smoking policy and letters were emailed/mailed to resident responsible parties who smoke. 8/14/2024 Residents who smoke were re-evaluated on 08/14/2024 using the facility smoking assessment. Ad-Hoc QAPI meeting was held on 8/17/2024 at 5:30 PM, with the Medical Director, NHA (Nursing Home Administrator), RDO (Regional Director of Operations) and DON to review the alleged incident, policy and procedure, and the plan for removal of immediacy. On 8/17/2024 in-servicing to all staff on smoking policy and procedure, admission checklist for paraphernalia checks reviewed, and questions when coming back from Out on Pass. Staff will receive Quiz post in-service to ensure understanding of process. 8/17/2024 Safe Surveys conducted. No issues at this time. Any issues will be brought to QAPI. 8/17/2024 Activity Director and Assistant in serviced on signing residents out and back in when out on activities as well as asking about paraphernalia. 8/17/2024 Cognitive Residents in serviced on Signing out and answering all questions on Sign out sheets. The policy pertaining to Smoking and Smoking Assessments were reviewed on 8/17/2024 by the DON, NHA (Nursing Home Administrator) and Medical Director. Starting on 8/13/2024, IDT (Interdisciplinary team), including Administrator, DON, ADON, Activity Director, MDS Coordinator, HR, BOM) will meet with residents daily Monday to Friday, and Manager on Duty Saturday and Sunday to determine if any paraphernalia was obtained. The findings will be immediately brought up to Administrator for further action, if necessary. Grievances will be reviewed during morning meeting with Administrator and IDT team members for any follow up needed. All grievances will be entered into Grievance log by Administrator and investigation form will be filled out accordingly. 8/17/2024 Activities director called RP's of smoking residents to inquire if they had any questions The DON/designee will monitor compliance by completing audit of ten (5) residents per week for four (4) weeks. This was initiated on 8/17/2024. Any identified concern will be addressed immediately and if trends and patterns are identified, the facility will conduct an Ad-Hoc QAPI meeting to discuss if additional interventions are needed to ensure compliance. The Administrator will be responsible to ensure this plan is completed on 8/18/2024. The RDO will provide oversight of DON and Administrators to ensure that the items on the plan of removal are reviewed and completed. Verification Process of the POR was initiated on 8/18/24 and completed on 8/19/24: Observation on 8/18/24 at 3 PM in smoking area revealed about 8 residents smoking. The SW was supervising the residents under the eve and the AIT was supervising the 2 residents under the covered patio. There was one metal ash tray at each station including a cigarette butt metal trash can. 1. Interview with the ADON on 8/16/24 at 10:20 AM revealed she in-serviced staff on the smoking policy and reporting a fire. 2. Review of staff sign in, dated 8/16/24, revealed in-service on the smoking policy and reporting a fire was provided on 8/18/24. There were 50 of 50 full time employees and 5 agency staff signatures. 3. Review of 143 resident safe surveys dated from 8/14/24 to 8/17/24 revealed staff conducted resident safe surveys every day. 4. Review of intake worksheet and interview with the ADM on 8/16/24 at 10 AM revealed the ADM reported the incident on 8/14/24. 5. Review of the POR revealed the AD was responsible re-educating residents on the smoking policy. Further review revealed the AD sent a letter with a copy of the smoking policy. She included documentation for each family member she did not reach and left a VM. Documentation also reflected the AD sent out a text message to family members as an additional attempt to make contact. Interviewed AD on 8/18/24 at 4:03 PM. She stated she called family members, left messages and or sent a text to ensure they understood the smoking policy and the amendments they made on the sign in and out document. The AD stated she would follow up and call the family members that she left a voicemail. 6. Review of smoking assessments revealed 12 Residents were assessed on 8/14/24 and the assessments reflected they were all safe smokers. 7. Review of sign in sheet for Ad-Hoc QAPI meeting held on 8/17/2024 at 5:30 PM revealed the NHA (Nursing Home Administrator), RDO (Regional Director of Operations) and DON signed attesting they reviewed the alleged incident, policy and procedure, and the plan for removal of immediacy. Further review revealed the Medical Director attended via telephone. 8. Review of sign in sheet for in-service, dated 8/17/24, on smoking policy and procedure, admission checklist for paraphernalia checks, and questions staff should ask when residents return from being out on pass. revealed 50 of 50 full time employees and 5 agency staff signatures. Review of signed quizzes by staff and review of text messages staff sent to the ADON revealed all staff completed a quiz with satisfactory results. 9. Review of 143 resident safe surveys from 8/14/24 to 8/17/24 revealed resident safe surveys were conducted every day. Further review revealed any issues would be brought up to the QAPI. 10. Review of in-service, dated 8/17/24, revealed the AD signed attesting she received training on ensuring Residents signed back in to the facility after being out on an activity and she would ask Resident about smoking paraphernalia. 11. Review of a sign in sheet, dated 8/17/24, for a resident in-service revealed instructions for the residents on signing out and answering all questions on the sign out sheet revealed 18 resident signatures who would go out on pass. 12. Interview on 8/18/24 at 3:51 PM with the ADM, DON and Regional Consultant revealed they and the Medical Director reviewed the Smoking and Smoking Assessment policies on 8/17/2024. 13. Interview on 8/18/24 at 3:51 PM with the ADM revealed starting on 8/13/2024, IDT (Interdisciplinary team), including Administrator, DON, ADON, Activity Director, MDS Coordinator, HR, BOM) would meet with residents daily, Monday to Friday, and the Manager on Duty on Saturday and Sunday would meet with residents to determine if any paraphernalia was obtained. The findings would be immediately brought up to him for further action, if necessary. Grievances would be reviewed during morning meetings with himself and the IDT team members for any follow up as needed. He would enter all grievances into the Grievance log and investigation form would be filled out accordingly. The ADM stated these daily checks would continue until staff felt comfortable residents were following the policy by not having paraphernalia on them. Review of a daily checks log revealed from 8/13/24 to 8/15/24 12 smoking residents were asked about smoking paraphernalia. 14. Interview on 8/18/24 at 3:51 PM with the ADM, DON, ADON and Regional Consultant revealed the DON/designee would monitor compliance of the smoking policy by completing an audit of (5) residents per week for four (4) weeks. They stated this was initiated on 8/17/2024. In addition, any identified concerns would be addressed immediately and if trends and patterns were identified, the facility would conduct an Ad-Hoc QAPI meeting to discuss if additional interventions were needed to ensure compliance. 15. Interview at 3:51 PM with ADM, DON, ADON and Consultant revealed nursing staff would continue asking residents daily about paraphernalia. The DON would interview 5 residents a week about any issues and paraphernalia. The ADON stated all staff was quizzed via text sent out; she sent a screen shot of the quiz and staff responded with their answers. Staff would conduct daily checks with residents on C and D halls. Residents on the A and B halls consisted of residents in the memory care units. The ADM and ADON stated none of the residents smoked until most recently Resident #3, in the men's unit decided he wanted to smoke. The ADM stated Resident #3 would join the rest of the residents at regularly scheduled smoking breaks every odd hour beginning at 7 AM with the last smoke break scheduled at 9 PM. Staff would escort him to the courtyard on the days he chose to smoke. The ADM stated he sent out an email, letter re-iterating the smoking P&P with edits including staff asking for paraphernalia after outings with the Residents. Staff followed up with a call to RPs for all smokers. He stated family/residents would have to sign out and back in before residents were allowed back into their room. Nursing staff would complete the admission checklist: nursing staff would ensure they asked the question about smoking and if the resident had smoking materials. Nursing staff would also ask residents if they had smoking materials upon readmissions. The ADM stated 100% of staff was in-serviced on the smoking and fire policies and quizzed including dietary and housekeeping. 16. Interview at 4:03 PM with the AD revealed she and her assistant would ensure residents signed out and back in after taking residents on outings. She stated they would ask Residents what they were taking with them and would ask about smoking paraphernalia upon their return. She stated she and her assistant would also be responsible for ensuring the residents/families signed the resident back in upon their return. She stated they would be quizzing everyone who left the facility about smoking paraphernalia and about the smoking policy. They would let the ADM know right away if residents noted with paraphernalia. The AD stated she called families and made sure they received a letter/email about the smoking policy and edits. She stated she would follow up with families who she left a VM. The AD stated she would also ask resident/families about smoking paraphernalia after returning from smoking breaks during visits. 17. Interview at 4:17 PM with the SW revealed she would be make sure cigarette butts were destroyed (completely put out) and dumped in the metal trash cans after smoke breaks. She would also ensure ash trays were emptied. The SW stated, in addition, she would, be asking relatives/families about paraphernalia. 18. Interview at 4:20 PM with the AIT revealed there was a new sign/in out sheet; staff was to ask residents upon return for paraphernalia. Staff was to continue supervision during smoke breaks. Nurses would inquire about smoking paraphernalia upon readmission. Weekend supervisor would make rounds, in-servicing staff, talking to residents making sure everyone was compliant with the smoking policy. 19. Interview at 4:24 PM with the DM revealed she was in-serviced about staff asking residents for smoking materials upon return from being out on pass. They also reviewed the fire policy. 20. Interview at 4:26 PM with the MS revealed he was in-serviced on checking resident rooms every day and would ask about smoking materials upon return from residents being out on pass. He stated residents who chose not to comply with the smoking policy would get a 30-day notice for discharge. He stated all staff was in-serviced about following the smoking rules during breaks: being more vigilant about ensuring residents did not obtain paraphernalia. The MS stated they would be ordering more ash trays. They would keep the courtyard cleaner by making sure there were not cigarette butts on the ground, emptied ash trays and trash cans daily. 21. Interview at 4:34 PM with RN B revealed nursing staff would be asking residents for smoking materials anytime they left the facility or upon their return. 22. Interview at 4:37 PM with MA E revealed nursing staff would be asking residents for smoking materials anytime they left the facility and/or upon their return. 23. Interview at 4:41 PM with RN D revealed staff was to ensure residents signed/out and back into the facility; nursing staff was to ensure they asked the questions about smoking materials upon admission. Staff was to reinforce the smoking rules ensuring residents adhered to it to ensure their safety. 24. Interview at 4:47 PM with CNA F revealed she understood the smoking policy and amendments made. She stated nursing staff would be asking residents about smoking materials anytime they left and returned to the facility. 25. Interview at 4:48 PM with CNA G revealed staff was in-serviced about the fire and smoking P&P including changes related to asking residents about smoking materials including new admissions; making sure residents signed out when going out on pass; the sign in and out sheet was updated, and they reviewed resident supervision while smoking in the courtyard. 26. Interview at 4:52 PM with CNA H revealed they reviewed the smoking and fire P&P and the changes made including asking residents about smoking materials anytime they left and returned to the facility. 27. Interview at 5:03 PM with CNA I revealed they reviewed the smoking and fire P&P and the changes made including asking residents about smoking materials anytime they left and returned to the facility. 28. Interview at 5:10 PM [NAME] J revealed they reviewed the smoking and fire P&P and the changes made including asking residents about smoking materials anytime they left and returned to the facility. 29. Interview at 5:14 PM with Dishwasher K revealed they reviewed the smoking and fire P&P and the changes made including asking residents about smoking materials anytime they left and returned to the facility. 30. Interview at 5:25 PM with LVN L revealed she they reviewed the smoking and fire P&P and the changes made including asking residents about smoking materials anytime they left and returned to the facility. 31. Interview at 5:30 PM with RA M revealed they reviewed the smoking and fire P&P and the changes made including asking residents about smoking materials anytime they left and returned to the facility. 32. Interview at 5:32 PM with MA N revealed they reviewed the smoking and fire P&P and the changes made including asking residents about smoking materials anytime they left and returned to the facility. 33. Interview at 5:48 PM with LVN O revealed they reviewed the smoking and fire P&P and the changes made including asking residents about smoking materials anytime they left and returned to the facility. 34. Interviews with smoking Residents from 6:00 PM to 6:30 PM included Resident #2 to Resident #13. All Residents verbalized an understanding of the smoking policy and stated they should not have cigarettes or smoking items on them. Furthermore, they could not keep smoking items in their room. Residents #2 to Resident #13 stated staff kept their cigarettes and lighter under lock and key and stated staff was stricter. 35. Attempted calls were made on 8/19/24 from 4:15 PM to 5:36 PM to family members for Resident #4, Resident #7, Resident #2 and Resident #5. A voicemail was left. 36. Telephone interviews on 8/19/24 from 4:15 PM to 5:36 PM with family members for Resident #6, Resident #11, Resident #9, Resident 8, and Resident #13 revealed they had not received a call from

Based on interviews, observation, and record reviews, the facility failed to protect residents' rights to be free from verbal abuse, physical abuse, and involuntary seclusion for 7 (Resident #1, 2, 3, 4, 5, 6, and 7) of 12 residents reviewed for abuse and neglect, in that: 1. Residents #2, 5, and 6 were pinched, pulled, and told bad words by CNA A on 01/11/24. 2. CNA A was arguing with Resident #4 in a disrespectful manner on 01/11/24. 3. CNA A was physically aggressive with Resident #7 on 01/11/24 4. Residents #1 and #3 revealed CNA A verbally abused them, undated. The noncompliance was identified as past noncompliance IJ (Immediate Jeopardy). The noncompliance began on 01/11/24 and ended on 01/12/24. The facility had corrected the noncompliance before the investigation began. The facility implemented interventions to prevent further abuse and neglect risks to include educating staff about abuse, neglect, exploitation, performing resident safe surveys to ensure safety of residents, and terminating the alleged perpetrator. This failure could affect all residents at the facility by placing them at risk for physical, mental, and emotional decline, psychosocial harm, and can lead to residents being at risk for harm and injury. The findings included: 1. Record review of Resident #2's face sheet revealed Resident #2 was a female initially admitted to the facility on [DATE] and readmitted [DATE]. Resident #2 had diagnoses to include major depressive disorder, anxiety disorder, altered mental status, dementia (loss of cognitive functioning that interferes with daily life and activities), and unspecified pain. Record review of Resident #2's BIMS report, completed 10/18/23, revealed resident had a BIMS of 03 out of 15, which signified severe cognitive impairment. Record Review of Resident #2's Nursing progress note, dated 01/11/24 at 05:09 PM, revealed a head-to-toe assessment with a slight discoloration identified on resident's left forearm identified. The MD and RP were notified. Record review of Resident #5's face sheet revealed Resident #5 was a female initially admitted to the facility on [DATE]. Resident #5 had diagnoses to include depression, cognitive communication deficit, anxiety disorder, restlessness and agitation, and mild cognitive impairment. Record review of Resident #5's BIMS report, completed 01/08/24, revealed resident had a BIMS of 03 out of 15, which signified severe cognitive impairment. Record Review of Resident #5's Nursing progress note, dated 01/11/24 at 05:05 PM, revealed a head-to-toe assessment with no skin concerns identified. The MD and RP were notified. Record review of Resident #6's face sheet revealed Resident #6 was a female initially admitted to the facility on [DATE]. Resident #6 had diagnoses to include major depressive disorder, cognitive communication deficit, anxiety disorder, and Alzheimer's disease (brain disorder that causes problems with memory, thinking, and behavior). Record review of Resident #6's BIMS report, completed 12/26/23, revealed resident had a BIMS of 02 out of 15, which signified severe cognitive impairment. Record Review of Resident #6's Nursing progress note, dated 01/11/24 at 05:07 PM, revealed a head-to-toe assessment with no skin concerns identified. The MD and RP were notified. Record Review of Accident/Incident Investigation Witness Statement on 01/11/24, written by NA E in regard to Residents #2, 5, and 6, reflected I report [CNA A] since today she was quite rude and abusive person with the residents, pinching them, pulling them to sit in their place, fighting with them and telling them bad words just because they were not letting her change their briefs. She doesn't let them walk in the hallway and wants to keep them sitting. Since 3:30 pm she took them to the dining room while they were trying to watch a movie. I told her it was too early for food and she got angry. I immediately reported it to my nurse. Attempted interview on 03/06/24 at 10:35-10:40 AM with Resident #2 and #6 with no success due to improper responses. Resident #5 was not in the facility for an interview. 2. Record review of Resident #4's face sheet revealed Resident #4 was a female initially admitted to the facility on [DATE]. Resident #4 had diagnoses to include dementia (loss of cognitive functioning that interferes with daily life and activities), unspecified hip pain, altered mental status, and hearing loss. Record review of Resident #4's BIMS report, completed 12/28/23, revealed resident had a BIMS of 07 out of 15, which signified severe impairment. Record Review of Resident #4's Nursing progress note, dated 01/11/24 at 05:06 PM, revealed a head-to-toe assessment with no skin concerns identified. The MD and RP were notified. Record Review of Accident/Incident Investigation Witness Statement on 01/11/24, written by MA H, reflected I was helping a resident to seat down in the tv room when [CNA A] was arguing in a [disrespectful] manner to the [Resident #4]. I told the CNA to not treat the resident that way. I immediately reported to my nurse. Attempted interview on 03/06/24 at 10:35-10:40 AM with Resident #4 with no success due to improper responses. 3. Record review of Resident #7's face sheet revealed Resident #7 was a female initially admitted to the facility on [DATE]. Resident #4 had diagnoses to include recurrent depressive disorders and unspecified pain. Record review of Resident #7's BIMS report, completed 10/18/23, revealed resident had a BIMS of 02 out of 15, which signified severe impairment. Record Review of Resident #7's Nursing progress note, dated 01/11/24 at 05:07 PM, revealed a head-to-toe assessment with no skin concerns identified. The MD and RP were notified. Record Review of Accident/Incident Investigation Witness Statement on 01/11/24, written by the Activities Director, reflected At 4:30 pm on 1/11 I witnessed [CNA A] aggressively shove a baby doll into [Resident #7] arms and forcefully sit her down. I then reported to ADON. Resident #7 was not in the facility for an interview. 4. Record review of Resident #1's face sheet revealed that Resident #1 was a male initially admitted to the facility on [DATE] and readmitted [DATE]. Resident #1 had diagnoses to include major depressive disorder, anxiety disorder, and unspecified pain. Record review of Resident #1's BIMS report, completed 01/30/24, revealed resident had a BIMS of 12 out of 15, which signified moderate cognitive impairment. Record review of Resident #3's face sheet revealed that Resident #3 was a male initially admitted to the facility on [DATE] and readmitted [DATE]. Resident #3 had diagnoses to include depression and anxiety disorder. Record review of Resident #3's BIMS report, completed 02/27/24, revealed resident had a BIMS of 13 out of 15, which signified intact cognition. During an interview on 03/06/24 at 10:42 AM, LVN B revealed CNA A was not physically or verbally abusive towards residents. LVN B mentioned residents would complain about not being able to understand CNA A and CNA A needed to speak more clearly when providing care with residents for them to not be confused and accepting of care. After 01/11/24 incidents of abuse from CNA A, LVN B revealed he reported to ADON prior behaviors he witnessed from other residents to CNA A due to their frustration with the miscommunication and care they would receive from CNA A. He further revealed this may have caused CNA A's inappropriate responses to the residents, which were unacceptable. During an interview on 03/06/24 at 10:57 AM, Resident #1 revealed CNA A was not good and she yelled at him multiple times. Resident #1 revealed he told a nurse (he could not recall their name) and the administrator about CNA A, but they did not do anything about it. He further revealed CNA A yelled at other residents too. During an interview on 03/06/24 at 11:25 AM, MA C revealed CNA A would overwhelm residents due to language barrier and not slowing down to speak with residents. MA C educated CNA A on the job about not overwhelming residents before it would escalate into a problem. MA C further revealed CNA A probably should not have worked in the women's secured unit based on her interactions with CNA A. MA C further revealed she could have written this complaint, had it addressed, and would do this in the future. During an interview on 03/06/24 at 03:22 PM, the ADON revealed 3 residents (2 out of the 3 residents were still at the facility) did not want CNA A to care for them. The ADON further revealed she did not ask why these residents did not want CNA A to be caring for them. The ADON was not able to provide any documentation that showed Residents #1 and #3 had complaints/grievances about CNA A. During an interview on 03/07/24 at 09:22 AM, CNA G revealed Resident #1 reported he did not want CNA A to care for him. CNA G did not ask why Resident #1 felt this way about CNA A, but shared this information with the ADON. CNA G further revealed she could have helped Resident #1 fill out a grievance form to address his complaint. During an interview on 03/08/24 at 10:22 AM, Resident #3 revealed CNA A yelled at him and he did not want CNA A to be in his area. He could not express how he felt during the interview, but he told a CNA, the ADON, and the Administrator D about CNA A but Administrator D didn't do anything about it. During an interview on 03/06/24 at 09:40 AM, the ADON revealed NA E came to Administrator D about abuse on 01/11/24. After this, the ADON interviewed staff about CNA A and 2 other staff (the Activities Director and MA H) confessed more incidents involving CNA A exhibiting abusive behaviors. The ADON revealed CNA A was immediately suspended pending investigations. During an interview on 03/06/24 at 10:13 AM, CNA F revealed CNA A had little patience with residents and should probably not have worked with the individuals in the women's secure unit. CNA F recalled since November 2023 CNA A would be more aggressive with residents in the women's secure unit and should have been more patient. CNA F revealed she had to tell CNA A to calm down with the residents. CNA F reported to her nurse about CNA A's behavior. CNA F further revealed residents would complain to CNA F about CNA A not being nice to them. CNA F further revealed she did not observe any abuse. CNA F could not remember any resident names, nurse names, or specific dates. CNA F revealed she had been trained after this incident on Abuse, Neglect, and Exploitation and was aware to contact the Administrator. During an interview on 03/06/24 at 10:42 AM, LVN B revealed CNA A was not physically or verbally abusive towards residents. LVN B mentioned residents would complain about not being able to understand CNA A and CNA A needed to speak more clearly when providing care with residents for them to not be confused and accepting of care. After 01/11/24 incidents of abuse from CNA A, LVN B revealed he reported to ADON prior behaviors he witnessed from other residents to CNA A due to their frustration with the miscommunication and care they would receive from CNA A. He further revealed this may have caused CNA A's inappropriate responses to the residents, which were unacceptable. LVN B revealed he had been trained and was aware of letting ADON, DON, and the Administrator know of suspected abuse, neglect, and exploitation. During an interview on 03/06/24 at 04:17 PM, MA H revealed she was passing out medications when she observed CNA A was impatient and had inappropriate tone/behavior [MA H did not reveal any arguing]. MA H further revealed she had not seen CNA A act like this towards residents before, but she had expressed stress with residents in the past. MA H revealed NA E came to her after NA E saw CNA A pinching residents when CNA A thought NA E was not looking. MA H further revealed NA E expressed she did not know what to do. After this conversation, MA H revealed she went with NA E to report to the nurse and the ADON. MA H was unable to identify the nurse that was working. MA H revealed she had been trained after incident and was aware of reporting abuse, neglect, and exploitation to the Administrator. During a combined interview on 03/07/24 at 09:49 AM with the Administrator and the ADON, the ADON revealed last week staff were trained on abuse, neglect, and exploitation. The Administrator showed documentation of safe surveys being done for every resident. Agency staff or anyone who comes into work for the facility is trained on abuse, neglect, and exploitation and reporting prior to working their shift. The Administrator and the ADON revealed agency staff and new staff members are trained on Abuse, Neglect, Exploitation and Reporting Incidents before they worked with residents. During an interview on 03/07/24 at 01:06 PM the Administrator and the ADON ensured staff are assessing residents to make sure they are safe in the facility. The Administrator revealed he will also check in with staff regularly to ensure they are aware of the facility's abuse, neglect, and exploitation policy. The following were interviews showing staff as educated on the Abuse, Neglect, and Exploitation policy: During an interview on 03/06/24 at 03:08 PM, the Director of Rehab, PT O, and OT P identified what abuse, neglect, and exploitation was and to report to the Administrator if they had any concerns. During an interview on 03/06/24 at 03:10 PM, the DM revealed he trained his staff on Abuse, Neglect, and exploitation and the Administrator is the Abuse Coordinator. During an interview on 03/07/24 at 02:50 PM LVN M shared examples of abuse and how to report abuse, neglect, and exploitation. He further revealed nurses are mandated reporters and he would report it to the state as well During an interview on 03/07/24 at 02:59 PM, LVN L identified examples of abuse, neglect, and exploitation and knew to report to the ADON, the DON, and the Administrator. She further revealed she will report to the state if she did not feel heard. During an interview on 03/07/24 at 03:01 PM, NA N revealed she was trained on abuse, neglect, and exploitation and knew the Administrator was the Abuse Coordinator. During an interview on 03/08/24 at 12:12 PM, HSK I, HSK J, and HSK K were able to identify what abuse, neglect, and exploitation were and knew to report straight to the administrator if they had any suspicion of residents being mistreated. During an interview on 03/07/24 at 04:01 PM, Human Resources revealed CNA A was suspended 1/11/24 and did not physically come into the facility. CNA A's time sheet revealed she clocked in on 01/16/24, 01/17/24, and 01/18/24. She further revealed the facility cannot terminate an employee until their Paid Time Off was paid out. Unable to connect with NA E via telephone on 03/22/24 at 12:17 PM and 04:25 PM. Observations from 03/05/24 through 03/08/24 revealed no incidents of abuse, neglect, exploitations. Observations revealed interactions between staff and residents yielded appropriate care with no deficiencies noted. Record Review of the facilities investigation report revealed NA E and MA H reported incidents involving CNA A to ADON at 04:15 PM. CNA A was immediately suspended. The facility reported to [state agency] at 07:28 PM. Record Review of 16 Resident Safe Surveys for the residents in the women's secure unit on 01/11/24 revealed compliance with the abuse, neglect, exploitation facility policy because residents reported feeling safe in the facility. Record Review of Residents #2. 4, 5, 6, and 7 revealed trauma-informed assessments were done 01/17/24 and staff requested evaluation for mental health by psychiatry. Record Review of the in-service attendance sheet, dated 01/12/24, presented by the ADON, revealed a topic of ABUSE/NEGLECT that included reviewing facility policies Abuse Prevention Program and Preventing Resident Abuse. Record review revealed 100% of the regular staff was trained, including Agency Staff that was available. Record Review of CNA A's human resources packet revealed CNA A was hired 04/14/23 and suspended 01/11/24. Record review of CNA A's Timesheet showed hours for 01/16/24, 01/17/24, and 01/18/24, to pay out her PTO(paid time off) although not physically worked. During a combined interview on 03/08/24 at 12:28 PM with the ADON and the Administrator, the ADON revealed staff got trained on grievances/complaints upon hire and yearly. The Administrator revealed he will combine training on grievances along with abuse, neglect, exploitation training. The Administrator further revealed he will train the staff to document all relevant concerns so he can solve any grievances or complaints that residents may have. The Administrator further revealed he believed addressing grievances/complaints prevented issues like abuse, documented any concerns, and monitored any possible trends. Record Review of the facility's Abuse Prevention Program policy, revised January 2011, revealed: Policy Statement: Our residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion . 1. Our facility is committed to protecting our residents from abuse by anyone including, but not necessarily limited to: facility staff . 3. Comprehensive policies and procedures have been developed to aid our facility in preventing abuse, neglect, or mistreatment of our residents. Our abuse prevention program provides policies and procedures that govern, as a minimum: c. Identification of occurrences and patterns of potential mistreatment/abuse; f. Timely and thorough investigations of all reports and allegations of abuse . Record Review of the facility's Preventing Resident Abuse policy, revised November 2010, revealed: 1. The facility's goal is to achieve and maintain an abuse-free environment. 2. Our abuse prevention/intervention program includes, but is not necessarily limited to, the following: a. Training all staff and practitioners how to resolve conflicts appropriately. q. Encouraging all personnel, residents, family members, visitors, etc., to report any signs or suspected incidents of abuse to facility management immediately. The noncompliance was identified as past noncompliance IJ (Immediate Jeopardy). The noncompliance began on 01/11/24 and ended on 01/12/24. The facility had corrected the noncompliance before the investigation began. The facility implemented interventions to prevent further abuse and neglect risks to include educating staff about abuse, neglect, exploitation, performing resident safe surveys to ensure safety of residents, and terminating the alleged perpetrator.

Based on interview, and record review, the facility failed to consult with the physician when the resident experienced a change in condition for 1 of 1 resident (Resident #1) reviewed for a change of condition, in that:. The facility failed to notify the physician when Resident #1 had bleeding to the bridge of the nose on 12/17/23 at 2:00 AM. LVN A was aware that Resident #1 had a fall with injury on 12/12/23 and neuro checks were done for 72 hours. The facility staff did not document an assessment, vital signs and communications with the physician for a period of 22 hours when the resident had a change of condition. Resident #1 was taken to theER on [DATE] at 12:46 AM and diagnosed with a subdural hematoma, nasal fracture, and rib fractures. An Immediate Jeopardy was identified on 01/12/24 at 12:05 PM. While the Immediate Jeopardy was removed on 01/13/24 at 5:10 PM, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not Immediate Threat due to the facility's need to monitor and evaluate the effectiveness of the plan of removal and corrective actions. This failure could affect residents by placing them at risk for serious injury, harm, impairment, or death. The findings included: Record review of Resident #1's Face Sheet printed 12/21/22 revealed Resident #1 was a [AGE] year-old male admitted on [DATE] and discharged to theER on [DATE]. Resident #1's diagnoses included: cerebral infarction (stroke), lack of coordination, dementia with agitation, cognitive communication deficits, and essential hypertension (primary). The RP was listed as a family member. Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed his primary reason for admission was coded as Other Neurological Conditions related to cerebral infarction [a brain lesion in which a cluster of brain cells die when they do not get enough blood; stroke]. Other active diagnosis included non-Alzheimer's vascular dementia [a group of symptoms that affects memory, thinking and interferes with daily life]. Resident #1 had a BIMS summary score of 3, indicative of severe cognitive deficits. Resident #1 had one fall since admission with a non-major injury. Resident #1 was coded as walking 50 feet with set-up assistance only and coded as contact guard assistance for walking 150 feet. Record review of Resident #1's Care Plan, undated, revealed he had a problem area in the category of Falls with a start date of 12/07/23. Additional problem area in the category of ADLs Functional Status related to cognitive impairment, lack of coordination and muscle weakness with a start date of 8/24/2023. Record review of Resident #1's physician orders dated December 2023 revealed Resident #1 was administered the following medications: *clopidogrel, tablet, 75 mg, 1 tablet daily (blood thinner) and *aspirin, tablet, chewable, 81 mg, 1 tablet daily (blood thinner). In a record review of a written statement dated 12/18/2023, CNA E stated she observed Resident #1 with blood on the bridge of his nose and immediately reported it to LVN A & B during shift change on 12/17/2023 at 6:00 a.m. (Note: Resident #1 was on blood thinners.) Record review of Resident #1's clinical record revealed no SBAR or head-to toe assessment was for Resident #1 on 12/17/23. Record review of Resident #1's Progress Notes revealed a late entry entered on 12/19/23 at 8:48 AM by LVN A for 12/17/23 5:38 AM of observed superficial abrasion approx[imately] 1.5 cm in legth[sic] .cleaned the dry blood from his nose and place a dressing on top to keep it clean from dirt and debri[sic]. Will inform oncoming nurse. [LVN B] Record review of Resident #1's Progress Notes revealed entry on 12/17/23 at 6:33 PM by LVN B that upon arrival of shift [12/17/23 6:00 AM] resident was found to [sic] bleeding from forehead and bridge of nose. No explanation given as to what occurd[sic] .Resident c/o [complained of] headache and face pain. Record review of Resident#1's Nurse Note dated 12/18/23 at 11:24 PM, authored by LVN C, read Off going nurse [LVN B] reported resident was found this morning with bleeding to his face. When I went to assess resident it was observed that he has nasal swelling and right facial swelling as well as abrasions to his [forehead]. Resident was at baseline for resident which is alert to self and able to follow very basic instruction. When asked resident if was in pain he stated yes and touched his nose. I could hear him trying to breathe through his nose. I asked if it was difficult to breathe through his nose and he stated yes. VS 133/81, 105, 95% room air, 21, 99.1. Resident ambulated throughout unit per his usual routine. Call placed to . Physicians expressing concern and they gave orders to send him out to . ER to be evaluated . Ambulance was called, and he is pending transport. Record review of Resident #1's Progress Notes revealed entry on 12/18/23 at 12:45 AM by LVN C observed that he has nasal swelling and right facial swelling as well as abrasions to forehead . Further documentation indicated resident stated yes when asked if he was in pain and yes to difficulty breathing through nose. Resident transferred to local emergency roiagnom on [DATE] at 12:46 AM. Record review of Resident #1's ER CT Scan of the Head without intravenous contrast, dated 12/18/23 at 2:25 AM, revealed an acute subdural hemorrhage throughout the left supratentorial (upper part of brain) brain and along the left greater than right tentorial (brain fold) leaflets .Punctate intraparenchymal (blood in tissue of brain) in the left occipital lobe (visual processing area of the brain) .Mild diffuse left cerebral edema. No midline shift. Review of CT Maxillofacial [related to the upper jaw, face, and neck] dated 12/18/2023 at 2:25 AM, revealed Nondisplaced right nasal bone fracture. Sharp angulation of the bony nasal septum. No other acute facial fractures. soft tissue swelling overlying the nose. Intracranial hemorrhage better evaluated on same day CT head. Review of CT Chest/Abdomen/Pelvis dated 12/18/2023 at 2:25 AM, revealed acute left posterolateral [back and side] 7th, 8th, 9th, 10th, and 11th left rib fractures. Record review of Resident #1's admitting hospital record dated 12/18/23 revealed reason for admissions was fall and rib fracture and SDH (subdural hematoma). Admitting diagnosis was SDH: sent to the ICU for SDH monitoring and treatment. Record review of Resident #1's Progress Notes revealed entry on 12/18/23 at 5:53 AM by the ADON that resident was transferred to higher acuity facility, due to subdural hematoma [bleeding inside the skull, but outside the actual brain tissue], large intraparenchymal hemorrhage [bleeding in the brain tissue], nasal fracture [broken bones], and multiple left rib fractures. Further documentation indicated telephone line to on-call physician service was not working properly, and the nurse notified resident's responsible party. Record review of Resident #1's Progress Notes revealed entry on 12/18/23 at 11:46 AM by Nurse F, PCP made aware of resident's [Resident #1's] transfer to higher level acuity facility. Record review of written statement authored by LVN B revealed that, on 12/17/23 at 6:00 AM, Resident #1 was still bleeding from his nose; first aide applied; sitting in a chair in the hallway. Resident#1 removed the bandaged off nose multiple times. Resident complained about a headache. At the end of her shift 6:00 PM, he was stable. Resident #1 stated he felt better. Record review of an email from LVN B dated 12/19/23 8:08 PM, LVN B stated the overnight nurse LVN A did not provide information on what happened to Resident #1 prior to the start of LVN B's shift on 12/17/23 at 6:00 AM. In an interview on 12/20/2023 at 2:00 PM, CNA E stated at the start of her shift on 12/17/2023, shortly after 6:00 AM, she alerted the overnight nurse, LVN A, and the oncoming nurse, LVN B, that Resident #1 was bleeding from the bridge of his nose. CNA E stated she was asked to clean Resident #1 up so that he could be better assessed by LVN B. CNA E stated Resident #1 ate breakfast like his normal self, but after breakfast stated he was not feeling well. CNA E stated she reported to LVN B that Resident #1 vomited, and wanted to lay down after breakfast, which was not his normal. CNA E stated Resident #1 did not eat lunch or dinner and wanted to sleep most of the day. CNA E stated throughout the day Resident #1 was found in the sleeping TV area, Dining area and once curled up in a fetal position in the hallway. CNA E stated she reported that information to LVN B as it occurred. CNA E stated, on occasion Resident #1 would not sleep well during the night and would nap during the day. CNA E stated it was not his normal to be sleeping in common areas. In an interview on 12/20/2023 at 4:35 PM, LVN B stated that the aide told her Resident #1 was bleeding from the bridge of his nose. LVN B stated she applied pressure for 15 minutes to stop the bleeding. LVN B stated the resident was on multiple blood thinners that made it difficult for the bleeding to stop completely. LVN B stated Resident #1 also had a known behavior of skin picking and was restless frequently. LVN B stated she applied a dressing to the wound, but Resident #1 removed it within 15 minutes. LVN B stated she put an alarm on her phone to remind her to check up on Resident #1 every 45 minutes to an hour. LVN B stated she instructed the aides to round more frequently on Resident #1. LVN B stated she did not recall any staff member alerting her to a change in Resident #1. LVN B stated when she assessed him that morning [12/17/2023] she had a suspicion the residents' nose was broken due to the change in the shape of the nose and the sound of his breathing. LVN B stated there was some bruising under the jaw from a fall earlier in the week. LVN B stated she did not assess his chest or back for further injuries. LVN B stated when the night shift nurse, LVN C, arrived on 12/17/2023 at 6:00 PM, LVN B insisted on walking rounds to give report on Resident #1. LVN B stated it took a few minutes to find Resident #1, as he was not in his designated room, and was actually standing in the last, empty room at the end of the hall with out the lights on. LVN B stated he laughed at them when she told him they were looking for him. LVN B stated Resident #1 could be heard to audibly be breathing through his nose, but it was labored. LVN B stated facial swelling and discoloration was now visible and that Resident #1 stated, it kind of hurts. LVN B stated she explained to LVN C that the previous overnight shift nurse, LVN A, did not provide an explanation as to what happened to Resident #1. In an interview on 12/20/2023 at 5:22 PM, LVN C stated that upon arrival to her shift on 12/17/2023 at 6:00 PM, LVN B requested that the two of them go look at Resident #1 for shift report. LVN C stated it looked like Resident #1 had a broken nose, and he admitted to some pain when asked. LVN C stated she told LVN B that she would be sending Resident #1 out to the emergency room because he didn't look right. LVN C stated she did not assess his chest or back for further injuries. LVN C stated she believed Resident #1 left via ambulance around 11:30 PM. LVN C stated she prioritized the evening medications on the secured unit for the men's hall, and the secured unit for the women's hall over sending Resident #1 out. LVN C stated that normally there was a certified medication aide, but that night [12/17/2023] there was not. LVN C stated on the few occasions there was not medication aide on the shift, it made the shift very hectic when she had to pass her own medications. LVN C stated she contacted the on-call physicians' group but was unable to leave a message. LVN C stated she contacted the residents responsible party and was also unable to leave a message. LVN C stated she called the ADON at that time but did not leave a message. LVN C stated she contacted the emergency room at the end of her shift [12/18/2023 at 6:00 AM] for an update on Resident #1 and was informed he was being transferred to a higher level of care [the local emergency room is free standing and does not have the ability to admit residents as there is no associated hospital with it]. LVN C stated it was after that phone call that she alerted the facility management to the situation. During an interview in Spanish on 01/11/24 at 11:56 AM, NA D stated he found Resident #1 ambulatory on Hall A on 12/17/23 at 2:00 AM and informed LVN A and returned to his duties. NA D stated that Resident #1 provided him with no explanation on the cause of the bleeding to the nose. During an interview on 01/11/24 at 11:35 AM, the ADON stated Resident#1 was found in A Hall, standing up and ambulatory, on 12/17/ 23 AM at 2:00 AM by NA D. The Nurse on duty was LVN A (agency) and she described in her Nurse Notes dated 12/17/23 at 5:38 AM that Resident #1 had superficial abrasion approximately 1.5 cm to the bridge of the nose. LVN A provided first aide. There was no description from NA D or LVN A on how the injury occurred on 12/17/23. Resident #1's BIMS score was 3 (severely impaired) and the resident did not state he had an injury. Resident, previous to the incident on 12/17/23, had a fall on 12/12/23 with injury to the bridge of the nose. On 12/12/23, the resident was not sent to the ER per recommendation by the physician. During an interview on 01/11/24 at 12:18 PM, the ADON stated: per nursing practice, if a head injury was suspected, neuro checks were started immediately. Neuro checks were done for 72 hours; namely, 15 minutes X4, 30 minutes X4; hourly X4 Q shift until 72 hours are completed. The ADON stated, no neuro checks were done on 12/17/23, she stated the bleeding to the nose was an old scab and nurses assumed it was an old injury from fall on 12/12/23 as stated in the nurses' notes . The ADON stated x-ray results on 12/18/23 from the ER (local hospital) revealed a non-displaced right rib fracture, sharp angulation of boney nasal septum reflected the resident's normal anatomy rather than a fracture, and no blood inside of nose. However, the ADON stated CT scan revealed an acute subdural hemorrhage throughout the left side of the head. Resident #1 did not return to the facility. The ADON stated the assumption was that the resident scratched his scab on 12/17/23 and neuro checks for the fall on 12/12/23 revealed no neuro issues. An attempted telephone interview on 01/11/24 at 12:39 PM to LVN B. LVN B's telephone would not accept messages. During a joint interview on 01/11/24 at 2:24 PM, with the ADON and the Director of Quality (Corporate), the Director of Quality (Corporate) stated: on the day of the incident 12/17/23 LVN C (Agency) did an SBAR on 12/17/23 at 10:00 PM. Resident #1 had right facial swelling and the resident complained of pain and had difficulties breathing through his nose. LVN A did not do an SBAR at 2:00 AM on 12/17/23 - she state the reason why the SBAR was not completed was unknown. The ADON stated she had no explanation as to why an SBAR was not done at 2:00 AM. The Director of Quality and the ADON stated no head-to-toe assessment was required based on history of fall with existing abrasion. They state there was no documented vitals taken on 01/17/23 at 2:00 AM. During a telephone interview on 01/11/24 at 2:35 PM, LVN A stated that she did not do a head-to-toe assessment or SBAR on the incident involving Resident #1 on 12/17/23 at 2:00 AM because the resident only had bleeding to the bridge of the nose and first aid was applied. LVN A stated she was aware Resident #1 had a fall on 12/12/23 and neuro checks were done for 72 hours. LVN A stated she did vital signs but could not remember whether the vital signs were documented. LVN A stated she did not communicate with the physician on 12/17/23 at 2:00 AM and did not seek a physician order to initiate neuro checks. During a telephone interview on 01/11/24 at 3:45 PM, the facility MD stated: if there was no evidence of a fall on 12/17/23 at 2:00 AM, there was no requirement that vitals or neurological checks be done since there was no evidence of trauma or change of condition. The MD stated what was given to Resident #1 was standard care rather than best care which would have involved vitals or neurological checks. The MD stated he nor the on-call physician were notified of the bleeding on 12/17/23 at 2:00 AM. The MD stated that during the delay of 22 hours standard care did not require vitals or neuro checks be done. The MD stated that a significant change, SDH, could have been occurring during the gap of 22 hours (01/17/23 at 2:00 AM to 01/18/23 at 12:46 AM). During a telephone interview on 01/11/24 at 4:45 PM, LVN A stated there was no evidence Resident #1 vomited on 12/17/23 or had a fall or change of condition. LVN A stated vitals and assessments were done but not documented because there was a shift change at 6:00 AM and the facility did not pay Agency Nurses for documentation after the shift change. LVN A stated that she was aware of Resident #1's fall on 12/12/23 and that 72 hour neurological checks had been completed on 12/15/23. LVN A stated that the physician was not notified on 12/17/23 at 2:00 AM or at the end of her shift at 6:00 AM. During an interview on 01/11/24 at 4:05 PM, the Director of Quality stated: given the circumstances LVN A fully assessed Resident #1 on 12/17/23 at 2:00 AM. LVN A did not document a change of condition in the resident, and vitals and neurological checks were not done for a period of 22 hours by nursing staff because Resident #1 did not reveal signs of a change of condition. During joint interview on 01/11/24 at 5:00 PM, the Director of Quality and the Administrator stated overtime was permitted for agency staff to document in the clinical record. Record review of Abuse Prevention Program revised January 2011, revealed, policy statement: residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion. Under step 3.) Comprehensive policies and procedures have been developed to aid our facility in preventing abuse, neglect .b.) Mandated staff training/ orientation programs that include such topics as abuse prevention, identifying and reporting of abuse . Record review of Preventing Resident Abuse policy revised November 2010 revealed under step 3j.) assessing, care planning, and monitoring residents with needs and behaviors that may lead to conflict or neglect; 3p.) ensure that the needs of each resident are met; 3q.) report any signs or suspected incidents . Record review of Abuse and Neglect: Clinical Protocol revised April 2013, revealed the nurse will assess the individual and document related findings. under Step 2.) The nurse will report findings to the physician . Record review of Reporting Abuse to Facility Management, revised December 2013, revealed policy statement, it is the responsibility of our employees .etc. to promptly report any incident or suspected incident of neglect or resident abuse, including injuries of unknown source .to facility management. Definitions provided of injuries of unknown source: 1.) Source of the injury was not observed by any person, or the source of the injury could not be explained by the resident; and 2.) the injury is suspicious because of a.) the extent of the injury, b.) the location of the injury. Neglect defined as: failure to provide goods and services necessary to avoid physical harm . Record review of Recognizing Signs and Symptoms of Abuse/Neglect, revised April 2012, revealed policy statement, facility will not condone any form of resident abuse or neglect .report any signs and symptoms of abuse/neglect to their supervisor .immediately. Examples of abuse/neglect provided included: inadequate provision of care, caregiver indifference to residents' care and needs. The Administrator was given the IJ template and was notified of the Immediate Jeopardy (IJ) on 01/12/2024 at 12:05 PM and a plan of removal (POR) was requested. On 01/12/2024 at 5:44 PM, the POR was accepted. It was documented as follows: Plan to remove immediate jeopardy. The facility failed to ensure that, based on the comprehensive assessment of a resident, the resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 1 of 1 resident (Resident #1) reviewed for receiving nursing services in that: Facility staff failed to respond appropriately when Resident #1 had a bleeding to the bridge of the nose on 12/17/2023 at 2:00 a.m. for documented assessment, vital signs and communications with the physician for a period of 18 hours when the resident had a change of condition; requiring an ER visit. F580 On 01/12/2024 the Administrator notifies Medical Director of immediate jeopardy. On 01/12/2024 resident #1 no longer resides in the facility. On 01/12/2024 all residents in the facilities will be assessed by Director of Quality/RN Designee for any changes in condition. Any findings will be communicated to the Medical Director for further interventions/orders and Resident/RP will be notified. On 01/12/2024 DOQ (Director of Quality, RN) completed one-on-one in-service with Assistant Director of Nursing on Changes in Condition, including timely assessment, physician notification, and follow physician recommendations. On 12/22/2023 Assistant Director of Nursing/Designee completed 100% in-service training on Notification to Management (IDT Team) of Any Injury or Change of Condition, training on Abuse/Neglect, training on Appropriate Assessments of Residents will be done in a Timely Manner on any Change of Condition or Injuries, and training on Notification to MD of any Injury or Change of Condition. Starting on 01/12/2024 the Assistant Director of Nursing/Designee initiated in-service with nurses on changes in condition, including timely assessment, physician notification, and follow physician recommendations. Education to be completed on 01/12/2024. Any staff that is not available will be trained prior to their next scheduled workday, including PRN and Agency staff. Ad-Hoc QAPI meeting was held on 01/12/2024, with the Medical Director, NHA (Nursing Home Administrator), Director of Quality, and Assistant Director of Nursing to review the alleged deficiencies, policy and procedure, and the plan for removal of immediacy. The policy pertaining to Change in condition and timely reporting was reviewed on 01/12/2024 by the NHA (Nursing Home Administrator), Assistant Director of Nursing, DOQ (Director of Quality), and Medical Director. Starting on 01/12/2024, IDT (Interdisciplinary team), including Administrator, Assistant Director of Nursing, and MDS Coordinator will review any changes in condition and events daily Monday to Friday, and Manager on Duty Saturday and Sunday to determine if timely notification and assessment was completed due to changes in condition. The findings will be immediately brought to the Administrator for further action, if necessary. On 01/12/2024 the RNC (Regional Nurse Consultant)/DOQ (Director of Quality) will start reviewing Events/Changes in Condition for validation of thorough assessment and timely notification weekly for four (4) weeks followed by monthly for 2 months. The Administrator/designee will monitor compliance by completing audit of five (5) residents per week for four (4) weeks. This was initiated on 01/12/2024. Any identified concern will be addressed immediately and if trends and patterns are identified, the facility will conduct an Ad-Hoc QAPI meeting to discuss if additional interventions are needed to ensure compliance for next 2 months. The Administrator will be responsible for ensuring this plan is completed on 01/12/2024. The COO will provide oversight of Administrator to ensure that the items on the plan of removal are reviewed and completed. Verification of the Plan of Removal: In an interview on 01/13/24 at 9:35 AM, the ADON stated there were three residents who had a recent change in their condition in the past week. Record review of the 3 residents who were identified with a change in their condition revealed each resident had been assessed by the nurse, the physician was notified, orders received were initiated and a SBAR was completed. Record review of facility's nurse staffing revealed: total of 27 (24 NAs, 3 LVNs). Record review of the 4 in-services on 12/22/23 revealed 59 signatures with a completion rate of 100%. During an interview on 01/11/24 at 11:10 AM, the ADON stated an in-service was conducted on 12/22/23 for 59 staff, the in-services as follows: *Notification to Management of Any Injury or Change of Condition, *Abuse and Neglect for 59 staff, *Appropriate Assessment Done in a Timely Manner, and *Notification too MD for 59 staff. Interviews on 01/13/24 10:24 AM to 4:00 PM with 3 of 5 facility nurses (3 LVNs) who worked on the 6 AM to 6 PM shift revealed they had been in-serviced on 01/12/24 on changes in condition, timely assessment, physician notification, and to follow physician recommendations. Interviews on 01/13/24 from 10:24 AM to 4:00 PM with 3 of 6 agency nurses (3 LVNs) who worked on the 6 PM to 6 AM shift revealed they had been in-serviced on 01/12/24 on changes in condition, timely assessment, physician notification, and to follow physician recommendations. In an interview on 1/13/24 at 11:07 AM, the Regional Nurse Consultant (RNC) stated she assisted the DOQ with assessing all the residents on 01/12/24. The RNC stated she assessed the 2 secured units and the DOQ assessed the residents on the other side of the building. RNC stated there were 2 residents whom she noticed there was a change from their normal baseline, which the floor nurse had already identified earlier in the day, the residents' physicians had been notified and she made sure an SBAR had been completed for those residents. The Regional Nurse Consultant stated she participated in the Ad Hoc QAPI meeting held on 01/12/24 with the Administrator, ADON, DOQ present in person and the Medical Director present via telephone. In a telephone interview on 01/13/24 at 2:05 PM, the Medical Director stated he was informed of the IT situation on 01/12/24, he participated via telephone in the Ad Hoc QAPI meeting held in the late afternoon on 01/12/24, and he approved the measures the facility was going to implement. The Medical Director stated the policy about Change in Condition and Timely Reporting was reviewed with him during the Ad-Hoc QAPI meeting. In an interview on 01/13/24 at 2:52 PM the RNC stated she would weekly run a report in the electronic charting system to see which residents had a new SBAR completed to identify residents who had a change in their condition and would do this for two months to monitor residents who had a change in their condition. In an interview on 01/13/24 at 2:58 PM, the ADON stated all the residents were assessed on 01/12/24 by the DOQ and RNC. The ADON stated she was in-serviced by the DOQ on change of resident's condition, timely notification to the physician, following the physician recommendations and on Abuse & Neglect. The ADON stated she had in-service all 12 nurses on changes in condition, timely assessment, physician notification, following physician recommendations and abuse and neglect. The ADON said an Ad Hoc QAPI meeting was held on 01/12/24 in the afternoon; she, the RNC, the DOQ and administrator were present, and the Medical Director attended via phone. The ADON stated the policy pertaining to Change in Condition and Timely reporting was reviewed during the ad-hoc QAPI meeting held on 01/12/24. ADON said on weekends, the Manager on Duty would monitor any changes in condition to the residents; and during the week the IDT would do the monitoring. The ADON stated if there was a change in the resident's condition the resident would be assessed, the physician would be notified, new orders received would be implemented and the resident's RP would be notified. The ADON stated she completed the monitoring of changes in resident's condition on 01/13/24, using a Daily Census Sheet, for the weekend Manager on Duty, any new findings would be assessed by the nurse and the Daily Census sheet was placed in the facility's POR white binder. In an interview on 01/13/24 at 3:15 PM, the Administrator stated all the residents were assessed by the RNC and the DOQ on 01/12/24, and the medical director was notified on 01/12/24 after the facility was informed of the IT. The Administrator said the DOQ conducted an in-service with the ADON on Changes in Condition, timely assessment, physician notification and following physician recommendations and 100% of the nurses were in-serviced by the ADON on 01/12/2024 on Notification to Management of any injury or change of condition, appropriate assessments of residents being done in a timely manner, notify the physician of change of condition, following physician recommendations, and abuse and neglect. The Administrator stated an Ad Hoc QAPI meeting was held on 01/12/24 after the facility's POR had been accepted with the Medical Director via phone, and the RNC, ROQ and ADON in person. The Administrator said the policy pertaining to Change in Condition and Timely Reporting was reviewed during the AD Hoc QAPI meeting. The Administrator stated changes in a residents' condition would be monitored by the IDT during the morning meeting; the facility activity report would be printed to show progress notes written in the past 24-hours; the nurses would attend the morning meeting and report on residents who had a change in their condition. He stated on the weekends the Manager on Duty would review the report for any changes of condition and notify the ADON or the Administrator if a resident had a change in their condition. The Administrator stated he would audit the activity report weekly to see if there was an event or change in a resident's vital signs, then he would review the resident's clinical record to see if it was a change in the residents' condition and notify the ADON. The Administrator said the COO would be consult the RNC and ROQ for monitoring of residents' change of condition, there would be weekly calls with the COO and the COO would visit the facility monthly to monitor the facility and his progress. Record review of the Daily Census Report dated 01/13/24 revealed Resident #1 was no longer in the facility. Record review of the facility's white binder with the POR documents revealed the following: *a Training In-Service Sign-in Sheets, dated 12/22/23, revealed 59 of 59 employees had been in-serviced by the ADON on Notification to MD of Any Injury or Change of Condition, Notification to Management (IDT Team) of Any Injury or Change of Condition, Appropriate Assessments of Residents Will be Done in a Timely Manner on Any Change of Condition or Injuries, and Abuse and Neglect. * an Ad Hoc QA Meeting Sign-in Sheet dated 01/12/24 was in the binder with the signature of the Administrator, ADON, Director of Quality, and the Regional Nurse Consultant. The Medical Director was listed as being in attendance via telephone. * a Census Report dated 01/13/24 with each residents' name highlighted to indicate the residents had been monitored for a change of their condition and was signed by the ADON at the bottom of the sheet. * an undated Review Change of Condition and Timely Notification of Assessments monitoring form had been created * a Daily Census Report dated 01/12/24 with each resident's name checked off and a copy of the progress note from the Director of Quality or the Regional Nurse Consultant for each resident assessed. Record review of the Training In-Service Sign-in Sheet dated 01/12/24 revealed the ADON was in-serviced on Change of Resident's Condition, Timely Notification to MD, following MD recommendations, and Abuse and Neglect. Record review of the i [TRUNCATED]

Based on interview and record review, the facility failed to ensure that, based on the comprehensive assessment of a resident, the resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 1 of 1 resident (Resident #1) reviewed for nursing services, in that: Facility staff failed to respond appropriately when Resident #1 had a bleeding to the bridge of the nose on 12/17/23 at 2:00 AM. The facility staff did not document an assessment, vital signs, and communications with the physician for a period of 22 hours when the resident had a change of condition. Resident #1 was taken to theER on [DATE] at 12:46 AM and diagnosed with a subdural hematoma. An Immediate Jeopardy was identified on 01/12/24 at 12:05 PM. While the Immediate Jeopardy was removed on 01/13/24 at 5:10 PM., the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not Immediate Jeopardy due to the facility's need to monitor and evaluate the effectiveness of the plan of removal and corrective actions. This failure could affect residents by placing them at risk for serious injury, harm, impairment, or death. The findings included: Record review of Resident #1's ER CT Scan dated 12/18/23 revealed an acute subdural hemorrhage throughout the left supratentorial (upper part of brain) brain and along the left greater than right tentorial (brain fold) leaflets .Punctate intraparenchymal (blood in tissue of brain) in the left occipital lobe (visual processing area of the brain).Mild diffuse left cerebral edema. No midline shift. Review of CT Maxillofacial [related to the upper jaw, face, and neck] dated 12/18/2023 at 2:25 AM, revealed Nondisplaced right nasal bone fracture. Sharp angulation of the bony nasal septum. No other acute facial fractures. Soft tissue swelling overlying the nose. Intracranial hemorrhage better evaluated on same day CT head. Review of CT Chest/Abdomen/Pelvis dated 12/18/2023 at 2:25 AM, revealed acute left posterolateral [back and side] 7th, 8th, 9th, 10th, and 11th left rib fractures. Record review of Resident #1's admitting hospital record dated 12/18/23 revealed reason for admissions was fall and rib fracture and SDH (subdural hematoma). Admitting diagnosis was SDH: sent to the ICU for SDH monitoring and treatment. Record review of Resident #1's Face Sheet printed 12/21/22 revealed Resident #1 was a [AGE] year-old male admitted on [DATE] and discharged to theER on [DATE]. Resident #1's diagnoses included: cerebral infarction (stroke), lack of coordination, dementia with agitation, cognitive communication deficits, and essential hypertension (primary). The RP was listed as a family member. Record review of Resident #1's physician orders dated December 2023 revealed: clopidogrel, tablet, 75 mg, 1 tablet daily (blood thinner) and aspirin, tablet, chewable, 81 mg, 1 tablet daily (blood thinner). Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed his primary reason for admission was coded as Other Neurological Conditions related to cerebral infarction [a brain lesion in which a cluster of brain cells die when they do not get enough blood; stroke]. Other active diagnosis included non-Alzheimer's vascular dementia [a group of symptoms that affects memory, thinking and interferes with daily life]. Resident #1 had a BIMS summary score of 3, indicative of severe cognitive deficits. Resident #1 had one fall since admission with a non-major injury. Resident #1 was coded as walking 50 feet with set-up assistance only and coded as contact guard assistance for walking 150 feet. Record review of Resident #1's Care Plan, undated, revealed he had a problem area in the category of Falls with a start date of 12/07/23; with the following interventions: refer to therapy, edited 12/12/23; attempt to discover cause and resolve reason for falls, created 12/08/2023; fall assessment per policy, created 12/08/2023. Additional problem area of Falls with a start date of 8/24/2023, with the following interventions: call light in reach at all times, created 8/25/2023; fall risk assessment per policy, created 8/25/2023; monitor routines, habits, tendencies preferences, behavior, ADL deficits, created 8/25/2023. Record review of Resident #1's clinical record revealed no SBAR, or head-to toe assessment done on Resident #1 by LVN A at 2:00 AM. [No documented evidence showed that vitals were taken or that the physician was notified on 12/17/23 at 2:00 AM.] Record review of Resident #1's Nurse Note dated 12/17/23 at 5:38 AM, authored by LVN A, reflected: Resident #1 was bleeding from his nose; assessed which revealed a superficial abrasion; appeared that he scratched some form of scab. First Aide was provided, and she (LVN A) would inform the on-coming nurse (LVN B). [No evidence existed that the physician was notified.] Record review of Resident #1's Progress Notes revealed entry on 12/17/23 at 6:33 PM by LVN B that upon arrival of shift [12/17/23 6:00 AM] resident was found to [sp] bleeding from forehead and bridge of nose. No explanation given as to what occurd[sp] .Resident c/o [complained of] headache and face pain. [No evidence existed that the physician was notified.] Record review of Resident#1's Nurse Note dated 12/18/23 at 11:24 PM, authored by LVN C, read Off going nurse [LVN B] reported resident was found this morning with bleeding to his face. When I went to assess resident, it was observed that he has nasal swelling and right facial swelling as well as abrasions to his [forehead]. Resident was at baseline for resident which is alert to self and able to follow very basic instruction. When asked resident if was in pain he stated yes and touched his nose. I could hear him trying to breathe through his nose. I asked if it was difficult to breathe through his nose and he stated yes. VS 133/81, 105, 95% room air, 21, 99.1. Resident ambulated throughout unit per his usual routine. Call placed to . Physicians expressing concern and they gave orders to send him out to . ER to be evaluated . Ambulance was called, and he is pending transport. Record review of Resident #1's Progress Notes revealed a late entry entered on 12/17/23 at 8:48 AM by LVN A for 12/17/23 5:38 AM of observed superficial abrasion approx. 1.5 cm in legth[sp] .cleaned the dry blood from his nose and place a dressing on top to keep it clean from dirt and debri[sp]. Will inform oncoming nurse. [No evidence existed that the physician was notified.] Record review of Resident #1's Progress Notes revealed entry on 12/18/23 at 12:45 AM by LVN C of observed that he has nasal swelling and right facial swelling as well as abrasions to forehead . Further documentation indicated resident stated yes when asked if he was in pain and yes to difficulty breathing through nose. Resident transferred to local emergency roiagnom on [DATE] at 12:46 AM. [Timeline was 22 hours.] Record review of Resident #1's Progress Notes revealed entry on 12/18/23 at 5:53 AM by ADON that resident was transferred to higher acuity facility, due to subdural hematoma [bleeding inside the skull, but outside the actual brain tissue], large intraparenchymal hemorrhage [bleeding in the brain tissue], nasal fracture [broken bones], and multiple left rib fractures. Further documentation indicated telephone line to on-call physician service was not working properly, and the nurse notified resident's responsible party. Record review of Resident #1's Progress Notes by Nurse F revealed entry on 12/18/23 at 11:46 AM that PCP made aware of resident's [Resident #1's] transfer to higher level acuity facility. In a record review of a written statement dated 12/18/2023, CNA E stated she observed Resident #1 with blood on the bridge of his nose and immediately reported it to LVN A & B during shift change on 12/17/2023 at 6:00 a.m. (Note: Resident #1 was on blood thinners.) In a record review of an email from LVN B dated 12/19/23 8:08 PM, LVN B stated the overnight nurse LVN A did not provide information on what happened to Resident #1 prior to the start of LVN B's shift on 12/17/23 at 6:00 AM. [No evidence existed that the physician was notified.] Recorded as Late Entry on 12/19/23 8:48 AM and authored by LVN A read Entry missing from 12/17 This nurse was informed by the aide that this resident was bleeding from his nose. This nurse went to assess the resident and observed a superficial abrasion approx[imately] 1.5cm in length [sic] to his nose which looked as perhaps he scratched off some of the formed scab that was there. This nurse cleaned the dry blood from his nose and placed a dressing on top to keep it clean from dirt and debri [sic]. Will inform oncoming nurse. Record review of statement on 12/29/23 authored by LVN B revealed that, on 12/17/23 at 6:00 AM, Resident #1 was still bleeding from his nose; first aide applied; sitting in a chair in the hallway. Resident#1 removed the bandaged off nose multiple times. Resident complained about a headache. At the end of her shift 6:00 PM, he was stable. Resident #1 stated he felt better. [No evidence existed that the physician was notified.] In an interview on 12/20/2023 at 2:00 PM, CNA E stated at the start of her shift on 12/17/2023, shortly after 6:00 AM, she alerted the overnight nurse, LVN A, and the oncoming nurse, LVN B, that Resident #1 was bleeding from the bridge of his nose. CNA E stated she was asked to clean Resident #1 up so that he could be better assessed by LVN B. CNA E stated Resident #1 ate breakfast like his normal self, but after breakfast stated he was not feeling well. CNA E stated she reported to LVN B that Resident #1 vomited, and wanted to lay down after breakfast, which was not his normal. CNA E stated Resident #1 did not eat lunch or dinner and wanted to sleep most of the day. CNA E stated throughout the day Resident #1 was found in the sleeping TV area, Dining area and once curled up in a fetal position in the hallway. CNA E stated she reported that information to LVN B as it occurred. CNA E stated, on occasion Resident #1 would not sleep well during the night and would nap during the day. CNA E stated it was not his normal to be sleeping in common areas. In an interview on 12/20/2023 at 4:35 PM, LVN B stated that the aide [CNA E] told her Resident #1 was bleeding from the bridge of his nose. LVN B stated she applied pressure for 15 minutes to stop the bleeding. LVN B stated the resident was on multiple blood thinners that made it difficult for the bleeding to stop completely. LVN B stated Resident #1 also had a known behavior of skin picking and was restless frequently. LVN B stated she applied a dressing to the wound, but Resident #1 removed it within 15 minutes. LVN B stated she put an alarm on her phone to remind her to check up on Resident #1 every 45 minutes to an hour. LVN B stated she instructed the aides to round more frequently on Resident #1. LVN B stated she did not recall any staff member alerting her to a change in Resident #1. LVN B stated when she assessed him that morning [12/17/2023] she had a suspicion the residents' nose was broken due to the change in the shape of the nose and the sound of his breathing. LVN B stated there was some bruising under the jaw from a fall earlier in the week. LVN B stated she did not assess his chest or back for further injuries. LVN B stated when the night shift nurse, LVN C, arrived on 12/17/2023 at 6:00 PM, LVN B insisted on walking rounds to give report on Resident #1. LVN B stated it took a few minutes to find Resident #1, as he was not in his designated room, and was actually standing in the last, empty room at the end of the hall with out the lights on. LVN B stated he laughed at them when she told him they were looking for him. LVN B stated Resident #1 could be heard to audibly be breathing through his nose, but it was labored. LVN B stated facial swelling and discoloration was now visible and that Resident #1 stated, it kind of hurts. LVN B stated she explained to LVN C that the previous overnight shift nurse, LVN A, did not provide an explanation as to what happened to Resident #1. In an interview on 12/20/2023 at 5:22 PM, LVN C stated that upon arrival to her shift on 12/17/2023 at 6:00 PM, LVN B requested that the two of them go look at Resident #1 for shift report. LVN C stated it looked like Resident #1 had a broken nose, and he admitted to some pain when asked. LVN C stated she told LVN B that she would be sending Resident #1 out to the emergency room because he didn't look right. LVN C stated she did not assess his chest or back for further injuries. LVN C stated she believed Resident #1 left via ambulance around 11:30 PM. LVN C stated she prioritized the evening medications on the secured unit for the men's hall, and the secured unit for the women's hall over sending Resident #1 out. LVN C stated that normally there was a certified medication aide, but that night [12/17/2023] there was not. LVN C stated on the few occasions there was not medication aide on the shift, it made the shift very hectic when she had to pass her own medications. LVN C stated she contacted the on-call physicians' group but was unable to leave a message. LVN C stated she contacted the residents responsible party and was also unable to leave a message. LVN C stated she called the ADON at that time but did not leave a message. LVN C stated she contacted the emergency room at the end of her shift [12/18/2023 at 6:00 AM] for an update on Resident #1 and was informed he was being transferred to a higher level of care [the local emergency room is free standing and does not have the ability to admit residents as there is no associated hospital with it]. LVN C stated it was after that phone call that she alerted the facility management to the situation. During an interview on 01/11/24 at 11:35 AM, the ADON stated: Resident#1 was found in A Hall, standing up and ambulatory, on 12/17/ 23 AM at 2:00 AM by NA D. The Nurse on duty was LVN A (agency) and she described in her Nurse Notes dated 12/17/23 at 5:38 AM that Resident #1 had superficial abrasion approximately 1.5 cm to the bridge of the nose. LVN A provided first aide. There was no description from NA D or LVN A on how the injury occurred on 12/17/23. Resident #1's BIMS score was 3 (severely impaired) and the resident did not state he had an injury. Resident, previous to the incident on 12/17/23, had a fall on 12/12/23 with injury to the bridge of the nose. On 12/12/23, the resident was not sent to the ER per recommendation by the physician. During an interview in Spanish on 01/11/24 at 11:56 AM, NA D stated he found Resident #1 ambulatory in Hall A on 12/17/23 at 2:00 AM and informed LVN A and returned to his duties. NA D stated that Resident #1 provided him with no explanation on the cause of the bleeding to the nose. During an interview 01/11/24 at 12:18 PM, the ADON stated: per nursing practice, if a head injury was suspected, neuro checks were started immediately. She stated Neuro checks were done for 72 hours; namely, 15 minutes X4, 30 minutes X4; hourly X4 Q shift until 72 hours are completed. The ADON stated, no neuro checks were done on 12/17/23 .the bleeding to the nose was an old scab and nurses assumed it was an old injury from fall on 12/12/23 as stated in the nurses' notes . The ADON added that x-ray results on 12/18/23 from the ER (local hospital) revealed a non-displaced right rib fracture, sharp angulation of boney nasal substance reflected the resident's normal anatomy rather than a fracture, and no blood inside of nose. However, the ADON stated CAT Scan revealed an acute subdural hemorrhage throughout the left side of the head. Resident #1 did not return to the facility. The ADON stated the assumption was that the resident scratched his scab on 12/17/23 and neuro checks for the fall on 12/12/23 revealed no neuro issues. Attempted telephone call on 01/11/24 at 12:39 PM to LVN B. LVN B's telephone would not accept messages. During a joint interview on 01/11/24 beginning at 2:24 PM, with the ADON and the Director of Quality (Corporate) stated: on the day of the incident 12/17/23 LVN C (Agency) did an SBAR on 12/17/23 at 10:00 PM. Resident #1 had right facial swelling and the resident complained of pain and had difficulties breathing through his nose. LVN A did not do an SBAR at 2:00 AM on 12/17/23 -she stated the reason why the SBAR was not completed was unknown. The ADON stated she had no explanation as to why an SBAR was not done at 2:00 AM. The Director of Quality and the ADON stated no head-to-toe assessment was required based on history of fall with existing abrasion. The Don stated, no documented vitals were taken on 01/17/23 at 2:00 AM. During a telephone interview on 01/11/24 at 2:35 PM, LVN A stated that she did not do a head-to-toe assessment or SBAR on the incident involving Resident #1 on 12/17/23 at 2:00 AM because the resident only had bleeding to the bridge of the nose and first aid was applied. LVN A stated she was aware Resident #1 had a fall on 12/12/23 and neuro checks were done for 72 hours. LVN A stated she did vital signs but could not remember whether the vital signs were documented. LVN A stated she did not communicate with the physician on 12/17/23 at 2:00 AM and did not seek a physician order to initiate neuro checks. During a telephone interview on 01/11/24 at 3:45 PM, the facility MD stated: if there was no evidence of a fall on 12/17/23 at 2:00 AM, there was no requirement that vitals or neurological checks be done since there was no evidence of trauma or change of condition. The MD stated what was given to Resident #1 was standard care rather than best care which would have involved vitals or neurological checks. The MD stated he nor the on-call physician were notified of the bleeding on 12/17/23 at 2:00 AM. The MD stated that during the delay of 22 hours standard care did not require vitals or neuro checks be done. The MD stated that a significant change, SDH, could have been occurring during the gap of 22 hours (01/17/23 at 2:00 AM to 01/18/23 at 12:46 AM). During a telephone interview on 01/11/24 at 4:45 PM, LVN A stated there was no evidence Resident #1 vomited on 12/17/23 or had a fall or change of condition. LVN A stated vitals and assessments were done but not documented because there was a shift change at 6:00 AM and the facility did not pay Agency Nurses for documentation after the shift change. LVN A stated that she was aware of Resident #1's fall on 12/12/23 and that 72-hour neurological checks had been completed on 12/15/23. LVN A stated that the physician was not notified on 12/17/23 at 2:00 AM or at the end of her shift at 6:00 AM. During an interview on 01/11/24 at 4:05 PM, the Director of Quality stated: given the circumstances LVN A fully assessed Resident #1 on 12/17/23 at 2:00 AM. LVN A did not document a change of condition in the resident, and vitals and neurological checks were not done for a period of 22 hours by nursing staff because Resident #1 did not reveal signs of a change of condition. During joint interview on 01/11/24 at 5:00 PM, the Director of Quality and the Administrator stated overtime was permitted for agency staff to document in the clinical record. Record review of Abuse Prevention Program revised January 2011, revealed, policy statement: residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion. Under step 3.) Comprehensive policies and procedures have been developed to aid our facility in preventing abuse, neglect .b.) Mandated staff training/ orientation programs that include such topics as abuse prevention, identifying and reporting of abuse . Record review of Preventing Resident Abuse policy revised November 2010 revealed under step 3j.) assessing, care planning, and monitoring residents with needs and behaviors that may lead to conflict or neglect; 3p.) ensure that the needs of each resident are met; 3q.) report any signs or suspected incidents . Record review of Abuse and Neglect: Clinical Protocol revised April 2013, revealed the nurse will assess the individual and document related findings. under Step 2.) The nurse will report findings to the physician . Record review of Reporting Abuse to Facility Management, revised December 2013, revealed policy statement, it is the responsibility of our employees .etc. to promptly report any incident or suspected incident of neglect or resident abuse, including injuries of unknown source .to facility management. Definitions provided of injuries of unknown source: 1.) Source of the injury was not observed by any person, or the source of the injury could not be explained by the resident; and 2.) the injury is suspicious because of a.) the extent of the injury, b.) the location of the injury. Neglect defined as: failure to provide goods and services necessary to avoid physical harm . Record review of Recognizing Signs and Symptoms of Abuse/Neglect, revised April 2012, revealed policy statement, facility will not condone any form of resident abuse or neglect .report any signs and symptoms of abuse/neglect to their supervisor .immediately. Examples of abuse/neglect provided included: inadequate provision of care, caregiver indifference to residents' care and needs. The Administrator was given the IJ template and was notified of the Immediate Jeopardy (IJ) on 01/12/2024 at 12:05 PM and a plan of removal (POR) was requested. On 01/12/2024 at 5:44 PM, the POR was accepted. It was documented as follows: Plan to remove immediate jeopardy. The facility failed to ensure that, based on the comprehensive assessment of a resident, the resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 1 of 1 resident (Resident #1) reviewed for receiving nursing services in that: Facility staff failed to respond appropriately when Resident #1 had a bleeding to the bridge of the nose on 12/17/2023 at 2:00 a.m. for documented assessment, vital signs and communications with the physician for a period of 22 hours when the resident had a change of condition; requiring an ER visit. On 01/12/2024 the Administrator notifies Medical Director of immediate jeopardy. On 01/12/2024 Resident #1 no longer resides in the facility. On 01/12/2024 all residents in the facilities will be assessed by Director of Quality/RN Designee for any changes in condition. Any findings will be communicated to the Medical Director for further interventions/orders and Resident/RP will be notified. On 01/12/2024 DOQ (Director of Quality, RN) completed one-on-one in-service with Assistant Director of Nursing on Changes in Condition, including timely assessment, physician notification, and follow physician recommendations. On 12/22/2023 Assistant Director of Nursing/Designee completed 100% in-service training on Notification to Management (IDT Team) of Any Injury or Change of Condition, training on Abuse/Neglect, training on Appropriate Assessments of Residents will be done in a Timely Manner on any Change of Condition or Injuries, and training on Notification to MD of any Injury or Change of Condition. Starting on 01/12/2024 the Assistant Director of Nursing/Designee initiated in-service with nurses on changes in condition, including timely assessment, physician notification, and follow physician recommendations. Education to be completed on 01/12/2024. Any staff that is not available will be trained prior to their next scheduled workday, including PRN and Agency staff. Ad-Hoc QAPI meeting was held on 01/12/2024, with the Medical Director, NHA (Nursing Home Administrator), Director of Quality, and Assistant Director of Nursing to review the alleged deficiencies, policy and procedure, and the plan for removal of immediacy. The policy pertaining to Change in condition and timely reporting was reviewed on 01/12/2024 by the NHA (Nursing Home Administrator), Assistant Director of Nursing, DOQ (Director of Quality), and Medical Director. Starting on 01/12/2024, IDT (Interdisciplinary team), including Administrator, Assistant Director of Nursing, and MDS Coordinator will review any changes in condition and events daily Monday to Friday, and Manager on Duty Saturday and Sunday to determine if timely notification and assessment was completed due to changes in condition. The findings will be immediately brought to the Administrator for further action, if necessary. On 01/12/2024 the RNC (Regional Nurse Consultant)/DOQ (Director of Quality) will start reviewing Events/Changes in Condition for validation of thorough assessment and timely notification weekly for four (4) weeks followed by monthly for 2 months. The Administrator/designee will monitor compliance by completing audit of five (5) residents per week for four (4) weeks. This was initiated on 01/12/2024. Any identified concern will be addressed immediately and if trends and patterns are identified, the facility will conduct an Ad-Hoc QAPI meeting to discuss if additional interventions are needed to ensure compliance for next 2 months. The Administrator will be responsible for ensuring this plan is completed on 01/12/2024. The COO will provide oversight of Administrator to ensure that the items on the plan of removal are reviewed and completed. Verification of the Plan of Removal: In an interview on 01/13/24 at 9:35 AM, the ADON stated there were three residents who had a recent change in their condition in the past week. Record review of the 3 residents who were identified with a change in their condition revealed each resident had been assessed by the nurse, the physician was notified, orders received were initiated and a SBAR was completed. Record review of facility's nurse staffing revealed: total of 27 (24 NAs, 3 LVNs). Record review of the 4 in-services dated 12/22/23 revealed 59 signatures with a completion rate of 100%. During an interview on 01/11/24 at 11:10 AM, the ADON stated: in-service was conducted from on 12/22/23 for 59 staff on (Notification to Management of Any Injury or Change of Condition; In-services for Abuse and Neglect for 59 staff; In service for Appropriate Assessment Done in a Timely Manner for 59 staff; In- service on Notification too MD for 59 staff.; Interviews on 01/13/24 at 10:24 AM to 4:00 PM with 3 of 5 facility nurses (3 LVNs) who worked on the 6 AM to 6 PM shift revealed they had been in-serviced on 01/12/24 on changes in condition, timely assessment, physician notification, and to follow physician recommendations and knew how to respond to a future change of condition. Interviews on 01/13/24 from 10:24 AM to 4:00 PM with 3 of 6 agency nurses (3 LVNs) who worked on the 6 PM to 6 AM shift revealed they had been in-serviced on 01/12/24 on changes in condition, timely assessment, physician notification, and to follow physician recommendations; and knew how to respond to a change of condition. In an interview on 1/13/24 at 11:07 AM, the Regional Nurse Consultant (RNC) stated she assisted the DOQ with assessing all the residents on 01/12/24. The RNC stated she assessed the 2 secured units and the DOQ assessed the residents on the other side of the building. RNC stated there were 2 residents whom she noticed there was a change from their normal baseline, which the floor nurse had already identified earlier in the day, the residents' physicians had been notified and she made sure an SBAR had been completed for those residents. The Regional Nurse Consultant stated she participated in the Ad Hoc QAPI meeting held on 01/12/24 with the Administrator, ADON, DOQ present in person and the Medical Director present by telephone. In a telephone interview on 01/13/24 at 2:05 PM, the Medical Director stated he was informed of the IJ situation on 01/12/24, he participated via telephone in the Ad Hoc QAPI meeting held in the late afternoon on 01/12/24, and he approved the measures the facility was going to implement. The Medical Director stated the policy about Change in Condition and Timely Reporting was reviewed with him during the Ad-Hoc QAPI meeting. In an interview on 01/13/24 at 2:52 PM the RNC stated she would weekly run a report in the electronic charting system to see which residents had a new SBAR completed to identify residents who had a change in their condition and would do this for two months to monitor residents who had a change in their condition. In an interview on 01/13/24 at 2:58 PM, the ADON stated all the residents were assessed on 01/12/24 by the DOQ and RNC. ADON stated she was in-serviced by the DOQ on change of resident's condition, timely notification to the physician, following the physician recommendations and on Abuse & Neglect. ADON stated she had in-service all 12 nurses on changes in condition, timely assessment, physician notification, following physician recommendations and abuse and neglect. ADON said an Ad Hoc QAPI meeting was held on 01/12/24 in the afternoon; she, the RNC, the DOQ and administrator were present, and the Medical Director attended via phone. ADON stated the policy pertaining to Change in Condition and Timely reporting was reviewed during the ad-hoc QAPI meeting held on 01/12/24. ADON said on weekends, the Manager on Duty would monitor any changes in condition to the residents; and during the week the IDT would do the monitoring. The ADON stated if there was a change in the resident's condition the resident would be assessed, the physician would be notified, new orders received would be implemented and the resident's RP would be notified. The ADON stated she completed the monitoring of changes in resident's condition on 01/13/24, using a Daily Census Sheet, for the weekend Manager on Duty, any new findings would be assessed by the nurse and the Daily Census sheet was placed in the facility's POR white binder. In an interview on 01/13/24 at 3:15 PM, the Administrator stated all the residents were assessed by the RNC and the DOQ on 01/12/24, and the medical director was notified on 01/12/24 after the facility was informed of the IJ. Administrator said the DOQ conducted an in-service with the ADON on Changes in Condition, timely assessment, physician notification and following physician recommendations and 100% of the nurses were in-serviced by the ADON on 01/12/2024 on Notification to Management of any injury or change of condition, appropriate assessments of residents being done in a timely manner, notify the physician of change of condition, following physician recommendations, and abuse and neglect. Administrator stated an Ad Hoc QAPI meeting was held on 01/12/24 after the facility's POR had been accepted with the Medical Director via phone, and the RNC, ROQ and ADON in person. Administrator said the policy pertaining to Change in Condition and Timely Reporting was reviewed during the AD Hoc QAPI meeting. Administrator stated changes in a residents' condition would be monitored by the IDT during the morning meeting; the facility activity report would be printed to show progress notes written in the past 24-hours; the nurses would attend the morning meeting and report on residents who had a change in their condition. He stated on the weekends the Manager on Duty would review the report for any changes of condition and notify the ADON or the Administrator if a resident had a change in their condition. Administrator stated he would audit the activity report weekly to see if there was an event or change in a resident's vital signs, then he would review the resident's clinical record to see if it was a change in the residents' condition and notify the ADON. Administrator said the COO would be consult the RNC and ROQ for monitoring of residents' change of condition, there would be weekly calls with the COO and the COO would visit the facility monthly to monitor the facility and his progress. Record review of the Daily Census Report dated 01/13/24 revealed Resident #1 was no longer in the facility. [TRUNCATED]

Based on observation, interview, and record review, the facility failed to provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 of 4 residents, (Resident #1) reviewed for behavioral health services in that: The facility failed to ensure Resident #1 was provided appropriate or timely behavioral health services after showing increased signs of aggression. This failure resulted in an IJ on 8/31/23 at 6:01 p.m. While the IJ was removed on 9/1/23 at 8:19 p.m., the facility remained out of compliance at a level of no actual harm with a potential for more than minimal harm that is not immediate jeopardy with a scope of pattern due to the facility's need to evaluate the effectiveness of their plan of removal. This deficient practice could result in residents with depression and/or mood disorders failing to attain or maintain their highest practicable physical, mental, and psychosocial well-being. The findings included: Record review of Resident #1's face sheet, dated 8/26/23 revealed a [AGE] year old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included schizophrenia (a disorder that affects a person's ability to think, feel and behave clearly), delusional disorders (a mental health condition in which a person can't tell what's real from what's imagined), anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), dementia without behavioral disturbance and impulse disorder (characterized by urges and behaviors that are excessive and/or harmful to oneself or others). Record review of Resident #1's most recent quarterly MDS assessment, dated 8/2/23 revealed the resident was severely cognitively impaired for daily decision-making skills. Record review of Resident #1's comprehensive care plan, edit date 8/23/23 listed the problem Mood State which included the following approaches: -Administer medications as ordered. Monitor and record effectiveness. Monitor and report any adverse side effects -Allow resident to have control over situations, if possible -Assign consistent staff member -Do not confront, argue against, or deny resident's thoughts -Maintain a calm environment and approach to the resident Further review of Resident #1's comprehensive care plan listed the problem Behavioral Symptoms, edit date 7/3/23, included the following approaches: -If elopement occurs, maintain supervision at a distance as tolerated by resident for safety concerns. Redirect resident when calm -Initiate one on one staff to resident observation. Maintain appropriate safety measures at all times -Consider placement on secure unit if wandering, elopement attempts continue -Psych referral as ordered. Initiate any new orders. Record review of Resident #1's physician orders revealed the following: -May see Respiratory, Podiatrist, Dentist, Optometrist/Ophthalmologist, Wound Specialist, and Mental Health professional as indicated/needed with start date 4/6/23 and no end date -Follow up with Psychology Services, with start date 6/9/23 and no end date Record review of the Psych Note Encounter by Psych (Psychiatric) NP B, dated 5/18/23 revealed in part, .[Resident #1] with a history of dementia, generalized anxiety disorder, impulse disorder and delusional disorder .Today he is being seen for increased agitation .staff reports he is eloped out of the building and when staff tried to bring him back, he became combative .He did not want to come back, was very resistant and agitated .[Resident #1] denies paranoia, denies past trauma, denies suicidal ideation, homicidal ideation, audio hallucinations and visual hallucinations .[Resident #1] continues to display agitation and anxiety .Will continue current dose .Give Clonazepam (a sedative) 1 mg x 1 dose for agitation .start Trazadone (an anti-depressant and sedative) 25 mg at 4 p.m. for agitation .return appointment 1 month with [Psychiatric NP B] . Record review of the Psych Encounter note written by Psych NP B, late entry 6/13/23 for visit date 6/7/23 revealed in part, .[Resident #1] with history of dementia, generalized anxiety disorder, impulse disorder, and delusional disorder .Staff report he is always aggressive, exit seeking and would fight before coming back to the building .Resident continues to display agitation and anxiety .Start Haldol (an antipsychotic used to treat mental disorders) 5mg/ml. Give 2.5mg IM every 6 hours PRN for restlessness and agitation. Order to expire in 14 days .Return appointment 1 month with [Psych NP B] . Record review of the Psych Encounter note written by Psych NP B, late entry 6/23/23 for visit date 6/21/23 revealed in part, .Resident with a history of dementia, generalized anxiety disorder, impulse disorder, and delusional disorder .constantly tries to elope the building .was getting angry and agitated talking to me .No GDR recommended at this time. Resident continues to display agitation and anxiety .Start Haldol 1mg gel. Apply 2 mg every 6 hours as needed, to wrist area, for restlessness and agitation for dementia with behavioral disturbance. Order valid for 14 days. Start Haldol 5mg/ml. Give 2.5 mg IM every 6 hours PRN for restlessness and agitation. Order to expire in 14 days .Return Appointment: 1 month with [Psych NP B] . Record review of the Neuropsychological Assessment by the Licensed Psychologist, dated 8/16/23 revealed in part, .Referred by medical for neurocognitive evaluation to clarify diagnosis and assist with treatment plan in the context of aggressive behaviors, and to assess for depression, anxiety, or any other psychiatric conditions that might be focus of attention at this time .Treatment Plan/Recommendations .Psychiatric and psychological treatment .Follow up with neuropsychological testing as soon as feasible . Record review of Resident #1's clinical record revealed the resident did not receive any routine psychiatric services after 6/21/23 until 8/16/23. Record review of the facility Event Report dated 7/5/23 and completed by LVN D reflected Resident #1 had a psychotic episode that caused injuries to others. The Event Report reflected, multiple staff members were pushed, punched and grabbed very aggressively. Under the section, Indicate Pharmacological measures taken, Other was checked and indicated, Haldol IM given by ADON per MD orders. Record review of the progress note written by the DON, dated 8/27/23 and time stamped 1:15 p.m. reflected, .obtaining verbal consent for new medication ABH (made from a combination of Ativan, a sedative to relieve anxiety, Benadryl an antihistamine and, Haldol an anti-psychotic used to treat mental disorders) gel for 'aggressive behaviors' .resident (Resident #1) behaviors had increased in frequency with increased agitation and aggressiveness towards other residents and staff. Record review of the progress note written by LVN A, dated 8/27/23 and time stamped 9:15 p.m. revealed in part, .Resident #1 coming out of the locked hall and acting aggressive toward staff . I am the nurse that administered ABH gel to the resident. During an interview on 08/28/23 LVN D reported Resident #1 had gotten out of the secure until multiple times. LVN D reported Resident #1 was held back by multiple staff when pushed his way out of the secured unit and pushed the MDS coordinator in June of 2023. LVN D reported staff held Resident #1 under the arms as he was swinging, and Resident #1 was eventually held down in a chair and given a Haldol injection. LVN A reported the DON, ADON and Administrator were present when this occurred and she did not feel anyone had training to handle Resident #1's behaviors. During an interview on 08/28/23 Nurse Aide F reported he was assigned to Resident #1 on 08/27/23 and Resident #1 became agitated and began kicking the air as he made his way out of the locked unit into the inner part of the facility. Nurse Aide F reported Resident #1 grabbed his shirt from the front and Nurse Aide H was there to assist and they both took Resident #1 by the arm and held him back and got him to the ground. Nurse Aide F reported Resident #1 was not appropriate for the facility and should reside somewhere where staff are trained. Nurse Aide F reported he was not trained to deal with Resident #1. During an interview on 08/29/23 The Assistant BOM reported Resident #1 hit Nurse Aide F on the upper chest and grabbed his shirt and shook him. The Assistant BOM reported the nurse aides held Resident #1's arms under his elbows and staff and Resident #1 fell to the ground and Resident #1 began to kick. The Assistant BOM reported LVN A applied ABH gel to Resident #1's hands. During an interview on 08/29/23 LVN E reported Resident #1 had a behavior in June of 2023 when he pushed the MDS coordinator and Resident #1 had a hold on the Activity Director and Resident #1 was restrained by staff using a restraint called bear paws. LVN E reported she and CNA I restrained Resident #1 and got him to the ground, and he began to relax. LVN E reported she had not been provided training on behaviors, or aggression and she did not know who the abuse coordinator was. LVN E reported she did not think staff were supposed to touch residents, but she did not think there was a way of getting around it. During an interview on 08/30/23 Nurse Aide G reported Resident #1 grabbed Nurse Aide F's shirt and Nurse Aide G went behind Resident #1 and put his arms around Resident #1's upper shoulder as if to grab him and Resident #1 swung his arm back and that's how they all fell to the floor. During an interview on 8/27/23 at 12:39 p.m., the Administrator stated, former Psych NP B left about a month ago and the new Psych NP V took over August 2023. The Administrator stated the Medical Director was doing psych evaluations after Psych NP B left. During an interview on 8/27/23 at 1:11 p.m., the ADON revealed Psych NP B had been providing psych services until July 2023. The ADON stated, Psych NP B left on medical leave and Psych NP W was filling in doing tele-visits until Psych NP V took over. The ADON stated, she did not recall Psych NP B making any medication changes for Resident #1. The ADON stated she believed Psych NP W had probably seen Resident #1 one time in July 2023. During a telephone interview on 8/28/23 at 9:35 a.m., Psych NP B revealed she had left on medical leave 6/26/23 and the consulting firm she was contracted with had provided an on-call psychiatric consultant until Psych NP V could take over as the new consultant. Psych NP B stated, I am a nurse practitioner, I was doing psychiatric evaluations and I am able to adjust medications for psychiatric services. Psych NP B stated, Resident #1 was exhibiting constant aggression, was probably not appropriate for the facility and had been refusing his medications. Psych NP B stated, since [Resident #1] was not taking his medication, there is not much that I can do and that is beyond me. Psych NP B stated, I did not make contact with the [Medical Director.] I didn't know I need to make contact with them. Psych NP B revealed she would report to nursing about her observations and there was no discussion about getting another psychological evaluation for [Resident #1]. During a telephone interview on 8/28/23 at 10:01 a.m., Psych NP V revealed she had gone into the facility for psychiatric evaluation of residents for the first time on 8/25/23. Psych NP V revealed in addition to working for the consulting firm as a psychiatric consultant, Psych NP V stated she also had a full-time job. Psych NP V stated, I don't have a list of any of the patients (seen in the facility on 8/25/23), I don't remember [Resident #1]. Psych NP V revealed she was capable of making medication changes or adjustments and would notify the Medical Director and the nurses. Psych NP V revealed maybe Psych NP W could be more informative about Resident #1. During an interview on 8/28/23 at 10:10 a.m., the DON revealed, Resident #1 had been seen by Psych NP W during telehealth visits but could not recall any dates. The DON stated she believed the new Psych NP V had seen Resident #1 on 8/25/23 when she was in the building, but Psych NP V did not communicate with her before leaving the facility. The DON revealed, the ADON had given Psych NP V a list of residents for psychiatric evaluation and follow up and Resident #1 was priority on the list. The DON stated, it was her expectation the Psych NP should communicate any recommendations or any written orders. The DON revealed, it typically took a couple of days for the Psych NP to upload their recommendations into the electronic record and did not know if any of the information on the report was communicated to the medical director. The DON stated, I feel if [Psych NP V] had made any medication changes for [Resident #1], the nurses would have gotten that. No new orders were put into the system for [Resident #1]. During a follow up interview on 8/28/23 at 10:27 a.m., the ADON stated, I reached out to [Psych NP W] about getting reports of visits with [Resident #1]. The ADON stated, she was not sure if she had reached out to Psych NP W about doing a psychiatric evaluation on Resident #1, I can't find anything about [Psych NP W] seeing [Resident #1]. During a telephone interview on 8/28/23 at 10:30 a.m., the Medical Director stated he was also the attending physician to Resident #1 and revealed the corporate office wanted one psychiatric company to provide psychiatric services. The Medical Director stated, Unfortunately, they don't have any local folks, and no one was able to come down since like June. The Medical Director revealed the Psych NP could make medication adjustments and were supervised by a licensed psychiatrist. The Medical Director stated, I can contact them, the Psych NP but have never actually had the Psych NP contact me. The Medical Director stated, [Psych NP B] started [Resident #1] on Haldol gel on 7/21/23. At that time, we were probably not aware [Resident #1] had schizoaffective disorder. At that point that was what was recommended, I had recommended the facility to either contact [Psych NP B] or give Haldol IM as needed. During a follow up interview on 8/28/23 at 12:14 p.m., the ADON revealed she had provided Psych NP V a prioritized list of the residents that needed a psychiatric evaluation or follow up for Friday 8/25/23, and Saturday 8/26/23. The ADON stated, Resident #1 was first to be seen on the list. The ADON stated, Psych NP V did not communicate with her when she left, did not exit with anyone, and had only met Psych NP V when she entered the building on 8/25/23. The ADON stated, Psych NP V was supposed to be back on Saturday 8/26/23 and Sunday 8/27/23, but [Psych NP V[ did not come back on Sunday. The ADON stated, when Psych NP B had done psychiatric visits, [Psych NP B] would not give us any feedback either, she would tell us she was here, we would give her a list and then that was it. [Psych NP B] would either e-mail us orders and then add her notes into the electronic record. The ADON stated she did not believe Psych NP B had made any real medication changes other than prn Haldol for Resident #1. The ADON revealed it took probably a week for Psych NP B to upload her visit notes into the electronic record. During an interview on 8/28/23 at 1:09 p.m., LVN C revealed she had made a list of the residents that needed to be seen for psychiatric evaluation and for follow up provided to Psych NP V for the visit on 8/25/23 but was not sure if Psych NP V had seen Resident #1. LVN C stated, [Resident #1] was first on the list. LVN C revealed, Psych NP B was never in the building and did telehealth with Resident #1. LVN C stated, our complaint was that [Psych NP B] was not coming in the building and had been mentioned during morning meeting with Administrative staff and would be told they would take it up with corporate. LVN C stated, Psych NP B did not make any significant medication changes and Resident #1 continued to take the same medications since his admission. During an interview on 8/28/23 at 2:53 p.m., the Administrator revealed, Psych NP B physically made psychiatric evaluations and follow ups once a month and then did telehealth visits due to illness. The Administrator stated, this guy, [Psych NP W] took over in July 2023 for [Psych NP B]. The Administrator revealed he had not recalled seeing Psych NP W in the building and may have met Psych NP W once. The Administrator stated, the contracted psychiatric company could have done a better job. I don't think, personal opinion, they (the residents) would have been better served if the Psych NP was coming into the building to do an actual assessment. The Administrator stated, the NP and even the Medical Director would not be able to prescribe those medications or maybe the Medical Director was not comfortable with doing that, I don't know. The Administrator revealed he believed Resident #1's disease process had progressed and was referred to a neuro psychologist because the services provided by the psychiatric company were not adequate, that's the [Medical Director's] opinion and I agree with him. The Administrator revealed, Resident #1's medications should have been reviewed and modified by a psychiatric hospital. During a telephone interview on 8/29/23 at 10:30 a.m., Psych NP W revealed he could not recall doing a psychiatric evaluation or follow up with Resident #1. Psych NP W stated he had a lot of residents and did not have his computer in front of him to verify if he had seen Resident #1. Psych NP W stated, I'm just covering, I do visits virtually. Psych NP W stated he would call back with more information. During a voicemail message on 8/29/23 at 3:02 p.m., Psych NP W stated, I never saw [Resident #1], I was just covering for emergency issues. [Resident #1] was never bought to my attention. I never saw [Resident #1], I never evaluated [Resident #1]. During a follow up interview on 8/29/23 at 5:08 p.m., the DON revealed, most residents in the facility had dementia and some required psychiatric services or evaluation. The DON stated, I know that psych services were available via telehealth and [Psych NP W] was our contact person for those residents that needed to be seen, after [Psych NP B] left. I called [Psych NP W] and left a message probably during the first incident when [Resident #1] burst through the doors in July. [Psych NP W] did not give me a response. I never got a return call. Record review of the facility policy and procedure titled, Dementia Residents and Managing Behaviors, undated, revealed in part, .Aggressive behaviors may be verbal or physical. They can occur suddenly, with no apparent reason, or result from a frustrating situation. While aggressive behaviors can be hard to cope with, understanding that the person with Alzheimer's or dementia is not acting this way on purpose can help .Treating Behavioral Symptoms .Anyone experiencing behavioral symptoms should receive a thorough medical checkup, especially when symptoms appear suddenly. Treatments depends on a careful diagnosis, determining possible causes and the types of behavior the person is experiencing . The Administrator was given the IJ template and was notified of the Immediate Jeopardy {IJ} on 8/29/23 at 4:15 p.m. and a plan of removal was requested. On 8/30/23 at 4:26 p.m., the facility provided a plan of removal that was accepted. It was documented as follows: SURVEY TYPE: Complaint Survey SURVEY DATE: 8/29/23 Plan for REMOVAL Plan to remove immediate jeopardy. F740 Resident #1 no longer resided at the facility On 8/29/23 all residents with behaviors and who refuse medications were assessed by DON (Director of Nursing)/Designee - no other residents have active attempt to elope or have signs of being a danger to themselves or others. The Medical Director was notified, and medications were reviewed - no new orders were provided. Behavioral services were notified by Administrator of immediate jeopardy on 8/29/2023 and behavioral services were provided by NP for identified residents with behaviors on 8/30/2023. On 8/29/2023 the Administrator and DON notified Medical Director of immediate jeopardy. Starting on 8/29/2023 the DON/Designee will initiate in-service with staff on de-escalation tactics for behavioral residents and residents who attempt to elope from the facility. The in-services will be completed on 8/29/2023. No staff member will be allowed to work without being in-serviced by DON/Designee. 9/1/23: DON and ADON initiated in-service of staff on de-escalation tactics for behaviors and elopement attempts reviewed and completed on 9/1/23. Ad-Hoc QAPI meeting was held on 8/29/2023, with the Medical Director, NHA (Nursing Home Administrator), RDO (Regional Director of Operations), DON, ADON (Assistant Director of Nursing), and RNC (Regional Nurse Consultant) to review the alleged deficiency, policy and procedure, and the plan for removal of immediacy. 9/1/23: A Sign in sheet was provided for QAPI meeting held on 8/31/23 that included the Medical Director, DON, Regional Nurse Consultant, ADON, Regional MDS, MDS Coordinator and Regional Director of operations. Starting on 8/29/2023, IDT (Interdisciplinary team), including Administrator, Director of Nursing, Assistant Director of Nursing, and MDS Coordinator will review events and progress notes for all residents in the facility daily Monday to Friday, and Manager on Duty Saturday and Sunday to determine if any residents have active attempts to elope and has aggressive behaviors toward others, MD notification, and need for plan of care updates. Any identified resident with behaviors, including attempts to elope will be referred to Behavioral services for evaluation in person or via Telehealth, starting 8/29/2023. The behavioral services will provide schedule for on-site visits to DON and Administrator on 8/30/2023 and will be available via Telehealth as needed. If Behavioral services require changes to the schedule, they will notify DON/Administrator via email of the changes and new schedule starting 8/29/2023. If behavioral services are unable to provide services, the Medical Director will be notified by DON/Designee and will review and address behavioral needs as necessary, starting 8/29/2023. The findings will be immediately brought up to the Administrator for further action, if necessary. 9/1/23: An IDT sign in sheet was reviewed for meeting on 8/29/23 that included the Administrator, DON, ADON and MDS coordinator. The Administrator/designee will monitor compliance by completing an audit of five (5) residents per week for four (4) weeks who are actively attempting to elope and/or have aggressive behaviors toward others. This was initiated on 8/29/2023. Any identified concerns will be addressed immediately and if trends and patterns are identified, the facility will conduct an Ad-Hoc QAPI meeting to discuss if additional interventions are needed to ensure compliance for next 2 months. 9/1/23: The administrator to monitor for compliance of at least 5 residents each week for the next 4 weeks of residents that are actively eloping and/or displaying aggression. Concerns identifying trends and patterns to be addressed at QAPI for additional interventions initiated on 8/29/23 was reviewed. The Administrator will be responsible for ensuring this plan is completed on 8/29/2023. The RDO will provide oversight of Administrator to ensure that the items on the plan of removal are reviewed and completed. Monitoring of the implementation of the POR: Plan to remove immediate jeopardy. Record review of the facility interviews with 70 residents on 8/30/23 revealed checklists were completed. Most of the residents in the facility, including residents in the secure units were not interview able, and those that were did not make any new allegations. Ad-Hoc QAPI meeting was held on 8/29/2023, with the Medical Director, NHA (Nursing Home Administrator), RDO (Regional Director of Operations), Director of Nursing, Assistant Director of Nursing, and RNC (Regional Nurse Consultant) to review the alleged deficiency, policy and procedure, and the plan for removal of immediacy. On 9/1/23, a sign-in sheet was reviewed for the QAPI meeting held on 8/31/23 that included the Medical Director, DON, Regional Nurse Consultant, ADON, Regional MDS, MDS Coordinator and Regional Director of operations. The IDT held on 8/29/23 included the Administrator, DON, ADON and MDS Coordinator for review of events and progress notes for all residents in the facility daily Monday to Friday and the Manager on Duty to review on Saturday and Sunday in order to determine if any residents had actively attempted to elope and if any residents displayed behaviors towards others. The report to include MD notification and care plan update. Any residents identified with behaviors, including elopement attempts would be referred to behavioral health services for evaluation via telehealth as needed. Any changes to the behavioral health services would require notification to the DON/Administrator via e-mail. If behavioral services could not be provided, the DON/Designee would notify the Medical Director to review and address behavioral needs as necessary. Any new findings would be immediately brought to the Administrator for further action if necessary. The IDT sign-in sheet was reviewed on 9/1/23. Record review of the facility in-service dated 8/31/23, titled Managing Difficult Behavior in Residents with Dementia revealed 67 facility employed staff signed the sign-in sheet. The facility had 55 total facility employees and utilized agency staff. During a joint interview on 9/1/23 at 5:22 p.m., the DON and the Administrator revealed the behavioral health in-service highlighted de-escalation tactics for residents who displayed aggressive behaviors and for residents who attempted elopement from the facility. The DON and Administrator revealed, events and progress notes would be reviewed daily to identify residents with behaviors or residents who attempted elopements from the facility, prompting scheduled behavioral health services for on-site visits or for tele-health visits as needed. The DON and Administrator revealed, if there were a scheduling conflict, the Medical Director would be notified to address behavioral needs. During a joint interview on 9/1/23 at 5:36 p.m., the DON, ADON, Regional Nurse Consultant, the COO and RN Director of Quality revealed review of the POR for behavioral health services for residents who displayed aggressive behaviors highlighted training on de-escalation tactics for residents, including those residents who attempted elopement from the facility and providing behavioral health services. 1. During an interview on 9/1/23 at 3:50 p.m., Housekeeping Staff J revealed she had worked for the facility for just 4 months and worked Monday through Saturday from 2:00 p.m. to 10:00 p.m. Housekeeping Staff J revealed she had been in-serviced on how to manage residents with aggressive behaviors that morning and revealed she was not to intervene, to report the behavior to the nurse and to keep other residents safe. 2. During an interview on 9/1/23 at 3:55 p.m., CNA L revealed she had worked for the facility off and on since January 2023 and worked 6:00 a.m. to 6:00 p.m. on a rotating schedule. CNA L revealed she had been in-serviced on managing residents with aggressive behaviors on 9/1/23 and the in-serviced included using de-escalation tactics such as distractions and talking to the residents. CNA L stated, if a resident became aggressive, report to the nurses and keep the residents safe. 3. During an interview on 9/1/23 at 4:00 p.m., the Assistant BOM revealed she worked every day with varying hours and had been in-serviced on de-escalating behaviors in the morning on 9/1/23. The Assistant BOM stated, de-escalation tactics included talking to the resident in a nice tone, acknowledge the resident by name, and conversing with the resident if confused or incoherent and try to create a calm environment. The Assistant BOM stated the nurses were to be notified if residents displayed aggressive behaviors. 4. During an interview on 9/1/23 at 4:05 p.m., the BOM stated she had worked for the facility for 5 years and worked Monday to Friday. The BOM stated she had been in-serviced on de-escalation strategies for residents with aggressive behaviors last week and the in-service highlighted keeping other residents safe during the aggression, divert the resident by offering snacks, taking them for a walk or to watch a movie. The BOM stated, report to the nurse when a resident displayed aggressive behaviors. 5. During an interview on 9/1/23 at 4:12 p.m., CNA L revealed she had worked for the facility for 2 years and worked from 6:00 a.m. to 6:00 p.m. on a rotating schedule. CNA L stated she had been in-serviced by the ADON on 9/1/23 on de-escalation strategies for residents with aggressive behavior. CNA L revealed the highlight of the in-service covered trying to calm the resident down, offer them snacks, talk to the resident, and keep other residents safe from harm. CNA L revealed, report to the nurse when a resident displayed aggressive behaviors. 6. During an interview on 9/1/23 at 4:16 p.m., CNA M revealed she had worked for the facility for about a month but had been employed over a year ago and had been working the 6:00 a.m. to 6:00 p.m. on a rotating schedule. CNA M stated she had been in-serviced on 9/1/23 on managing residents with aggressive behaviors. CNA M stated, the in-service highlighted keeping other residents safe, divert the resident displaying aggression by offering an activity or snack and to report to the nurse a resident who displayed aggressive behaviors. 7. During an interview on 9/1/23 at 4:23 p.m., Nurse Aide N revealed she had worked for the facility for 6 months and worked from 6:00 a.m. to 6:00 p.m. on a rotating schedule. Nurse Aide N stated she had received an in-service by the ADON on managing residents with aggressive behaviors on 8/31/23. Nurse Aide N revealed, staff should try to calm the aggressive resident by offering a snack, play music, put on a movie. Nurse Aide N revealed she was to report to the nurse if a resident displayed aggressive behaviors. 8. During an interview on 9/1/23 at 4:28 p.m., CNA O revealed she had worked for the facility for 2 years and worked from 6:00 a.m. to 6:00 p.m. on a rotating shift. CNA O revealed she had been in-serviced on abuse/neglect in the morning on 9/1/23. CNA O revealed the in-service highlighted types of abuse such as verbal, physical, restraints, and yelling at residents. CNA O revealed abuse/neglect was to be reported to the Administrator while keeping the residents safe. 9. During an interview on 9/1/23 at 4:35 p.m., Nurse Aide P revealed she had worked for the facility for 2 weeks and worked the 6:00 a.m. to 6:00 p.m. shift on a rotating schedule. Nurse Aide P stated she had been in-serviced on residents who displayed aggression this week and the in-service highlighted trying to calm the resident, take them to a quiet place or offer an activity. Nurse Aide P revealed, report to the nurse when a resident displayed aggressive behaviors. 10. During an interview on 9/1/23 at 4:40 p.m., Kitchen Staff Q revealed she had worked for the facility for the past 6 weeks and had been in-serviced on managing residents with aggressive behaviors this week. Kitchen Staff Q stated if a resident became aggressive, talk to them, keep other residents safe and report to the nurse. 11. During an interview on 9/1/23 at 4:46 p.m., LVN C revealed she had worked for the facility for 8 years and worked varying shifts and had been in-serviced this week on various subjects including behavioral

Based on observation, interview and record review, the facility failed to ensure the Resident(s) environment remained as free of accident hazards as possible and each resident received supervision and assistance devices to prevent accidents for 1 of 4 residents (Resident #1) reviewed for elopements in that: The facility failed to provide adequate safety interventions to prevent Resident #1 from elopement. Resident #1 had elopement events recorded on 5/18/23, 5/27/23, 8/22/23, 8/25/23. On 8/26/23, Resident #1 was found in the middle of the street a half mile down the road from the secure unit. These failures resulted in an IJ on 8/26/23 at 6:00 p.m. While the IJ was removed on 9/1/23 at 8:19 p.m., the facility remained out of compliance at a level of no actual harm with a potential for more than minimal harm that is not immediate jeopardy with a scope of pattern due to the facility's need to evaluate the effectiveness of their plan of removal. This failure placed residents at risk for harm, injury, or death due to elopement. The findings included: Record review of Resident #1's face sheet, dated 8/26/23 revealed a [AGE] year old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included schizophrenia (a disorder that affects a person's ability to think, feel and behave clearly), delusional disorders (a mental health condition in which a person can't tell what's real from what's imagined), anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), dementia without behavioral disturbance and impulse disorder (characterized by urges and behaviors that are excessive and/or harmful to oneself or others). Record review of Resident #1's most recent quarterly MDS assessment, dated 8/2/23 revealed the resident was severely cognitively impaired for daily decision-making skills and required set up only for bed mobility and transfers. Record review of Resident #1's comprehensive care plan, edit date 8/23/23 listed the problem Mood State which included the following approaches: -Allow resident to have control over situations, if possible -Assign consistent staff member -Do not confront, argue against, or deny resident's thoughts -Maintain a calm environment and approach to the resident Further review of Resident #1's comprehensive care plan listed the problem Behavioral Symptoms, edit date 7/3/23, included the following: Potential/high risk for injury related to identified elopement risk factors and or exit seeking behavior related to: Cognitive Impairment/loss, poor safety awareness, history of elopement. Unsuccessful elopement attempt 5/18/23-No injury. Unsuccessful Elopement attempt 5/27/23-no injury. New event 6/3/23 (7:37 a.m.)-Unsuccessful Elopement attempt/no injury. New event 6/3/23 (8:50 a.m.)-Unsuccessful Elopements attempt/no injury. And included the following approaches: -If elopement occurs, maintain supervision at a distance as tolerated by resident for safety concerns Redirect resident when calm -Initiate one on one staff to resident observation. Maintain appropriate safety measures at all times -Consider placement on secure unit if wandering, elopement attempts continue Record review of Resident #1's current order summary, undated revealed the following: -Admit to facility male secure unit for wandering, with start date 4/6/23 and no end date Record review of Resident #1's Elopement Risk Assessment, dated 4/6/23 revealed the resident was at risk of elopement with interventions that included for routine monitoring and re-direction. Record review of Resident #1's Secure Unit Consent, dated 4/6/23 revealed the following: -Based on the Elopement Assessment, the resident has the following indicators for an appropriate admission unto the Secure Unit: Diagnosis of dementia or Alzheimer's or confusion, ambulates independently, pace, wander, try to get out of the door and exhibit signs of sundowners. Benefits of a Secure Unit: allows the resident to ambulate independently in a controlled, safe environment; protection for external stressors and expectations that may increase anxiety. Potential Risks of Secure Unit: anxiety due to inability to come and go at will, Residents may wander into others personal space and pick up/take personal items. Record review of Resident #1's Elopement Risk Assessment, dated 8/26/23 revealed the resident was at risk of elopement with interventions that included for routine monitoring, re-direction, and involvement of psychosocial and/or activity program. Record review of Resident #1's history and physical dated 4/7/23 revealed the resident was previously at another facility and was moved due to elopement with police report filed as a missing person. Further review of Resident #1's history and physical revealed the resident was found 2.5 miles away from the facility by CNA staff. [Resident #1] is now admitted to the facility in memory care locked unit. Record review of the Event Report created by LVN A, dated 5/18/23 and time stamped 10:23 a.m., revealed Resident #1 was off of A hall with staff members walking on the trail right behind the building. [Resident #1] left A hall without the nurse but was intercepted prior to leaving the property. This nurse and 2 other staff members walked on the walking trail with [Resident #1] and got him back inside without incident. Record review of the Event Report created by LVN A, dated 5/27/23 and time stamped 10:30 a.m., revealed Resident #1 went out the back door of A hall due to the alarm being disabled. Staff and other residents saw the patient and was able to get him before he was able to get off property. Record review of the progress note by LVN C, dated 6/3/23 and time stamped 7:37 a.m. revealed, roughly around 7:15 a.m., nursing staff heard the alarms going off at the back door in A hall (secure unit) when the aides followed the resident, she found the fence magnetic unlocked and the fence door open. Shift nurse went to look for the resident along with nursing staff, [Resident #1] was found behind the laundry room on a walking path and was brought back to the facility. Record review of the progress note by LVN C, dated 6/3/23 and time stamped 8:50 a.m. revealed around 8:30 a.m. the shift nurse heard the alarms go off again and nursing staff ran out the door to look for [Resident #1], and once again the fence was opened, and the magnetic lock was opened again. Nursing staff and aides went looking for [Resident #1] and found him walking on the pathway again, [Resident #1] was found by nursing staff and brought the resident back to the facility. Record review of the progress note by the Regional Nurse Consultant dated 8/22/23 and time stamped 9:38 a.m. revealed Resident #1 became upset and busted through the doorway on the secure unit then exited outside front door, accompanied by facility staff. The Regional Nurse consultant wrote, when I got outside [Resident #1] was across the parking lot heading towards the highway in front of the facility. The [Administrator] and [ADON] were walking behind [Resident #1]. Record review of the progress note by LVN C, dated 8/25/23 and time stamped 9:00 a.m., revealed Resident #1 started to yell and hitting the air and stated, 'I am going through those door [sic]. The progress notes further revealed, Resident #1 did bust through the door of the secured unit and then resident began to go towards the font door and Resident #1 was within eyesight the whole time. [Resident #1] began to walk down the street, 911 and ambulance was called for assist, [Resident #1] ended up being in police custody. Record review of the Observation Detail List Report created by LVN S, dated 8/26/23 and time stamped 2:40 p.m., revealed Resident #1 forced door open and walked half mile down the road. During interview with Police on 8/26/23 at 10:28 a.m. , they state a call was received from facility staff stating that Resident #1 walked out of the front door and was headed toward the duck pond that was located across the street. During an interview on 8/26/23 at 12:17 p.m., CNA X revealed Resident #1 had tried to leave several times and if that happens, we follow the resident. CNA X stated, [Resident #1] tried to leave today (8/26/23, from the secure unit), has left at least two times this month and had been caught in the front yard. CNA X stated, Resident #1 had gotten as far as the street up to the little park with the ducks across the street. CNA X stated he was assisting a resident with a shower in the secure unit and heard the door alarm go off. CNA X stated, I saw the back door open, and I went to see, and I didn't see anybody. I called the nurse and [Laundry Staff Y] followed [Resident #1] out. During an interview on 8/26/23 at 12:17 p.m., Laundry Staff Y stated, Resident #1 left on 8/26/23 before 10:00 a.m., from the back door (of secure unit) and Laundry Staff Y followed him. Laundry Staff Y revealed Resident #1 kept telling her he just wanted to walk and pushed the back gate open. Laundry Staff Y stated, [Resident #1] kept saying he wanted to go to the main street where the cars were driving. Laundry Staff Y revealed she used her cell phone to call for help and LVN S took over and walked with Resident #1. During an interview on 8/26/23 at 1:13 p.m., LVN S stated he was working on B Hall on 8/26/23 and heard the alarm going off at approximately 8:00 a.m. LVN S stated, CNA X told him he believed Resident #1 went out of the unit but did not see Resident #1 push the door. LVN S stated he saw Resident #1 with Laundry Staff Y and Resident #1 repeatedly said I'm walking. LVN S stated he was on the phone with the ADON and was instructed by the ADON to call the police and to stay with Resident #1. LVN S stated when the police came, he and Resident #1 were driven back to the facility. LVN S stated, the DON instructed staff that Resident #1 was not to be physically stopped when he left and only to follow Resident #1 anytime he left the unit or the building. During an interview on 8/26/23 at 1:40 p.m., LVN C stated she was working in C hall on 8/26/23 at approximately 7:30 a.m. or 7:45 a.m. when she saw Resident #1 walking by outside of a resident's window. LVN C revealed she made her way to A hall secure unit and asked CNA X where Resident #1 was to which CNA X replied, he got out. LVN C stated she then went out the front door while calling the ADON and was told to go back to the facility as LVN S was already on the phone with police trying to get Resident #1 back to the facility. LVN C stated Resident #1 had walked on a specific route and stated, it's a very busy road. LVN S stated, the road has a sidewalk part of it, so I consider that off the property. LVN S stated, yesterday (8/25/23) at approximately 8:07 a.m., [Resident #1] hit the front door, gets down like a linebacker with his arm and punches the door and gets it open. LVN S stated, [Resident #1} did the same thing to the front door and went out. So, then me and [Resident #]1 went across the parking lot into the green grass and then he turned right, and we were going down the main road. LVN C stated, so then I called 911 and told them I am in the middle of the road, the Emergency Medical Technicians blocked one side of the street and then police blocked the other and I blocked the other, making a triangle. LVN C stated, if Resident #1] is off the property he's off the property but I don't know if I would consider that an elopement, I was with him the whole time. During an interview on 8/26/23 at 2:55 p.m., the ADON stated, the incident on 8/25/23 occurred around 8:00 a.m. when Resident #1 busted from the secure unit, hit the egress door from the front entry door with staff following. The ADON revealed, Resident #1 was followed by herself and LVN C when LVN C called 911 to get police and EMS to help. The ADON stated Resident #1 kept saying he was going for a stroll. The ADON revealed, Resident #1 was gone from the facility from approximately 8:14 a.m. to 8:37 a.m. after Resident #1 was placed in the EMS vehicle. The ADON stated, this was not the first time [Resident #1] had left (the facility). I don't consider it was elopement because we had sight of [Resident #1] the entire time. The ADON revealed, the last time Resident #1 tried to leave was on 8/22/23 at 9:19 a.m. During an interview on 8/26/23 at 3:48 p.m., the MDS Coordinator revealed, on 8/25/23 he was informed by LVN C Resident #1 had gone out the door and left and the ADON had called the police. The MDS Coordinator stated, I saw[ Resident #1] come into the facility with a police officer and [Resident #1] appeared calm and chuckled a little bit saying, 'everything was ok' and did not seem in distress. The MDS Coordinator revealed, that was not the first time Resident #1 had left the facility and revealed a similar incident occurred earlier in the week. The MDS Coordinator stated, according to the definition, I would say yes, that would be considered an elopement or at least an attempt. The MDS Coordinator revealed he relied on his superiors to determine if that type of incident would be reportable. The MDS Coordinator stated, if [Resident #1] was in that situation, because of aggressiveness and behavior to only follow [Resident #1] if he leaves but not to physically prevent him from leaving and follow and stay to keep safe and talk to the resident. During an interview on 8/26/23 at 5:54 p.m., the DON stated, according to our policy, we don't consider it an elopement, we stay with [Resident #1] when he has left the unit. [Resident #1] is never out of our site. I don't believe that is a true elopement. The DON further stated, Resident #1 leaving was not an elopement and out policy is no because he was never missing, but I know that it's not safe when [Resident #1] leaves. We can't take him down; we are not trained. During an interview on 8/26/23 at 6:14 p.m., the Administrator revealed he believed Resident #1 leaving the facility was not considered an elopement because staff followed the resident, kept the resident within their sight and the resident did not have any injuries. The Administrator further stated, we call the police when [Resident #1] leaves but during that time we verbally prompt him to come back. During a follow up interview on 8/27/23 at 9:16 a.m., the Administrator stated, when [Resident #1] first admitted , he was automatically placed in the secure unit, we knew [Resident #1] had a history of elopement from the other facility. The Administrator re-iterated, every time [Resident #1] had left the building he had never been hurt. We have never had injuries. During an interview on 8/27/23 at 10:18 a.m., Resident #1 stated he had been in the facility a little while, recalled being in the hospital the day before but did not know why. Resident #1 stated the police had taken him to the hospital but he was not sick. Resident #1 stated, the police hold me down, they have guns. During a telephone interview on 8/28/23 at10:30 a.m., the Medical Director revealed he believed Resident #1 was not appropriate for the facility due to aggressive behaviors. The Medical Director stated, I am informed every time [Resident #1] attempts an elopement. [Resident #1] will intermittently kick out a window. The Medical Director revealed, Resident #1 could initially be re-directed, did not believe Resident #1 leaving the facility was a true elopement because when the resident leaves, staff follow. The Medical Director stated he had been given information that Resident #1 had made it to the street, staff are with him, but only that [Resident #1] had made it out. During an interview on 8/28/23 at 12:51 p.m., RN Z revealed she had been in the facility when Resident #1 had tried to leave the facility. RN Z stated, we stay with [Resident #1], we walk with him. We call other staff, re-set the alarm, and do a head count. RN Z stated, I know [Resident #1] wanted to cross the street but have not witnessed him going into the street. RN Z revealed she was not sure if Resident #1's attempts to leave were considered an elopement. Record review of the facility policy and procedure titled, Wandering, Unsafe Resident, revision date August 2014 revealed in part, .The facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk of elopement .A missing resident is considered a facility-wide emergency .If a resident is missing, the elopement/missing resident emergency procedure will be initiated .If the resident was not authorized to leave, initiate a search of the building(s) and premises .If the resident is not located, notify the Administrator and the Director of Nursing Services .Initiate an extensive search of the surrounding area .When the resident returns to the facility, the Director of Nursing Services or Charge Nurse shall .Examine the resident for injuries .Complete and file an incident report . The Administrator was given the IJ template and was notified of the Immediate Jeopardy {IJ} on 8/26/23 at 6:00 p.m. and a plan of removal was requested. On 8/29/23 at 11:03 a.m. the facility provided a plan of removal that was accepted. It was documented as follows: SURVEY TYPE: Complaint SURVEY DATE: 8/26/2023 Plan for REMOVAL F689 Residents #1 was assessed by DON on 8/26/2023 and support was provided as accepted, physician was notified of the alleged deficiency on 8/26/23. Order was provided by Physician to send patient to the hospital for evaluation, RP was notified by Administrator of alleged deficiencies and plan of correction. Upon return to the facility from the hospital Resident #1 will be observed 1:1 on 8/26/23 and will continue until another placement is obtained. Medication management was reviewed by Physician and new orders in place as of 8/26/2023 with monitoring by nurses' effectiveness, facility will redirect resident by taking him for walks/outing as needed; including decrease active attempts of eloping, plan of care updated. On 8/26/23 all residents on Secure units were assessed by DON/Designee - no other residents have active attempt to elope. The Medical Director was notified - no new orders were provided. On 8/26/2023 the Administrator and Director of Nurses notified the Medical Director of immediate jeopardy. Starting on 8/26/2023 the Director of Nursing/Designee will initiate in-service with staff on adequate supervision to prevent a resident from leaving the facility, including policies on elopement/missing resident, how to handle residents who become agitated/aggressive and or attempt to elope was included in the 8/26/23 education. The in-services will be completed on 8/26/2023. No staff member will be allowed to work without being in-serviced by DON/Designee. 9/1/23: DON and ADON initiated in-service on adequate supervision to prevent elopement and handling residents with agitation/aggression was reviewed and completed on 8/26/23. Ad-Hoc QAPI meeting was held on 8/26/2023, with the Medical Director, NHA (Nursing Home Administrator), RDO (Regional Director of Operations), Director of Nursing, Assistant Director of Nursing, and RNC (Regional Nurse Consultant) to review the alleged deficiency, policy and procedure, and the plan for removal of immediacy. 9/1/23: Sign in sheet provided for QAPI meeting held on 8/26/23 that included the Medical Director, DON, Regional Nurse Consultant, ADON, Regional MDS, MDS Coordinator and Regional Director of Operations. Starting on 8/26/2023, IDT (Interdisciplinary team), including Administrator, Director of Nursing, Assistant Director of Nursing, and MDS Coordinator will review headcount of all residents residing on secure units in the facility daily Monday to Friday, and Manager on Duty Saturday and Sunday to determine if any residents have active attempts to elope and was appropriate supervision provided, MD notified, and plan of care updated. IDT team will utilize daily census roster to visually verify residents in the facility at least once a day starting 8/26/2023. The findings will be immediately brought up to the Administrator for further action, if necessary. 9/1/23: The sign in sheet provided of IDT meeting review for elopement and supervision and facility monitoring Monday to Friday and Manager on Duty Saturday and Sunday with the findings reported to administrator initiated 8/26/23 was reviewed. The Administrator/designee will monitor compliance by completing an audit of five (5) residents on secure unit per week for four (4) weeks who are actively attempting to elope and were adequate supervision provided to prevent from patient eloping. This was initiated on 8/26/2023. Any identified concerns will be addressed immediately and if trends and patterns are identified, the facility will conduct an Ad-Hoc QAPI meeting to discuss if additional interventions are needed to ensure compliance for next 2 months. 9/1/23: The administrator to monitor for compliance of at least 5 residents each week for the next 4 weeks of residents that have behaviors/aggression, with MD notification for request of behavioral services, initiated on 8/26/23 was reviewed. The Administrator will be responsible for ensuring this plan is completed on 8/26/2023. The RDO will provide oversight of Administrator to ensure that the items on the plan of removal are reviewed and completed. Monitoring of the implementation of the POR: Plan to remove immediate jeopardy. During a joint interview on 9/1/23 at 5:36 p.m., the DON, ADON, Regional Nurse Consultant, the COO and RN Director of Quality revealed review of the POR for elopements highlighted training providing adequate supervision for preventing elopement and strategies for coping with residents who exhibited agitation and/or aggression. Record review of the facility in-service dated 8/29/23, titled De-Escalation tactics for behavioral residents and residents who attempt to elope from the facility and Wandering, Unsafe Resident, revealed 67 facility employed staff signed the sign-in sheet. The facility had 55 total facility employees and utilized agency staff. During a joint interview on 9/1/23 at 5:22 p.m., the DON and the Administrator revealed the elopement in-service highlighted strategies for addressing residents with aggression and strategies for prevention of elopements. 1. During an interview on 9/1/23 at 3:50 p.m., Housekeeping Staff J revealed she had worked for the facility for just 4 months and worked Monday through Saturday from 2:00 p.m. to 10:00 p.m. Housekeeping Staff J revealed she had been in-serviced on elopements and learned only to follow the resident who tried to elope and keep safe. Housekeeping Staff J revealed she was report to the nurse if a resident attempted to elope. Housekeeping J stated it was important to try to talk to the resident and distract to prevent elopement. 2. During an interview on 9/1/23 at 3:55 p.m., CNA L revealed she had worked for the facility off and on since January 2023 and worked 6:00 a.m. to 6:00 p.m. on a rotating schedule. CNA L revealed she had been in-serviced on elopement and dealing with residents who had aggression on 9/1/23. CNA L revealed if a resident attempted to leave to report to the nurse and try to talk to the resident, follow the resident and keep safe. CNA L acknowledged most residents in the facility had dementia and you have to talk to them and distract them, so they don't get aggressive. 3. During an interview on 9/1/23 at 4:00 p.m., the Assistant BOM revealed she worked every day with varying hours and had been in-serviced on elopement and how to care for residents with aggressive behaviors on the morning of 9/1/23. The Assistant BOM revealed, if a resident tried to elope, report it, talk to the resident, follow them and be aware of their surroundings. The Assistant BOM stated, if a resident goes missing, call the Administrator and if we can't find them call the police. The Assistant BOM revealed staff had to try to de-escalate the behavior by talking in a nice tone, acknowledge by name and if confuse or incoherent, try to converse with them. 4. During an interview on 9/1/23 at 4:05 p.m., the BOM stated she had worked for the facility for 5 years and worked Monday to Friday. The BOM stated she had been recently in-serviced on elopements and how to care for residents with aggressive behaviors. The BOM revealed the in-services highlighted how to keep other residents safe and diversion tactics for a resident who displayed aggression. The BOM revealed the resident could be diverted by offering snacks, take for a walk or watch a movie, talk to the resident, and offer an activity. The BOM revealed, if a resident tried to leave, verbally re-direct and report to the nurse. 5. During an interview on 9/1/23 at 4:12 p.m., CNA L revealed she had worked for the facility for 2 years and worked from 6:00 a.m. to 6:00 p.m. on a rotating schedule. CNA L stated she had been in-serviced by the ADON on 9/1/23 on elopement and residents with aggression. CNA L revealed staff had to report to the Administrator and nursing staff if a resident had displayed aggressive behavior. CNA L revealed, if a resident tried to leave, try to talk to them, calm them down, offer snacks. 6. During an interview on 9/1/23 at 4:16 p.m., CNA M revealed she had worked for the facility for about a month but had been employed over a year ago and had been working the 6:00 a.m. to 6:00 p.m. on a rotating schedule. CNA M stated she had been in-serviced on 9/1/23 on elopement and caring for residents who had aggression. CNA M revealed the in-services highlighted using verbal re-direction, diversions such as playing games, activities and offering snacks. CNA M revealed if a resident tried to leave, notify the nurse, and follow the resident to keep safe. 7. During an interview on 9/1/23 at 4:23 p.m., Nurse Aide N revealed she had worked for the facility for 6 months and worked from 6:00 a.m. to 6:00 p.m. on a rotating schedule. Nurse Aide N stated she had received an in-service by the ADON on 8/31/23 on elopements and dealing with residents who displayed aggression. Nurse Aide N revealed the in-services highlighted de-escalating aggression by offering snacks, put on a movie, play music and trying to keep the resident calm. Nurse Aide N revealed if a resident tried to leave the facility, report to the nurse, follow the resident and keep them safe. 8. During an interview on 9/1/23 at 4:28 p.m., CNA O revealed she had worked for the facility for 2 years and worked from 6:00 a.m. to 6:00 p.m. on a rotating shift. CNA O revealed she had been in-serviced on elopements and caring for residents who had aggression. CNA O revealed the in-services highlighted on keeping the residents safe, using diversion to keep the resident from elopement and keeping a calm environment. CNA O revealed if a resident attempted to elope, report to the nurse. 9. During an interview on 9/1/23 at 4:35 p.m., Nurse Aide P revealed she had worked for the facility for 2 weeks and worked the 6:00 a.m. to 6:00 p.m. shift on a rotating schedule. Nurse Aide P stated she had been in-serviced on elopements and working with residents who aggression this week. Nurse Aide P revealed the in-services highlighted tactics on diverting the behavior such as offering snacks, talking to the resident in a calm voice and finding a quiet place. Nurse Aide P revealed, for a resident who tried to elope, keep calm, keep them safe, follow the resident, report to the nurse, and get help. 10. During an interview on 9/1/23 at 4:40 p.m., Kitchen Staff Q revealed she had worked for the facility for the past 6 weeks and had been in-serviced on elopements and dealing with residents who had aggression this week. Kitchen Staff Q revealed the in-services given taught about keeping the residents safe from residents who exhibited aggression and reporting to the nurse. Kitchen Staff Q revealed, if a resident tried to elope, try to follow them, talk nicely to the resident, and get help. 11. During an interview on 9/1/23 at 4:46 p.m., LVN C revealed she had worked for the facility for 8 years and worked varying shifts and had been in-serviced this week. LVN C stated, residents with aggression had to be verbally re-directed to de-escalate the aggression. LVN C stated, staff should try diverting the behavior by offering going for a walk or playing music. LVN C stated if the resident's aggression continued to escalate, continue to verbally re-direct and report to administrative staff. LVN C revealed, if a resident tried to elope, make sure you are always with the resident, keep them safe, get help, try to re-direct and report to the Administrator. 12. During an interview on 9/1/23 at 4:59 p.m., Dietary Aide R revealed he had worked for the facility for approximately 2 weeks and was in-serviced on 9/1/23 on elopement and aggressive behaviors. Dietary Aide R revealed, if residents got aggressive, give them their space, do not touch them and report to the nurse. Dietary Aide R revealed if a resident tried to elope, follow the resident, and call for help. 13. During an interview on 9/1/23 at 5:02 p.m., LVN S revealed he had worked for the facility for less than a month and worked the weekend shifts. LVN S revealed he had been in-serviced on 9/1/23 on elopements and residents with aggressive behaviors. LVN S revealed the in-services highlighted on diversion tactics for de-escalating aggressive behaviors such as talking to the resident, keeping calm and offering an activity. LVN S revealed, if a resident tried to elope, try to verbally re-direct, follow the resident and report to the Administrator. 14. During an interview on 9/1/23 at 5:26 p.m., the Maintenance Director revealed he had worked for the facility for 2 months and worked varying hours and days and was on call 24/7. The Maintenance Director stated he had been in-serviced on 8/31/23 and 9/1/23 on various subjects including elopements and residents with aggression. The Maintenance Director revealed, if a resident got upset, give them room, and keep other residents safe, then report to the nursing staff. The Maintenance Director revealed, if a resident tried to elope, follow the resident and don't leave them out of your site and report to nursing. 15. During an interview on 9/1/23 at 7:51 p.m., Nurse Aide T revealed he had worked for the facility for 7 months and worked the 6:00 p.m. to 6:00 a.m. shift on a rotating schedule. Nurse Aide T revealed he had been in-serviced this week on residents with aggression and elopement. Nurse Aide T revealed, if a resident tried to elope or was showing aggression, do not touch them, talk calmly to them, keep the resident safe and report to the nurse. 16. During an interview on 9/1/23 at 7:57 p.m., Nurse Aide U revealed he had worked for the facility for 7 months and worked the 6:00 p.m. to 6:00 a.m. shift on a rotating schedule. Nurse Aide U revealed he had been in-serviced on elopements and residents who exhibited aggressive behaviors this week. Nurse Aide U revealed the in-services highlighted how to de-escalate the situation, so the resident does not get physical by verbally re-directing and keeping other residents safe. Nurse Aide U revealed, if a resident tried to elope, do not touch the resident, follow from a distance and report to the nurse. The Administrator was notified on 9/1/23 at 8:19 p.m., the Immediate Jeopardy was removed. While the immediacy was removed on 9/1/23, the facility remained out of compliance at a scope of pattern with no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility continuing to monitor the plan of removal.

Based on observation, interview, and record review the facility failed to ensure residents were free from physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms for 1 of 4 residents (Resident #1) reviewed for freedom from physical and chemical restraints, in that: The facility failed to ensure Resident #1 was free from any physical or chemical restraints when exhibiting aggressive behaviors These failures resulted in an IJ on 8/31/23 at 6:01 p.m. While the IJ was removed on 9/1/23 at 8:19 p.m., the facility remained out of compliance at noactual harm with a potential for more than minimal harm that is not immediate jeopardy with a scope of pattern due to the facility's need to evaluate the effectiveness of their plan of removal. This deficient practice could place residents at risk of unnecessary restriction of their freedom of movement (any change in place or position for the body or any part of the body that the person is physically able to control). The findings included: Record review of Resident #1's face sheet, dated 8/26/23 revealed a [AGE] year old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included schizophrenia (a disorder that affects a person's ability to think, feel and behave clearly), delusional disorders (a mental health condition in which a person can't tell what's real from what's imagined), anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), dementia without behavioral disturbance and impulse disorder (characterized by urges and behaviors that are excessive and/or harmful to oneself or others). Record review of Resident #1's most recent quarterly MDS assessment, dated 8/2/23 revealed the resident was severely cognitively impaired for daily decision-making skills. Record review of Resident #1's comprehensive care plan, edit date 8/23/23 listed the problem Mood State which included the following approaches: -Allow resident to have control over situations, if possible -Assign consistent staff member -Do not confront, argue against, or deny resident's thoughts -Maintain a calm environment and approach to the resident Further review of Resident #1's comprehensive care plan listed the problem Behavioral Symptoms, edit date 7/3/23, included the following approaches: -If elopement occurs, maintain supervision at a distance as tolerated by resident for safety concerns. Redirect resident when calm -Initiate one on one staff to resident observation. Maintain appropriate safety measures at all times -Consider placement on secure unit if wandering, elopement attempts continue Further review of Resident #1's comprehensive care plan did not address an assessment for the use of restraints or the need for the use of restraints. Record review of the progress note written by LVN A, titled Elopement, dated 5/18/23 and time stamped 10:57 a.m. revealed in part, Resident #1 was very agitated and wanted to go off the property for a walk .resident on the walking trail for a few minutes and we were able to get him back into the facility without incident . Record review of the progress note written by LVN A, titled Elopement, dated 5/18/23 and time stamped 11:00 a.m. revealed in part, .Psychiatric NP B .was notified and saw the patient via telehealth. New order received for one time dose of Clonazepam 1mg (a benzodiazepine prescribed to treat generalized anxiety), administered by this nurse . Record review of the Psych Encounter note written by Psychiatric NP B, late entry 6/13/23 for visit date 6/7/23 revealed in part, .Resident #1 with history of dementia, generalized anxiety disorder, impulse disorder, and delusional disorder .Staff report he is always aggressive, exit seeking and would fight before coming back to the building .Resident continues to display agitation and anxiety .Start Haldol (an antipsychotic used to treat mental disorders) 5mg/ml. Give 2.5mg IM every 6 hours PRN for 'restlessness and agitation.' Order to expire in 14 days . Record review of the Psych Encounter note written by Psychiatric NP B, late entry 6/23/23 for visit date 6/21/23 revealed in part, .Resident with a history of dementia, generalized anxiety disorder, impulse disorder, and delusional disorder .constantly tries to elope the building .was getting angry and agitated talking to me .No GDR recommended at this time. Resident continues to display agitation and anxiety .Start Haldol 1mg gel. Apply 2 mg every 6 hours as needed, to wrist area, for 'restlessness and agitation' for dementia with behavioral disturbance. Order valid for 14 days. Start Haldol 5mg/ml. Give 2.5 mg IM every 6 hours PRN for 'restlessness and agitation.' Order to expire in 14 days . Record review of the progress note written by LVN C, dated 6/23/23 and time stamped 5:37 p.m. revealed in part, .Shift nurse heard the alarms going off on the hall when the nurse went all [sic] the hall found the door open and the resident (Resident #1) in the yard hiding in the bushes .MD gave new PRN orders nurse will carry those orders out . Record review of the facility Event Report dated 7/5/23 and completed by LVN D revealed Resident #1 had a psychotic episode that caused injuries to others. The Event Report revealed, multiple staff members were pushed, punched and grabbed very aggressively. Under the section, Indicate Pharmacological measures taken, Other was checked and indicated, Haldol IM given by ADON per MD orders. Record review of the progress note written by the DON, dated 8/27/23 and time stamped 1:15 p.m. revealed in part, .obtaining verbal consent for new medication ABH (made from a combination of Ativan, a sedative to relieve anxiety, Benadryl an anti-histamine and, Haldol an anti-psychotic used to treat mental disorders) gel for 'aggressive behaviors' .resident (Resident #1) behaviors had increased in frequency with increased agitation and aggressiveness towards other residents and staff . Record review of the progress note written by LVN A, dated 8/27/23 and time stamped 9:15 p.m. revealed in part, .Resident #1 coming out of the locked hall and acting aggressive toward staff . I am the nurse that administered ABH gel to the resident . During a telephone interview on 8/28/23 at 10:30 a.m., the Medical Director stated, We don't think the resident [Resident #1] is appropriate for this facility. He has proved he is not appropriate for this facility. The Medical Director further stated, [Psychiatric NP B] is perfectly capable of making medication adjustments and they are supervised by a licensed psychiatrist. No reason why this should not have been handled. The Medical Director further stated, I have recommended the facility to either contact [Psychiatric NP B] or give Haldol IM as needed. During an interview on 8/28/23 at 12:14 p.m., the ADON revealed, Resident #1 had been seen by Psychiatric NP B and stated, but I don't believe she made any real medication changes other than PRN Haldol. During an interview on 8/28/23 at 5:52 p.m., LVN A revealed, Resident #1 had a behavior on 8/27/23 and was surrounded by 3 male aides and Resident #1 was getting really mad at one of the male aides, Nurse Aide F. LVN A revealed, the next thing she knew, Resident #1 was by the front door sitting on the ground, one male aide holding him by one arm facing forward and the other aide holding the resident by the other arm and the third aide, Nurse Aide F holding down the resident's legs. LVN A stated she told the Aides to let Resident #1 go and then LVN A applied the ABH gel to Resident #1. LVN A stated, we are a restraint free facility, no we should not have been restraining [Resident #1]. LVN A revealed she told Nurse Aide F he could not do that, restrain Resident #1 to which Nurse Aide F replied, am I in trouble now? LVN A stated, what I did see is [Nurse Aide F] and the other two male aides restrain [Resident #1]. During an interview on 8/28/23 at 7:22 p.m., LVN D revealed Resident #1 resided in the male secure unit and had gotten out multiple times. LVN D revealed approximately one month ago, June 2023, Resident #1 barged outside of the secure unit. LVN D revealed Resident #1 was held back by multiple staff members after the resident pushed the MDS Coordinator. LVN D stated, staff tried to hold [Resident #1] under the arms as he was swinging. LVN D revealed, Resident #1 was eventually held down in a chair and the ADON gave the resident a Haldol injection. LVN D stated, I feel bad they had to tranquilize him to get him to calm down. LVN D stated, the [ADON], the [DON] and the [Administrator] were all here in the facility when this incident with [MDS Coordinator] occurred, and they were aware [Resident #1] was held down. LVN D stated, I do not feel like anyone here is trained to deal with [Resident #1's] behaviors. LVN D stated, Agency LVN E, who no longer worked for the facility, used to work in a psychiatric facility and had told other staff how to hold Resident #1 in a seated position. During an interview on 8/28/23 at 7:23 p.m., Nurse Aide F revealed he was assigned one to one to Resident #1 on 8/27/23. Nurse Aide F revealed, Resident #1 became agitated on 8/27/23 after Nurse Aide G asked the resident if he was okay and the resident started kicking the air and moving his hands rapidly. Nurse Aide F stated, Resident #1 moved towards the door leading to the front with Nurse Aide G and himself following and Resident #1 pushed open the door from the locked unit and moved toward the inner facility. Nurse Aide F stated, Nurse Aide H came to assist as Resident #1 grabbed Nurse Aide F's shirt from the front. Nurse Aide F stated, they both [Nurse Aide G] and [Nurse Aide H] took [Resident #1] by an arm and held him back and we got him to the ground so the nurses could apply the ABH cream on him. Nurse Aide F stated, [Resident #1] wasn't able to get up. Nurse Aide F stated, I don't think [Resident #1] is appropriate for this facility, he needs to be somewhere where staff are trained for that. I am not trained to deal with that on a regular basis. Nurse Aide F stated, We have been instructed to keep [Resident #1] in the unit but didn't really get any instruction on how to keep him in the unit. During an interview on 8/29/23 at 8:59 a.m., the Assistant BOM revealed, an incident occurred on 8/27/23 at approximately 7:00 p.m. or 7:30 p.m., before preparing to leave her office. The Assistant BOM stated, Resident #1 was observed heading in the direction past the nurse's station toward the front door. The Assistant BOM stated, her office was close to the facility front door and observed Resident #1 followed by Nurse Aide F, Nurse Aide G and Nurse Aide H. The Assistant BOM stated, LVN A had her gloves on ready to apply the ABH gel when Resident #1 hit Nurse Aide F on the upper chest, then grabbed Nurse Aide F's shirt and started to shake him. The Assistant BOM stated, at that point [Nurse Aide G] and [Nurse Aide H] come in and they are right by my office door wall and in the meantime, I am trying to call the [Administrator]. At this point, the guys are trying to hold [Resident #1] and they are holding his arms, like under his elbows and [Nurse Aide F] is still trying to get loose. Everybody goes down, they fall down, and [Resident #1] starts to kick. The Assistant BOM revealed, LVN A then applied the ABH gel to Resident #1's hands. The Assistant BOM stated, it had been discussed during in-services that staff were not to touch Resident #1 because it would escalate his anxiety and aggression. During a telephone interview on 8/29/23 at 3:02 p.m., Agency LVN E revealed she had worked at the facility through a contracted agency but discontinued her contract after 30 days. Agency LVN E revealed, Resident #1 had behaviors that were sometimes avoidable but sometimes not. Agency LVN E revealed an incident occurred in June 2023 in which Resident #1 pushed the MDS Coordinator and had also made contact with the Activity Director. Agency LVN E stated, everyone swarms, [Resident #1] seems like he is going towards everybody and there is a lot of yelling, I step back because less is more. Agency LVN E further stated, [Resident #1] had a hold of the [Activity Director] and is not letting go. [Resident #1] was restrained, because that is what it was called. But [Resident #1] could still move. Agency LVN E revealed, the physical restraint used on Resident #1 was called bear paws so as not to cause bruising while being restrained. Agency LVN E stated, she and CNA I restrained Resident #1 and once we got him to the ground, [Resident #1] starts to relax. Agency LVN E stated, the restraint to Resident #1 lasted a total time of 15 to 20 minutes until the police arrived. Agency LVN E revealed, the facility had not provided training on anything related to the incident, nothing on dementia, nothing on aggression, nothing on behaviors. Agency LVN E stated she did not know who the Abuse Coordinator was and approximately a month ago was given a paper to sign on an in-service on abuse and neglect. Agency LVN E stated, I do not think we are supposed to touch them (residents) but there was no way of getting around it. During an interview on 8/29/23 at 5:47 p.m., the DON stated, Resident #1 could not be stopped from having behaviors and just to keep him safe. The DON revealed staff could not lay hands on Resident #1 and to make sure all the residents were safe. The DON stated, our policy is to follow [Resident #1], keep him safe and call police to help us get him back into the building safely. During an interview on 8/30/23 at 2:38 p.m., Nurse Aide G revealed an incident occurred on 8/27/23 at approximately 7:00 p.m., after the residents had eaten, in which Resident #1 got out of the secure unit with Nurse Aide F following, who was assigned the resident's 1 to 1. Nurse Aide G stated, Resident #1 grabbed Nurse Aide F's shirt and Nurse Aide G came behind [Resident #1] and put my arms around his upper shoulder as if to grab him and [Resident #1] took his arm and swung it back and that's how we fell on the floor. Nurse Aide G stated, he, Resident #1, Nurse Aide F and Nurse Aide H fell together on the floor with the force of Resident #1 trying to swing at them and Resident #1 still holding onto Nurse Aide F's shirt. Nurse Aide G stated, I have never seen any staff hold [Resident #1], we try to talk to him and calm him down. Nurse Aide G revealed he did not consider the incident on 8/27/23 resulted in Resident #1 being restrained. During an interview on 8/30/23 at 3:29 p.m., the Administrator revealed, the Assistant BOM contacted him by phone on 8/27/23 at approximately 7:20 p.m. regarding the incident in which Resident #1 came out of the secure unit and was followed by Nurse Aide F, Nurse Aide G and Nurse Aide H. The Administrator stated, the Assistant BOM was giving the Administrator a narrative while it was going on. The Administrator stated, basically, [Resident #1] rushed [Nurse Aide F] and grabbed him, and two other aides pulled the resident off of [Nurse Aide F.] The Administrator stated, [Nurse Aide F] was standing in front of [Resident #1] because another resident was in [Resident #1's] path. The Administrator further stated, the other two aides grabbed [Resident #1] by the arms and pulled him back while [Resident #1] was holding onto [Nurse Aide F's] shirt, and they all fell down. The Administrator stated, [Nurse Aide F] held one of [Resident #1's] legs because he was kicking him, just didn't want him to hurt anybody and then the nurse put the cream on him and then [Resident #1] got up by himself and went for a walk with them. [Resident #1] was not restrained. The Administrator stated, I have never been informed [Resident #1] had ever been restrained. The Administrator revealed he recalled the incident in which Resident #1 pushed the MDS Coordinator. The Administrator stated, [Resident #1] pushed the [MDS Coordinator] and the staff, don't recall who it was, held [Resident #1] down. I think it was one (staff) on each side of him, to calm him down. The Administrator stated, again [Resident #1] was not hurt. The Administrator stated, the incident with the [MDS Coordinator], we didn't know what to do and [Resident #1] was held down to keep him from hurting other people, I'm sure. The Administrator revealed, the staff at the facility were not trained to deal with that kind of behavior. During an interview on 8/30/23 at 4:11 p.m., the MDS Coordinator revealed he recalled the incident in which Resident #1 pushed him. The MDS Coordinator revealed, staff were guiding Resident #1 to sit in a wheelchair, holding the resident's arms and the resident was resistive and combative. The MDS Coordinator stated, Resident #1 got up from the wheelchair and two staff, could not recall who, had their arms under the resident's upper arms and they backed up until they backed up against the wall and slid down the wall still holding [Resident #1] by the arms and talking to him and then the police showed up. The MDS Coordinator revealed, there was one nurse, Agency LVN E who stated she was trained for this (restraints). The MDS LVN stated, they were restraining [Resident #1], I would think, but it was a reasonable intervention because it was a very erratic behavior. [Resident #1] was kind of out of control. During a follow up interview on 8/31/23 at 8:22 a.m., the DON revealed, the facility did not do behavioral health training of staff and staff were only instructed to remove them (residents) and calm the situation. The DON stated, most of our residents don't have violent behaviors. [Resident #1] seemed to be the one factor in these situations. During an interview on 8/31/23 at 1:18 p.m., CNA I stated, he had not heard or seen residents being restrained. CNA I revealed, residents, including Resident #1, could not be restrained, and staff should not provoke or argue with the residents, leave them be and keep residents safe. CNA I denied ever having restrained Resident #1. Record review of the facility policy and procedure titled Abuse Prevention Program, revision date April 2013, revealed in part, .Our residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion .1. Our facility is committed to protecting our residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies providing services to our residents, family members, legal guardians, surrogates, sponsors, friends, visitors or any other individual .a. Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish .5. Along with other staff and management, the Medical Director will help identify situations that might constitute or could be constituted as neglect; for example .inappropriate management of problematic behavior .repeated failure to check for correct application of restraints . Record review of the facility's policy and procedure titled Use of Restraints, revision date December 2007 revealed in part, .Restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience .6. Prior to placing a resident in restraints, there shall be a pre-restraining assessment and review to determine the need for restraints. The assessment shall be used to determine possible underlying causes of the problematic medical symptoms and to determine if there are less restrictive interventions (programs, devices, referrals, etc.) that may improve the symptoms .19. Documentation regarding the use of restraints shall include: a. Full documentation of the episode leading to the use of the physical restraint. This includes not only the resident symptoms but also the conditions, circumstances, and environment associated with the episode; b. A description of the resident's medical symptoms (i.e., an indication or a characteristic of a physical or psychological condition) that warranted the use of restraints; c. How the restraint use benefits the resident by addressing the medical symptom; d. The type of the physical restraint used; e. The length of effectiveness of the restraint time; and f. Observation, range of motion and repositioning flow sheets . The Administrator was given the IJ template and was notified of the Immediate Jeopardy {IJ} on 8/31/23 at 6:01 p.m. and a plan of removal was requested. On 9/1/23 at 8:38 a.m., the facility provided a plan of removal that was accepted. It was documented as follows: SURVEY TYPE: Complaint Survey SURVEY DATE: 8/31/23 Plan for REMOVAL Plan to remove immediate jeopardy. F604 On 8/31/23, Resident #1 no longer resided at the facility, confirmed on 8/31/23. On 8/31/2023 the Regional Nurse Consultant completed in-service with the DON, ADON and the Administrator on abuse and neglect, abuse and neglect reporting guidelines/policy, abuse, and neglect, physical and chemical restraint prevention and how to care for patients with aggressive behavior. On 8/31/2023 DON and ADON assessed residents for any signs or symptoms of physical or chemical restraints with no other residents identified. The Medical Director was notified there were no changes in condition by the DON on 8/31/23. On 8/31/2023 the Director of Nursing and ADON initiated in-service with facility staff on abuse and neglect, physical and chemical restraint prevention and dealing with residents with aggressive behaviors. Education to be completed on 8/31/23. The in-service was completed on 9/1/23. On 8/31/23 the Administrator and the Regional Reimbursement Consultant will complete safe surveys with residents, to ensure the health and safety of all residents. The IDT, NHA (Nursing Home Administrator), DON, ADON, Regional Nurse Consultant, and MDS Coordinator will review the findings and will immediately notify the Administrator for further action, if necessary. The safety survey was completed on 9/1/23. On 8/31/23 an Ad-Hoc QAPI meeting was held with the Medical Director, NHA (Nursing Home Administrator), DON, Regional Nurse Consultant, Assistance Director of Nursing, Regional MDS, Regional Director of Operations and MDS Coordinator to review the deficiency and the plan for removal of immediacy. Sign-in sheet was reviewed on 9/1/23. Starting on 8/31/2023, IDT (Interdisciplinary team), including Administrator, DON, ADON and MDS Coordinator will review abuse and neglect monitoring Monday to Friday, and Manager on Duty Saturday and Sunday for 1 month to ensure the health and safety of the residents. The findings will be immediately brought up to the Administrator for further action, if necessary. A sign-in sheet was provided of the IDT meeting with the aforementioned staff on 9/1/23. The Administrator/designee will monitor compliance by completing an audit of residents that have behaviors/aggression every week for four (4) weeks, MD being notified, Family being notified, and behavioral services to be notified. If Behavioral Services is not available, then the Medical Director will be notified for any psychosocial concerns. This will be initiated on 8/31/2023. Any identified concerns will be addressed immediately and if trends and patterns are identified, the facility will conduct an Ad-Hoc QAPI meeting to discuss if additional interventions are needed to ensure compliance for the next 2 months. The facility provided an audit dated 8/31/23, initiated by the administrator on 9/1/23. The Administrator will be responsible for ensuring this plan is completed on 8/31/2023. The RDO will provide oversight of Administrator and DON to ensure that the items on the plan of removal are reviewed and completed. Monitoring of the implementation of the POR: Plan to remove immediate jeopardy. During an observation and interview on 9/1/23 at 8:03 p.m., Resident #2 was in his room lying in bed watching television. Resident #2 revealed he felt safe and had been asked by facility staff about abuse/neglect. Resident #2 stated, you're the third person who has asked me. Resident #2 did not appear to be in any obvious distress or discomfort. During an observation and interview on 9/1/23 at 8:08 p.m., Resident #3 was in her room sitting up in a wheelchair. Resident #3 did not appear to be in any obvious distress or discomfort. Resident #3 stated the ADON had talked to her on 8/31/23 about abuse/neglect. Resident #3 stated she felt safe in the facility. During an observation and interview on 9/1/23 at 8:11 p.m., Resident #4 appeared well-groomed and appropriately dressed and did not appear to be in any obvious distress or discomfort. Resident #4 stated she had been asked by the ADON about abuse and revealed she wanted to be with her boyfriend. Record review of the facility interviews with 70 residents on 8/30/23 revealed a safety survey was completed. Most of the residents in the facility were not interview able, and those that were did not make any new allegations of abuse or neglect. Record review of the facility Ad-Hoc QAPI meeting held on 8/31/23 revealed signatures for the Medical Director, NHA (Nursing Home Administrator), DON, Regional Nurse Consultant, Regional MDS, Regional Director of Operations and the MDS Coordinator. A log was created for the IDT to review and monitor for abuse and neglect Monday to Friday and the Manager on Duty for Saturday and Sunday to be monitored for 1 month to ensure the health and safety of the residents. Any adverse findings would be reported to the Administrator for further action if necessary. Record review of the facility IDT meeting held on 8/31/23 included the Administrator, DON, ADON and MDS coordinator revealed the Administrator would monitor for compliance by completing an audit of 5 residents per week for the next 4 weeks of residents with behaviors/aggression with MD notification for request of behavioral services, initiated on 8/31/23. The log dated 9/1/23 revealed 5 random residents were chosen for the audit and signed by the Administrator. During a joint interview on 9/1/23 at 5:36 p.m., the DON, ADON, Regional Nurse Consultant, the COO and RN Director of Quality revealed review of the POR for abuse/neglect highlighted training on identifying and reporting suspected abuse, restraints and dealing with residents with aggressive behaviors. Record review of the facility in-service dated 8/31/23, titled Abuse Neglect Policy/Reporting Guidelines/Abused and Neglect Pathways revealed 67 facility employed staff signed the sign-in sheet. The facility had 55 total facility employees and utilized agency staff. Record review of the facility in-service dated 8/31/23, titled Restraints Prevention/How to Care for Patients with Aggressive Behaviors revealed 67 facility employed staff signed the sign-in sheet. The facility had 55 total facility employees and utilized agency staff. Record review of the facility in-service dated 8/31/23, titled Managing Difficult Behavior in Residents with Dementia revealed 67 facility employed staff signed the sign-in sheet. The facility had 55 total employees and utilized agency staff. During a joint interview on 9/1/23 at 5:22 p.m., the DON and the Administrator revealed the abuse/neglect in-service highlighted identifying forms of abuse, reporting suspected abuse for investigation and adhering to reporting guidelines. 1. During an interview on 9/1/23 at 3:50 p.m., Housekeeping Staff J revealed she had worked for the facility for just 4 months and worked Monday through Saturday from 2:00 p.m. to 10:00 p.m. Housekeeping Staff J revealed she had been in-serviced on abuse/neglect and the use of restraints that morning and revealed she was to report abuse/neglect to the Administrator and to keep the residents safe. Housekeeping Staff J stated, we do not restrain, try not to touch the resident and be patient. 2. During an interview on 9/1/23 at 3:55 p.m., CNA L revealed she had worked for the facility off and on since January 2023 and worked 6:00 a.m. to 6:00 p.m. on a rotating schedule. CNA L revealed she had been in-serviced on abuse/neglect and the use of physical/chemical restraint prevention on 9/1/23 and the in-serviced covered identifying abuse/neglect and to report to the Administrator while keeping the residents safe. CNA L further revealed, Residents who have dementia can become aggressive and forms of distraction had to be used but residents could not be restrained. CNA L revealed, if the resident became aggressive, keep other residents safe and report to the nurse. 3. During an interview on 9/1/23 at 4:00 p.m., the Assistant BOM revealed she worked every day with varying hours and had been in-serviced on abuse/neglect and physical/chemical restraint prevention in the morning on 9/1/23. The Assistant BOM stated, abuse/neglect was to be reported to the DON and the Administrator. The Assistant BOM stated, remove the resident from an unsafe environment and keep them safe. The Assistant BOM stated, we do not do restraints, we can't force a resident to stay in a chair and no one can hold down or pull down a resident. The Assistant BOM stated, it was facility policy to try to de-escalate a behavior by talking in a nice tone, acknowledging the resident by name and keep the environment calm. The Assistant BOM stated, aggression in residents would be reported to the nurse. 4. During an interview on 9/1/23 at 4:05 p.m., the BOM stated she had worked for the facility for 5 years and worked Monday to Friday. The BOM stated she had been in-serviced on abuse/neglect last week and was to report suspicion of wrongdoing to the residents to the Administrator. The BOM stated, if the Administrator was not available, abuse and neglect should be reported to the DON and the charge nurse. The BOM stated, an in-service on restraints was given and highlighted how restraints were a form of abuse and were not practiced in the facility. The BOM revealed if a resident exhibited aggressive behavior, the staff were supposed to keep other residents safe and divert the resident exhibiting aggression by offering snacks, take them for a walk or watch a movie. The BOM revealed, residents exhibiting aggressive behaviors should be reported to the Administrator and the nursing staff. 5. During an interview on 9/1/23 at 4:12 p.m., CNA L revealed she had worked for the facility for 2 years and worked from 6:00 a.m. to 6:00 p.m. on a rotating schedule. CNA L stated she had been in-serviced by the ADON on 9/1/23 on abuse/neglect, restraints and how to handle residents with aggressive behavior. CNA L revealed the highlight of the in-service covered identifying abuse/neglect and the process for reporting, not restraining residents because it was a form of abuse and using diversion tactics for residents who exhibited aggressive behavior. CNA L revealed abuse/neglect was reported to the Administrator while keeping the resident safe. CNA L revealed the use of restraints was against facility policy and aggressive behavior was to be reported to the Administrator and nursing staff. 6. During an interview on 9/1/23 at 4:16 p.m., CNA M revealed she had worked for the facility for about a month but had been employed over a year ago and had been working the 6:00 a.m. to 6:00 p.m. on a rotating schedule. CNA M stated she had been in-serviced on 9/1/23 on abuse/neglect, restraints and working with residents with behaviors. CNA M stated, abuse was physical, verbal, and emotional. CNA M stated if abuse/neglect was suspected, report to the Administrator and if not available, report to the DON and the charge nurse. CNA M revealed [TRUNCATED]

Based on observation, interview, and record review, the facility failed to protect a resident's right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 of 4 residents (Resident #1) reviewed for abuse, in that: The facility failed in that they used physical and chemical restraints on Resident #1 when he began exibiting aggressive and exit seeking behaviors. Resident #1's behaviors included; hitting, scratching, pulling, pushing, kicking and grabbing clothes. These failures resulted in an IJ on 8/31/23 at 6:01 p.m. While the IJ was removed on 9/1/23 at 8:19 p.m., the facility remained out of compliance at a level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy with a scope of pattern. This deficient practice placed residents at risk of psychosocial harm, feeling disrespected or uncomfortable, decreased self-esteem, impaired quality of life and abuse. The findings included: Record review of Resident #1's face sheet, dated 8/26/23 revealed a [AGE] year old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included schizophrenia (a disorder that affects a person's ability to think, feel and behave clearly), delusional disorders (a mental health condition in which a person can't tell what's real from what's imagined), anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), dementia without behavioral disturbance and impulse disorder (characterized by urges and behaviors that are excessive and/or harmful to oneself or others). Record review of Resident #1's most recent quarterly MDS assessment, dated 8/2/23 revealed the resident was severely cognitively impaired for daily decision-making skills. Record review of Resident #1's comprehensive care plan, edit date 8/23/23 listed the problem Mood State which included the following approaches: -Allow resident to have control over situations, if possible -Assign consistent staff member -Do not confront, argue against, or deny resident's thoughts -Maintain a calm environment and approach to the resident Further review of Resident #1's comprehensive care plan listed the problem Behavioral Symptoms, edit date 7/3/23, included the following approaches: -If elopement occurs, maintain supervision at a distance as tolerated by resident for safety concerns. Redirect resident when calm -Initiate one on one staff to resident observation. Maintain appropriate safety measures at all times -Consider placement on secure unit if wandering, elopement attempts continue Record review of the progress note written by LVN A, titled Elopement, dated 5/18/23 and time stamped 10:57 a.m. revealed in part, Resident #1 was very agitated and wanted to go off the property for a walk .resident on the walking trail for a few minutes and we were able to get him back into the facility without incident . Record review of the progress note written by LVN A, titled Elopement, dated 5/18/23 and time stamped 11:00 a.m. revealed in part, .Psychiatric NP B .was notified and saw the patient via telehealth. New order received for one time dose of Clonazepam 1mg (a benzodiazepine prescribed to treat generalized anxiety), administered by this nurse . Record review of the Psych Encounter note written by Psychiatric NP B, dated 5/18/23 revealed in part, .Resident #1 with a history of dementia, generalized anxiety disorder, impulse disorder, and delusional disorder .Today he is being seen for increased agitation. Staff reports he is eloped out of the building and when staff tried to bring him back, he became combative. He did not want to come back in, was very resistant and agitated .Denies paranoia. Denies past trauma. Denies suicidal ideation, homicidal ideation, audio hallucinations and visual hallucinations .No GDR recommended at this time. Resident #1 continues to display agitation and anxiety. Will continue current dose . Further review of the Psych Encounter Note revealed Give Clonazepam (a sedative) 1 mg x 1 dose for agitation .Start Trazadone (an anti-depressant and sedative) 25 mg at 4 PM for agitation .return appointment 1 month with Psychiatric NP B . Record review of the Psych Encounter note written by Psychiatric NP B, late entry 6/13/23 for visit date 6/7/23 revealed in part, .Resident #1 with history of dementia, generalized anxiety disorder, impulse disorder, and delusional disorder .Staff report he is always aggressive, exit seeking and would fight before coming back to the building .Resident continues to display agitation and anxiety .Start Haldol (an antipsychotic used to treat mental disorders) 5mg/ml. Give 2.5mg IM every 6 hours PRN for 'restlessness and agitation.' Order to expire in 14 days . Record review of the Psych Encounter note written by Psychiatric NP B, late entry 6/23/23 for visit date 6/21/23 revealed in part, .Resident with a history of dementia, generalized anxiety disorder, impulse disorder, and delusional disorder .constantly tries to elope the building .was getting angry and agitated talking to me .No GDR recommended at this time. Resident continues to display agitation and anxiety .Start Haldol 1mg gel. Apply 2 mg every 6 hours as needed, to wrist area, for 'restlessness and agitation' for dementia with behavioral disturbance. Order valid for 14 days. Start Haldol 5mg/ml. Give 2.5 mg IM every 6 hours PRN for 'restlessness and agitation.' Order to expire in 14 days . Record review of the progress note written by LVN C, dated 6/23/23 and time stamped 5:37 p.m. revealed in part, .Shift nurse heard the alarms going off on the hall when the nurse went all [sic] the hall found the door open and the resident (Resident #1) in the yard hiding in the bushes .MD gave new PRN orders nurse will carry those orders out . Record review of the facility Event Report dated 7/5/23 and completed by LVN D revealed Resident #1 had a psychotic episode that caused injuries to others. The Event Report revealed, multiple staff members were pushed, punched and grabbed very aggressively. Under the section, Indicate Pharmacological measures taken, Other was checked and indicated, Haldol IM given by ADON per MD orders. Record review of the Neuropsychological Assessment by the Licensed Psychologist, dated 8/16/23 revealed in part, .Referred by medical for neurocognitive evaluation to clarify diagnosis and assist with treatment plan in the context of aggressive behaviors, and to assess for depression, anxiety, or any other psychiatric conditions that might be focus of attention at this time .Patient is NOT currently a danger to self/others .Treatment Plan/Recommendations .Psychiatric and psychological treatment .Follow up with neuropsychological testing as soon as feasible . Record review of the progress note written by the DON, dated 8/27/23 and time stamped 1:15 p.m. revealed in part, .obtaining verbal consent for new medication ABH (made from a combination of Ativan, a sedative to relieve anxiety, Benadryl an anti-histamine and, Haldol an anti-psychotic used to treat mental disorders) gel for 'aggressive behaviors' .resident (Resident #1) behaviors had increased in frequency with increased agitation and aggressiveness towards other residents and staff . Record review of the progress note written by LVN A, dated 8/27/23 and time stamped 9:15 p.m. revealed in part, .Resident #1 coming out of the locked hall and acting aggressive toward staff . I am the nurse that administered ABH gel to the resident . During a telephone interview on 8/28/23 at 10:30 a.m., the Medical Director stated, We don't think the resident [Resident #1] is appropriate for this facility. He has proved he is not appropriate for this facility. The Medical Director further stated, [Psychiatric NP B] is perfectly capable of making medication adjustments and they are supervised by a licensed psychiatrist. No reason why this should not have been handled. The Medical Director further stated, I have recommended the facility to either contact [Psychiatric NP B] or give Haldol IM as needed. During an interview on 8/28/23 at 12:14 p.m., the ADON revealed, Resident #1 had been seen by Psychiatric NP B and stated, but I don't believe she made any real medication changes other than PRN Haldol. During an interview on 8/28/23 at 5:52 p.m., LVN A revealed, Resident #1 had a behavior on 8/27/23 and was surrounded by 3 male aides and Resident #1 was getting really mad at one of the male aides, Nurse Aide F. LVN A revealed, the next thing she knew, Resident #1 was by the front door sitting on the ground, and Nurse Aide G holding Resident #1 by one arm facing forward and Nurse Aide H holding the resident by the other arm and the third aide, Nurse Aide F holding down the resident's legs. LVN A stated she told the Aides to let Resident #1 go and then LVN A applied the ABH gel to Resident #1. LVN A stated, we are a restraint free facility, no we should not have been restraining [Resident #1]. LVN A revealed she told Nurse Aide F he could not do that, restrain Resident #1 to which Nurse Aide F replied, am I in trouble now? LVN A stated, what I did see is [Nurse Aide F] and the other two male aides restrain [Resident #]1. During an interview on 8/28/23 at 7:22 p.m., LVN D revealed Resident #1 resided in the male secure unit and had gotten out multiple times. LVN D revealed approximately one month ago, June 2023, Resident #1 barged outside of the secure unit. LVN D revealed Resident #1 was held back by multiple staff members after the resident pushed the MDS Coordinator. LVN D stated, staff tried to hold [Resident #1] under the arms as he was swinging. LVN D revealed, Resident #1 was eventually held down in a chair and the ADON gave the resident a Haldol injection. LVN D stated, I feel bad they had to tranquilize [Resident #1] to get him to calm down. LVN D stated, the [ADON], the [DON] and the [Administrator] were all here in the facility when this incident (with the MDS Coordinator) occurred, and they were aware [Resident #1] was held down. LVN D stated, I do not feel like anyone here is trained to deal with [Resident #1's] behaviors. LVN D stated, Agency LVN E, who no longer worked for the facility, used to work in a psychiatric facility and told other staff how to hold Resident #1 in a seated position. During an interview on 8/28/23 at 7:23 p.m., Nurse Aide F revealed he was assigned one to one to Resident #1 on 8/27/23. Nurse Aide F revealed, Resident #1 became agitated on 8/27/23 after Nurse Aide G asked the resident if he was okay and the resident started kicking the air and moving his hands rapidly. Nurse Aide F stated, Resident #1 moved towards the door leading to the front with Nurse Aide G and himself following and Resident #1 pushed open the door from the locked unit and moved toward the inner facility. Nurse Aide F stated, Nurse Aide H came to assist as Resident #1 grabbed Nurse Aide F's shirt from the front. Nurse Aide F stated, they both [Nurse Aide G and Nurse Aide H] took [Resident #1] by an arm and held him back and we got him to the ground so the nurses could apply the ABH cream on him. Nurse Aide F stated, [Resident #1] wasn't able to get up. Nurse Aide F stated, I don't think [Resident #1] is appropriate for this facility, he needs to be somewhere where staff are trained for that. I am not trained to deal with that on a regular basis. Nurse Aide F stated, We have been instructed to keep [Resident #1] in the unit but didn't really get any instruction on how to keep him in the unit. During an interview on 8/29/23 at 8:59 a.m., the Assistant BOM revealed, an incident occurred on 8/27/23 at approximately 7:00 p.m. or 7:30 p.m., before preparing to leave her office. The Assistant BOM stated, Resident #1 was observed heading in the direction past the nurse's station toward the front door. The Assistant BOM stated, her office was close to the facility front door and observed Resident #1 followed by Nurse Aide F, Nurse Aide G and Nurse Aide H. The Assistant BOM stated, LVN A had her gloves on ready to apply the ABH gel when Resident #1 hit Nurse Aide F on the upper chest, then grabbed Nurse Aide F's shirt and started to shake him. The Assistant BOM stated, at that point [Nurse Aide G[ and [Nurse Aide H] come in and they are right by my office door wall and in the meantime, I am trying to call the [Administrator]. At this point, the guys are trying to hold [Resident #1] and they are holding his arms, like under his elbows and [Nurse Aide F] is still trying to get loose. Everybody goes down, they fall down, and [Resident #1] starts to kick. The Assistant BOM revealed, LVN A then applied the ABH gel to Resident #1's hands. The Assistant BOM stated, it had been discussed during in-services that staff were not to touch Resident #1 because it would escalate his anxiety and aggression. During a telephone interview on 8/29/23 at 3:02 p.m., Agency LVN E revealed she had worked at the facility through a contracted agency but discontinued her contract after 30 days. Agency LVN E revealed, Resident #1 had behaviors that were sometimes avoidable but sometimes not. Agency LVN E revealed an incident occurred in June 2023 in which Resident #1 pushed the MDS Coordinator and had also made contact with the Activity Director. Agency LVN E stated, everyone swarms, [Resident #1] seems like he is going towards everybody and there is a lot of yelling, I step back because less is more. Agency LVN E further stated, [Resident #1] had a hold of the [Activity Director] and is not letting go. [Resident #1] was restrained, because that is what it was called. But [Resident #1] could still move. Agency LVN E revealed, the physical restraint used on Resident #1 was called bear paws so as not to cause bruising while being restrained. Agency LVN E stated, she and CNA I restrained Resident #1 and once we got him to the ground, he [Resident #1] starts to relax. Agency LVN E stated, the restraint to Resident #1 lasted a total time of 15 to 20 minutes until the police arrived. Agency LVN E revealed, the facility had not provided training on anything related to the incident, nothing on dementia, nothing on aggression, nothing on behaviors. Agency LVN E stated she did not know who the Abuse Coordinator was and approximately a month ago was given a paper to sign on an in-service on abuse and neglect. Agency LVN E stated, I do not think we are supposed to touch them (residents) but there was no way of getting around it. During an interview on 8/29/23 at 5:47 p.m., the DON stated, Resident #1 could not be stopped from having behaviors and just to keep him safe. The DON revealed staff could not lay hands on Resident #1 and to make sure all the residents were safe. The DON stated, our policy is to follow [Resident #1], keep him safe and call police to help us get him back into the building safely. During an interview on 8/30/23 at 2:38 p.m., Nurse Aide G revealed an incident occurred on 8/27/23 at approximately 7:00 p.m., after the residents had eaten. Nurse Aide G stated Nurse Aide F had been assigned Resident #1's one to one staff when Resident #1 got out of the secure unit with Nurse Aide F following. Nurse Aide G stated, Resident #1 grabbed Nurse Aide F's shirt and Nurse Aide G came behind [Resident #1] and put my arms around his upper shoulder as if to grab him and [Resident #1] took his arm and swung it back and that's how we fell on the floor. Nurse Aide G stated, he, Resident #1, Nurse Aide F and Nurse Aide H fell together on the floor with the force of Resident #1 trying to swing at them and Resident #1 still holding onto Nurse Aide F's shirt. Nurse Aide G stated, I have never seen any staff hold him [Resident #1], we try to talk to him and calm him down. Nurse Aide G revealed he did not consider the incident on 8/27/23 resulted in Resident #1 being restrained. During an interview on 8/30/23 at 3:29 p.m., the Administrator revealed, the Assistant BOM contacted him by phone on 8/27/23 at approximately 7:20 p.m. regarding the incident in which Resident #1 came out of the secure unit and was followed by Nurse Aide F, Nurse Aide G and Nurse Aide H. The Administrator stated, the Assistant BOM was giving the Administrator a narrative while it was going on. The Administrator stated, basically, [Resident #1] rushed [Nurse Aide F] and grabbed him, and two other aides pulled the resident off of [Nurse Aide F]. The Administrator stated, [Nurse Aide F] was standing in front of [Resident #1] because another resident was in [Resident #1's] path. The Administrator further stated, the other two aides grabbed [Resident #1] by the arms and pulled him back while [Resident #1] was holding onto [Nurse Aide F's] shirt, and they all fell down. The Administrator stated, [Nurse Aide F] held one of[ Resident #1's] legs because he was kicking him, just didn't want him to hurt anybody and then the nurse put the cream on him and then [Resident #1] got up by himself and went for a walk with them. [Resident #1] was not restrained. The Administrator stated, I have never been informed [Resident #1] had ever been restrained. The Administrator revealed he recalled the incident in which Resident #1 pushed the MDS Coordinator. The Administrator stated, [Resident #1] pushed the [MDS Coordinator] and the staff, don't recall who it was, held [Resident #1] down. I think it was one (staff) on each side of him, to calm him down. The Administrator stated, again [Resident #1] was not hurt. The Administrator stated, the incident with the [MDS Coordinator], we didn't know what to do and [Resident #1] was held down to keep him from hurting other people, I'm sure. The Administrator revealed, the staff at the facility were not trained to deal with that kind of behavior. During an interview on 8/30/23 at 4:11 p.m., the MDS Coordinator revealed he recalled the incident in which Resident #1 pushed him. The MDS Coordinator revealed, staff were guiding Resident #1 to sit in a wheelchair, holding the resident's arms and the resident was resistive and combative. The MDSCoordinator stated, Resident #1 got up from the wheelchair and two staff, could not recall who, had their arms under the resident's upper arms and they backed up until they backed up against the wall and slid down the wall still holding the resident by the arms and talking to him and then the police showed up. The MDS Coordinator revealed, there was one nurse, Agency LVN E who stated she was trained for this (restraints). The MDS Coordinator stated, they were restraining him, I would think, but it was reasonable intervention because it was a very erratic behavior, he [Resident #1] was kind of out of control. During a follow up interview on 8/31/23 at 8:22 a.m., the DON revealed, the facility did not do behavioral health training of staff and staff were only instructed to remove them (residents) and calm the situation. The DON stated, most of our residents don't have violent behaviors. [Resident #1] seemed to be the one factor in these situations. During an interview on 8/31/23 at 1:18 p.m., CNA I stated, he had not heard or seen residents being restrained. CNA I revealed, residents, including Resident #1, could not be restrained, and staff should not provoke or argue with the residents, leave them be and keep residents safe. CNA I denied ever having restrained Resident #1. Record review of the facility's policy and procedure titled Abuse Prevention Program, revision date April 2013, revealed in part, .Our residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion .1. Our facility is committed to protecting our residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies providing services to our residents, family members, legal guardians, surrogates, sponsors, friends, visitors or any other individual .a. Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish .5. Along with other staff and management, the Medical Director will help identify situations that might constitute or could be constituted as neglect; for example .inappropriate management of problematic behavior .repeated failure to check for correct application of restraints . The Administrator was given the IJ template and was notified of the Immediate Jeopardy {IJ} on 8/31/23 at 6:01 p.m. and a plan of removal was requested. On 9/1/23 at 8:38 a.m., the facility provided a plan of removal that was accepted. It was documented as follows: SURVEY TYPE: Complaint Survey SURVEY DATE: 8/31/23 Plan for REMOVAL Plan to remove immediate jeopardy. F600 On 8/31/23, Resident #1 no longer resided at the facility On 8/31/2023 the Regional Nurse Consultant completed in-service with the DON, ADON and the Administrator on abuse and neglect, abuse and neglect reporting guidelines/policy, abuse, and neglect CE pathways, and on reporting then investigating to follow the current regulatory provider letter. On 8/31/2023 DON and ADON assessed residents residing on Hall A (secure unit) for signs and symptoms of abuse, no negative findings. The Medical Director was notified of no changes in condition by DON on 8/31/2023. On 8/31/2023 the Director of Nursing and ADON initiated in-service with facility staff on abuse and neglect, abuse, and neglect reporting guidelines/policy, reporting abuse to management staff/abuse coordinator. Education to be completed on 8/31/23. Any staff that is not available will be educated prior to their next scheduled workday. The in-service was completed on 9/1/23. On 8/31/23 the Administrator and the Regional Reimbursement Consultant will complete safe surveys with residents, to ensure the health and safety of all residents. The IDT, NHA (Nursing Home Administrator), DON, ADON, Regional Nurse Consultant, and MDS Coordinator will review the findings and will immediately notify the Administrator for further action, if necessary. The safety survey was completed on 9/1/23. On 8/31/23 an Ad-Hoc QAPI meeting was held with the Medical Director, NHA (Nursing Home Administrator), DON, Regional Nurse Consultant, Assistance Director of Nursing, Regional MDS, Regional Director of Operations and MDS Coordinator to review the deficiency and the plan for removal of immediacy. Sign-in sheet was reviewed on 9/1/23. Starting on 8/31/2023, IDT (Interdisciplinary team), including Administrator, DON, ADON and MDS Coordinator will review abuse and neglect monitoring Monday to Friday, and Manager on Duty Saturday and Sunday for 1 month to ensure the health and safety of the residents. The findings will be immediately brought up to the Administrator for further action, if necessary. A sign-in sheet was provided of the IDT meeting with the aforementioned staff on 9/1/23. The Administrator/designee will monitor compliance by completing an audit of residents that have behaviors/aggression every week for four (4) weeks, MD being notified, Family being notified, and behavioral services to be notified. If Behavioral Services is not available, then the Medical Director will be notified for any psychosocial concerns. This will be initiated on 8/31/2023. Any identified concerns will be addressed immediately and if trends and patterns are identified, the facility will conduct an Ad-Hoc QAPI meeting to discuss if additional interventions are needed to ensure compliance for the next 2 months. The facility provided an audit dated 8/31/23, initiated by the administrator on 9/1/23. The Administrator will be responsible for ensuring this plan is completed on 8/31/2023. The RDO will provide oversight of Administrator and DON to ensure that the items on the plan of removal are reviewed and completed. Monitoring of the implementation of the POR: Plan to remove immediate jeopardy. During an observation and interview on 9/1/23 at 8:03 p.m., Resident #2 was in his room lying in bed watching television. Resident #2 revealed he felt safe and had been asked by facility staff about abuse/neglect. Resident #2 stated, you're the third person who has asked me. Resident #2 did not appear to be in any obvious distress or discomfort. During an observation and interview on 9/1/23 at 8:08 p.m., Resident #3 was in her room sitting up in a wheelchair. Resident #3 did not appear to be in any obvious distress or discomfort. Resident #3 stated the ADON had talked to her on 8/31/23 about abuse/neglect. Resident #3 stated she felt safe in the facility. During an observation and interview on 9/1/23 at 8:11 p.m., Resident #4 appeared well-groomed and appropriately dressed and did not appear to be in any obvious distress or discomfort. Resident #4 stated she had been asked by the ADON about abuse and revealed she wanted to be with her boyfriend. Record review of the facility interviews with 70 residents on 8/30/23 revealed the safety survey was completed. Most of the residents in the facility were not interview able, and those that were did not make any new allegations of abuse or neglect. Record review of the facility Ad-Hoc QAPI meeting held on 8/31/23 revealed signatures for the Medical Director, NHA (Nursing Home Administrator), DON, Regional Nurse Consultant, Regional MDS, Regional Director of Operations and the MDS Coordinator. A log was created for the IDT to review and monitor for abuse and neglect Monday to Friday and the Manager on Duty for Saturday and Sunday to be monitored for 1 month to ensure the health and safety of the residents. Any adverse findings would be reported to the Administrator for further action if necessary. Record review of the facility IDT meeting held on 8/31/23 included the Administrator, DON, ADON and MDS coordinator revealed the Administrator would monitor for compliance by completing an audit of 5 residents per week for the next 4 weeks of residents with behaviors/aggression with MD notification for request of behavioral services, initiated on 8/31/23. The log dated 9/1/23 revealed 5 random residents were chosen for the audit and signed by the Administrator. During a joint interview on 9/1/23 at 5:36 p.m., the DON, ADON, Regional Nurse Consultant, the COO and RN Director of Quality revealed review of the POR for abuse/neglect highlighted training on identifying and reporting suspected abuse. Record review of the facility in-service dated 8/31/23, titled Abuse Neglect Policy/Reporting Guidelines/Abused and Neglect Pathways revealed 67 facility employed staff signed the sign-in sheet. The facility had 55 total facility employees and utilized agency staff. During a joint interview on 9/1/23 at 5:22 p.m., the DON and the Administrator revealed the abuse/neglect in-service highlighted identifying forms of abuse, reporting suspected abuse for investigation and adhering to reporting guidelines. 1. During an interview on 9/1/23 at 3:50 p.m., Housekeeping Staff J revealed she had worked for the facility for just 4 months and worked Monday through Saturday from 2:00 p.m. to 10:00 p.m. Housekeeping Staff J revealed she had been in-serviced on abuse/neglect that morning and revealed she was to report abuse/neglect to the Administrator and to keep the residents safe. 2. During an interview on 9/1/23 at 3:55 p.m., CNA L revealed she had worked for the facility off and on since January 2023 and worked 6:00 a.m. to 6:00 p.m. on a rotating schedule. CNA L revealed she had been in-serviced on abuse/neglect on 9/1/23 and the in-serviced covered identifying abuse/neglect and to report to the Administrator while keeping the residents safe. 3. During an interview on 9/1/23 at 4:00 p.m., the Assistant BOM revealed she worked every day with varying hours and had been in-serviced on abuse/neglect in the morning on 9/1/23. The Assistant BOM stated, abuse/neglect was to be reported to the DON and the Administrator. The Assistant BOM stated, remove the resident from an unsafe environment and keep them safe. 4. During an interview on 9/1/23 at 4:05 p.m., the BOM stated she had worked for the facility for 5 years and worked Monday to Friday. The BOM stated she had been in-serviced on abuse/neglect last week and was to report suspicion of wrongdoing to the residents to the Administrator. The BOM stated, if the Administrator was not available, abuse and neglect should be reported to the DON and the charge nurse. 5. During an interview on 9/1/23 at 4:12 p.m., CNA L revealed she had worked for the facility for 2 years and worked from 6:00 a.m. to 6:00 p.m. on a rotating schedule. CNA L stated she had been in-serviced by the ADON on 9/1/23 on abuse/neglect. CNA L revealed the highlight of the in-service covered identifying abuse/neglect and the process for reporting. CNA L revealed abuse/neglect was reported to the Administrator while keeping the resident safe. 6. During an interview on 9/1/23 at 4:16 p.m., CNA M revealed she had worked for the facility for about a month but had been employed over a year ago and had been working the 6:00 a.m. to 6:00 p.m. on a rotating schedule. CNA M stated she had been in-serviced on 9/1/23 on abuse/neglect. CNA M stated, abuse was physical, verbal, and emotional. CNA M stated if abuse/neglect was suspected, report to the Administrator and if not available, report to the DON and the charge nurse. 7. During an interview on 9/1/23 at 4:23 p.m., Nurse Aide N revealed she had worked for the facility for 6 months and worked from 6:00 a.m. to 6:00 p.m. on a rotating schedule. Nurse Aide N stated she had received an in-service by the ADON on abuse/neglect on 8/31/23. Nurse Aide N stated abuse could be verbal, physical, or making a resident do something they did not want. Nurse Aide N stated she was supposed to report abuse/neglect to the Administrator and to the nurse. 8. During an interview on 9/1/23 at 4:28 p.m., CNA O revealed she had worked for the facility for 2 years and worked from 6:00 a.m. to 6:00 p.m. on a rotating shift. CNA O revealed she had been in-serviced on abuse/neglect in the morning on 9/1/23. CNA O revealed the in-service highlighted types of abuse such as verbal, physical, restraints, and yelling at residents. CNA O revealed abuse/neglect was to be reported to the Administrator while keeping the residents safe. 9. During an interview on 9/1/23 at 4:35 p.m., Nurse Aide P revealed she had worked for the facility for 2 weeks and worked the 6:00 a.m. to 6:00 p.m. shift on a rotating schedule. Nurse Aide P stated she had been in-serviced on abuse/neglect this week and the in-service highlighted on identifying abuse/neglect and reporting to the Administrator. 10. During an interview on 9/1/23 at 4:40 p.m., Kitchen Staff Q revealed she had worked for the facility for the past 6 weeks and had been in-serviced on abuse/neglect this week. Kitchen Staff Q stated abuse/neglect was physical or verbal and was not allowed. Kitchen Staff Q revealed if she suspected abuse/neglect she was supposed to report it to the Administrator and keep the residents safe. 11. During an interview on 9/1/23 at 4:46 p.m., LVN C revealed she had worked for the facility for 8 years and worked varying shifts and had been in-serviced this week. LVN C stated, abuse/neglect was physical, verbal, misappropriation and emotional like making fun of them especially for psych residents, they will think you are talking about them, and it angers them. LVN C revealed, abuse/neglect was to be reported to the Administrator. 12. During an interview on 9/1/23 at 4:59 p.m., Dietary Aide R revealed he had worked for the facility for approximately 2 weeks and was in-serviced on 9/1/23 on abuse/neglect. Dietary Aide R stated abuse/neglect was verbal, physical, and emotional. Dietary Aide R stated,

Based on observation, interview and record review, the facility failed to provide evidence that all alleged violations of neglect, abuse, misappropriation of property were thoroughly investigated in order to prevent further potential neglect, abuse, misappropriation while the investigation was in progress for 4 of 5 residents (Resident #3, #11, #27 and #36 ) reviewed for investigation of abuse, in that: The facility did not thoroughly investigate complaints that Residents #3, #11, #27 and # 36 were verbally abused by Nurse X and suffered psychosocial harm. These failures resulted in an IJ on 03/01/23 at 6:45 PM. While the IJ was removed on 03/03/23 at 12:40 PM., the facility remained out of compliance at a level of actual harm that is not immediate jeopardy with a scope of pattern due to facility's need to evaluate the effectiveness of their plan of removal and complete training. This deficient practice could place residents at risk for harm, a diminished quality of life, and psychosocial harm. The findings were: 1. Record review of Resident #11's face sheet reflected Resident #11 was a [AGE] year-old female admitted on [DATE] with diagnosis including rhabdomyolysis (condition of muscle deterioration and kidney damage), diabetes mellitus (disease that affects the body's ability to process glucose), and hypertensive heart disease (heart problems that occur with long term high blood pressure). RP was listed as the resident. Record review of Resident #11's MDS assessment reflected a BIMS of 10, indicating moderately impaired cognitive status. Also, record review of Resident #11's ADLs included: bed mobility-supervision with set-up; transfer-supervision with set-up; and eating was-supervision with set-up. Record review of Resident #11's care plan dated 12/13/22 listed the problem of Behavioral Systems which included the Approach .Approach and speak in a calm manner . Record review of Resident #11's signed HHS Form 4825-A (written statement), dated June 2005 read: She (Nurse X) is rude She said that I need to fast and not eat everything She (Nurse X) saw me trying to get past my wheelchair and she laughed at me. [There were no other witnesses to the alleged said incident.] Record review of Resident #11's EMR revealed weight of 313 pounds on 02/01/23. Record review of Resident #11's nurse note dated 02/20/23 authored by Nurse X read. [Resident #11] can be uncooperative with staff. resident will cover her food at meal time and tell [Nurse X] what are you looking at .resident is disrespectful to staff and other resident. In an observation on 2/10/2023 at 7:48 AM, breakfast was being served in the communal dining area with the TV on a loud volume. The communal dining area was brightly lit. In an interview on 2/10/2023 at 7:50 AM, Resident #11 stated she was upset because Nurse X refused to let her eat breakfast in her room that morning [A resident's right]. Resident #11 stated she advised Nurse X that she was not feeling well due to a migraine and wanted to eat in her room because it was not as loud or bright. Resident #11 stated she was upset because Nurse X was so rude about it. Resident #11 stated she had also asked the ADON to eat in her room. In an interview on 2/10/2023 7:55 AM, Nurse X stated she would prefer residents not eat in their room. Nurse X declined further interview and walked abruptly away from this surveyor and Resident #11. In an interview on 2/10/2023 at 7:56 AM, the ADON stated she was aware of the request, and did not know that Nurse X had refused Resident #11's request. The ADON stated she would find Resident #11's breakfast tray and take it to Resident 11's room immediately. The ADON stated some residents preferred to eat in the dining area, and it was unusual for Resident #11 to request to eat in her room. [The ADON honored the resident's request to eat in her room.] Observation and interview on 03/01/23 at 08:35 AM , Resident #11 was in room watching TV, cleaned and groomed, alert and oriented.; wheelchair present. The resident did not reveal signs or symptoms of sadness, fear, or anxiety (as a response to verbal abuse). The resident requested door be closed for the interview. Resident was eating her breakfast in the room. The Resident stated, .not that long ago (Nurse X) was rude to me .she said I could not eat in my room on 02/02/23 .I was upset she has always been rude to me .maybe she does not like me .she yells at me and laughs at me .yesterday (02/28/23) she laughed at me .as I struggled with my wheelchair .I complained in the past to the Administrator and he let me eat in my room .I'm not afraid of her I want her to be polite. Record review of Resident Council Minutes for the past 9 months ( June 2022 to March 2023) read: on 02/16/23: night staff needs better communications [In reference to Nurse X]. During an interview on 03/01/23 at 2:13 PM, the ADON stated Nurse X tried to get Resident #11 to eat in the dining room for socialization reasons. Resident #11's tray was in the dining hall and taken to the resident. The ADON was not aware of verbal abuse by Nurse X towards Resident #11. The ADON stated that Resident #11, Resident #27, and Resident #3 told her (ADON) of instances where Nurse X could come across being load. The ADON stated the instances were never recorded as grievances; and she recalled the said residents saying not wanting to file a grievance against Nurse X; but their denial (Resident #11, #27 and #3) was not documented as a grievance or investigated. Regarding the Resident Council minutes dated 08/22/23, the ADON recalled speaking to Nurse X about modulating her volume when speaking to residents. The ADON did not consider the minutes on the concern over communications to be a grievance only to be a concern to be discussed with Nurse X. ADON described Nurse X, as a phenomenal and an excellent nurse in providing nursing care. 2. Record review of quarterly MDS dated [DATE], revealed Resident #3 was a [AGE] year-old-male admitted [DATE] with the diagnosis of diffuse traumatic brain injury (widespread traumatic injury to the tissues of the brain, usually mechanical forces such as those that are present in high velocity road traffic accidents). The summary BIMS score of 14 was indicative of intact cognition. ADLs revealed: transfer and bed mobility required limited assistance with one person physical assistance and supervision with set-up for eating. Record review of Resident #3's face sheet dated, 03/01/23, revealed the RP was a family member. Record review of Resident #3's care plan dated 2/15/23 read, the Problem .Behavioral Symptoms . Approach .maintain calm environment .anticipate behavior and re-direct .ensure staff is aware of resident('s) behaviors and successful interventions. Record review of Resident #3's written statement on HHS form 4825-A, [dated 03/01/23] read, (Nurse X) does not speak what is not true [resident had communication and writing deficits during the interview]. Record review of Resident # 3's nurse notes from 01/01/23 to 03/01/23 authored by Nurse X revealed no negative behaviors by Resident #3 directed at Nurse X. Record review of Resident #3's email to a Family Member K dated 11/22/2021 read, [ .(Nurse X)] .called me crazy. In an interview on 2/08/2023 at 1:46 PM, Resident #3 stated he would like to talk about something but was afraid he may get in trouble. Resident #3 stated Nurse X treated many people, including him, like mud. He stated every time he came to Nurse (X) for something, she made sure her back was turned toward him so she could quickly walk away from him. Resident #3 stated Nurse X would go into a different room, so he would not know where she was when he needed something. He stated she was nice to some residents and obviously had her favorites. Resident #3 stated Nurse X embarrassed him in the past when she said something about his mother after he asked her a question. Resident #3 stated Nurse X exclaimed, your momma wouldn't like you screaming like that. Resident #3 stated he does not like to be around Nurse X. Resident #3 stated he had mentioned it to staff, but they don't care what I say about Nurse [X] because they like Nurse [X]. Observation and interview on 03/01/23 at 9:02 AM , Resident #3 was in bed watching TV, cleaned and groomed, alert and oriented but with communication deficits. No signs of anxiety, sadness or fear. The Resident stated, .[Nurse X] treats me like mud .she wants to talk to other residents not me .I want her to become better .I complained to everybody [Administrator and DON] but nothing happens . During an interview on 03/02/23 at 3:14 PM, Family Member K stated Nurse X had been extremely rude to the Family Member K and to Resident #3. Family Member K stated that [Nurse X] threatened to withhold (Resident #3's) medication or give him (Resident #3) extra medication to control (Resident #3). [Family Member did not report the allegation to facility management] Family Member K stated that about 6 months ago (November 2022), she told former Administrator O about Nurse X's verbal abuse and former Administrator O said he would check; but never informed Family Member K of any internal investigation outcomes. Family Member K stated they received numerous emails from (Resident #3) complaining about Nurse X's behavior. Record review of email from Resident #3 dated 11/22/21 read Nurse X called Resident #3 crazy. Record review of email from Resident #3 dated 03/02/23 read [Nurse X ] lied. During an interview on 03/02/23 at 3:48 PM, former Administrator O stated, I do not remember a verbal complaint from a family member about six months ago involving Nurse (X) and a resident (Resident #3) . The former Administrator O the residents may have mis-interpreted Nurse X's tone [speaking loudly]. 3. Record review of the quarterly Minimum Data Set, dated dated dated [DATE] revealed Resident #36 was a [AGE] year-old male admitted [DATE]. Active diagnosis included hip fracture; cerebral palsy (impaired muscle coordination); moderate intellectual disabilities; Lack of coordination. Brief Interview for Mental Status score of 13 indicative of intact cognition. ADL for bed mobility and transfer was limited assistance with one person physical help; eating was supervision with set-up. Record review of Resident #36's care plan, dated 09/03/21 read, Problem .Behavioral Symptoms .Approach .Provide opportunities for expression of feelings related to situational stressor . Record review of Resident #36's written statement, transcribed by the Surveyor, on 03/01/23 at 09:47 AM read, I do not feel comfortable with [Nurse X]. She yells at me and screams at people. She tells me to sit down in a loud voice. Get rid of her (Nurse X) Hire someone else. Record review of Resident # 36' nurse notes from 01/01/23 to 03/01/23 authored by Nurse X revealed no negative behaviors by Resident #36 directed at Nurse X. In an interview on 2/08/2023 at 11:53 AM Resident #36 stated Nurse X was frequently rude to him and other residents. Nurse X frequently yells and hollers. Resident #36 stated he did not like to ask Nurse X for assistance. Resident #36 stated, It doesn't do any good to complain about staff here when asked to whom he had reported his concerns. Observation and interview on 03/01/23 at 9:38 AM , Resident #36 was in his room sitting on a wheelchair listening to country music. The resident displayed no signs of distress, anxiety, fear or sadness. Resident #36 stated, Nurse X had the habit of yelling at him. He complained the Administrator and the DON about Nurse X's yelling but no changed occurred. 4. Record review of quarterly MDS dated [DATE] revealed Resident #27 was a [AGE] year-old female with an admitted [DATE] . Active diagnosis included cerebral palsy (impaired muscle movements); cellulitis (bacterial skin infection) of left and right lower limb; lymphedema (swelling); and lack of coordination. The BIMS summary score of 13 was indicative of intact cognition. ADLs revealed: bed mobility and transfer were limited assistance with one person physical assist; eating was supervision with set-up. Record review of Resident #27's care plan, dated 01/03/23 revealed that Resident #27 had to be approached in a calmed manner. Record review of Resident #27's written statement on Form 4827-A dated 3/1/27 at 10:19 AM read, [Nurse X] talks to us like we are babies Don't do this like a slap on the hand Take a lot of food from peoples plates to feed her cats. Record review of Resident # 27' nurse notes from 01/01/23 to 03/01/23 authored by Nurse X revealed no negative behaviors by resident directed at Nurse X. In an interview on 02/08/2023 at 3:23 PM, Resident #27 stated Nurse X was often rude to her. Resident #27 stated Nurse X frequently speaks to her in a harsh tone. Resident #27 stated it made her feel bad and Resident #27 wished she was not at this facility when spoken to in that manner. Resident #27 further stated [Nurse X] does not pay my bills, and I am not her child so she shouldn't speak to me like that! Resident #27 stated it made her feel bad and she would return to her room to cry when Nurse X spoke to her condescendingly. Resident #27 stated she had previously told other aides and the ADON that she did not like Nurse X, but Nurse X continued to act bossy over me. Observation and interview on 03/01/23 at 10:12 AM , Resident #27 was attending a church service; sitting on a wheelchair, alert and oriented. There were no signs of sadness, anxiety or fear . The Resident stated, she told the surveyor that Nurse X treated her like a child. Resident #27 added that she once cried after being treated as a child by Nurse X. Resident #27 complained to the Administrator about Nurse X's tone and behaviors but no actions were taken against Nurse X. Record review of Resident # 27's nurse notes from 01/01/23 to 03/01/23 authored by Nurse X revealed no negative behaviors by Resident#27 directed at Nurse X. In a group interview on 2/09/2023 at 9:30 AM, with the DON, the Regional Nurse, and the ADON, the ADON stated she did the facility staffing. She further revealed Nurse X was the only full-time nurse on staff, other than the DON. The ADON stated Nurse X worked 12 hour shifts 6:00 AM to 6:00 PM Monday through Saturday and Sundays off. When asked if she felt this was ok for RN to work this many hours, ADON stated, yes, she is one of our best nurses. She does just fine. When the DON was asked if she was aware of any issues or complaints concerning Nurse X being rude to residents, she replied No, that's just the way Nurse X talks to people. The DON stated Nurse X knew which residents needed a firmer approach. The DON stated that Nurse X really cared for the residents at the facility. When asked if the DON felt Nurse X was able to maintain a therapeutic relationship working that many hours each week she replied yes. The DON further explained that Nurse X had been offered more money to go to another facility but would not leave her people. In an interview on 2/10/2023 at 4:00 PM, Nurse X stated she was the primary (nurse) that worked Monday through Saturday 6:00 a.m. to 6:00 p.m. When asked if she knew what abuse and neglect of a resident was, she stated yes, this can be verbal or physical abuse like talking ugly to a person. She further revealed that staff including herself should speak respectfully to residents. She stated the facility had presented many in-services about abuse and neglect and she had attended several of them. When asked how she would feel if she was spoken to in an aggressive or disrespectful way she stated, I would not like that. When asked if she ever recalled speaking disrespectful or less than polite to a resident or family member, she stated no. During the interview, Nurse X was asked what the negative outcome would be if a resident was spoken to in a harmful or disrespectful manner. Nurse X revealed the resident could become agitated, frustrated, or even depressed. She said she felt it could hurt the resident mentally. When asked if residents are allowed to decline services, Nurse X stated yes, they do have the right. She stated they should be encouraged to proceed with the service if it benefits them. Nurse X further revealed she wanted all of her residents to get the services that they needed. She stated she felt that they needed to get out of their rooms and be social. When asked if the resident did not want to go out of their room and you were their nurse, what would you do. She stated, I would ask them questions like 'why do you not want to go?' and then go from there, meaning see what was wrong. During an interview on 03/01/23 at 10:59 AM, the facility physician stated Nurse X was direct .and does not cuddle residents. The physician added this was the first time he heard about Nurse X possibly verbally abusing residents. Nurse X was described as a dedicated nurse that was sometimes misunderstood by residents because of her directness and need for a different bedside manner. The physician stated he never received any complaints of verbal abuse from residents or families about Nurse X when he visited the facility. During an interview on 03/01/23 at 2:43 PM, The DON stated Nurse X was outstanding and you would not find a better nurse. The DON stated that Nurse X was sometimes firm with residents; meaning more direct but not abusive. The DON added that at staff meetings, administration addressed communications and speaking to a resident in a better tone. No resident filed a complaint about verbal abuse involving Nurse X or any other staff to the DON. No formal investigations were done or HHS was not contacted. I have verbally counseled [Nurse X about one month ago in February 2023, but did not document it as part of the disciplinary process. The QAPI monthly minutes, per DON, had not developed an action plan dealing with communication. Per the DON, Nurse X was allowed to continue to work after the survey entrance (02/07/23) until the present because she (DON) did not believe that verbal abuse was present perpetrated by Nurse X.[Procedure for allegation of abuse was to report to the Abuse Coordinator, document the allegation or grievance and investigate. The DON was made aware in the interview that four residents and a family member had alleged verbal abuse by Nurse X.] During an interview on 03/01/23 at 3:02 PM, the Administrator stated he assumed the role of administrator on 01/16/23. He stated that there had been no documented grievances for the past 9 months involving verbal abuse or staff speaking loudly or rudely to residents. The Administrator was made aware of alleged rude tones by Nurse X by the Activity Director in the month of February 2023. The Administrator stated his response to the allegation of rudeness by Nurse X in February 2023 was: I am encouraging structure in meetings .I have visited with the residents and heard their concerns about rudeness .just information as I was transitioning not an official complaint .no actions plans have been developed and have not reported to HHS any verbal abuse by any staff or done any formal investigations. The Administrator stated that no action plan at the monthly QAPI meeting had been developed for communications. The Administrator stated that per abuse policy if there was an allegation of abuse the alleged perpetrator would be suspended pending an investigation. The Administrator stated, I did not suspend her (Nurse X) because rude tone did not rise to verbal abuse level requiring a suspension and a formal investigation .I read the minutes from the Resident Council meeting but did not see it as formal grievance . During an interview on 03/01/22 at 3:25 PM, Nurse X stated she worked Monday to Saturday 6:00 AM to 6:00 PM. She received abuse training on 02/11/23 and the highlights of the training were: report abuse to the Administrator, keep residents safe, and not engage in any abuse. Verbal abuse was defined as belittling the resident and being disrespectful. Nurse X stated that a loud voice or tone is not abuse. For residents that cannot hear, Nurse X stated that 'sometimes you need to raise voice to be heard. Regarding Resident # 27, Nurse X stated: she might have spoken loud to Resident #27 but not in a rude manner. Nurse X there were no issues of communication between her/him and Resident #3 except Resident #3 had communication deficits. As for Resident #36, Nurse X stated there were no issues. Nurse X added that Resident #11 had a weight problem; but she (Nurse X denied ever laughing or belittling the resident. Nurse X stated she was not soft spoken and the residents might misunderstand her tone as abuse. Nurse X stated that the ADON spoke to her about her loud tone; and encouraged her to use a softer tone. Nurse X recalled that after the state visit (02/10/23) the DON spoke to her about her tone and that residents might misunderstand; and to speak softer. I have apologized to [Resident #3] around January (2023) because we could not understand each other . Nurse X concluded that she had not verbally abused any resident and denied her interactions with any resident constituted willful verbal abuse or rudeness. During an interview on 03/01/23 at 1:58 PM, Activity Director stated regarding the Resident Council Minutes (February 2023), communication involved the tone of staff at night; and the staff were loud. The Activity Director could not comment on the 08/11/22 and 06/09/22 minutes because she was not an employee at the facility. She attended training on abuse and neglect. She added, I told the Administrator and DON about the tone issue (raised at the February 2023 Resident Council Minutes in morning meeting around 02/17/23 and no new interventions were instituted .we just talked about having better communications . During an interview on 03/03/23 at 8:36 AM, Anonymous Party P stated they heard about allegations of verbal abuse involving Nurse X in January 2023 and conveyed the allegation to the DON. The DON did not contact Anonymous Party P with results involving any investigation of Nurse X. At a resident council meeting in February, Anonymous Party P heard allegations of verbal abuse by staff and Nurse X. The verbal abuse was not intentional by Nurse X, but she would come across as verbally abusing residents and not caring. Record review of Nurse X's training record revealed Nurse X attended Abuse/Neglect training on 02/23/23. Record review of facility's sign-in sheet on facility's Abuse and Neglect policy revised April 2013 revealed Nurse X signed the sheet. Record review of Nurse X's time card revealed she worked 6 days per week (Monday to Saturday) 06:00 AM to 6:00PM from 01/29/23 to 03/01/23. Record review of Nurse X's annual competency evaluation dated 09/01/2019 revealed she was rated as satisfactory for Knowledge of Abuse/Neglect Protocol; and Nurse X signed the evaluation on 09/01/2019. Record review of Nurse X's Skills checklist dated 01/03/23 read, the Role of Charge Nurse .Receives and gives pertinent care reports to .the DON .Documents and reports changes of condition and unusual occurrences to the MD, Family, and DON . Nurse X was rated as demonstrating said competencies on 01/03/23. Record review of facility's in-service sign in sheet for the training on Abuse & Neglect dated 02/23/23 revealed Nurse X attended the training and signed the attendance sheet. Record review of facility's Reporting Abuse to Facility Management revised February 2014 read, Abuse is defined as the willful infliction of injury, unreasonable confinement. intimidation, or punishment with resulting physical harm, pain or mental anguish . Further the said policy defined verbal abuse as .any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents . The policy further read, .The staff, with the physician's input (as needed), will investigate alleges occurrences of abuse and neglect to clarify what happened and identify possible causes. The Administrator was given the IJ template and was notified of the Immediate Jeopardy {IJ} on 03/01/23 at 6:45 PM; and a plan of removal was requested. On 03/02/23 at 4:45 PM, the facility's provided a plan of removal that was accepted. It was documented as follows: SURVEY TYPE: Annual Survey SURVEY DATE: 3/1/2023 Plan for REMOVAL Plan to remove immediate jeopardy. F610 Residents #3, 11, 27, and 36 were assessed by DON and support was provided as accepted, physician was notified of the alleged deficiency on 3/1/23. There were no new orders obtained. Affected residents' responsible parties were notified by DON and ADON of alleged deficiencies and plan of correction. On 3/1/2023 Administrator reported allegations of abuse to THHS and initiated investigation immediately. Nurse X was immediately suspended by DON and Administrator on 3/1/23. On 3/1/2023 the DON (director of nursing) and Administrator interviewed all residents in the facility to determine if any other residents experienced any psychosocial harm from verbal abuse from Nurse X or from any other staff. There was no concern identified. The interviews were completed before midnight on 3/1/2023. Ad-Hoc QAPI meeting was held on 3/1/2023, with the Medical Director, NHA (Nursing Home Administrator), RDO (Regional Director of Operations) and DON to review the alleged deficiencies, policy and procedure, and the plan for removal of immediacy. On 3/1/2023 the RDO completed 1:1 in-service on Abuse, grievances, and communication with Administrator, DON, and ADON. Starting on 3/1/2023, the facility leadership (Administrator, DON, and ADON) will complete education with all staff on Verbal Abuse, grievances process, and communication, to ensure that each resident receives the services consistent with the professional standards of practice, comprehensive person-centered care plan and the residents' goals and preferences. The training was initiated on 3/1/2023 and will be completed on 3/2/2023. Staff will not be allowed to work until they receive the training. The policy pertaining to Abuse and Grievances were reviewed on 3/1/2023 by the DON, NHA (Nursing Home Administrator) and Medical Director. Starting on 3/1/2023, IDT (Interdisciplinary team), including Administrator, DON, ADON, Activity Director, MDS Coordinator, HR, BOM) will meet with residents daily Monday to Friday, and Manager on Duty Saturday and Sunday to determine if any allegations of abuse or grievances toward staff members arise. The findings will be immediately brought up to Administrator for further action, if necessary. Grievances will be reviewed during morning meeting with Administrator and IDT team members for any follow up needed. All grievances will be entered into Grievance log by Administrator and investigation form will be filled out accordingly. On 3/2/2023 the RDO will start reviewing Grievance log and investigation forms weekly for four (4) weeks followed by monthly reviews after. 3/2/2023 RDO will provide physical oversight at facility weekly x4 weeks and then monthly reviews after. The DON/designee will monitor compliance by completing audit of ten (10) residents per week for four (4) weeks. This was initiated on 3/2/2023. Any identified concern will be addressed immediately and if trends and patterns are identified, the facility will conduct an Ad-Hoc QAPI meeting to discuss if additional interventions are needed to ensure compliance. The Administrator will be responsible to ensure this plan is completed on 3/2/2023. The RDO will provide oversight of DON and Administrators to ensure that the items on the plan of removal are reviewed and completed. Monitoring of the implementation of the POR: Plan to remove immediate jeopardy. Observation and interview on 03/02/23 at 2:57 PM, Resident was in his room listening to music waiting for his smoke break. The resident stated he had no fears, did not feel anxious, was not sad, and felt happy. The resident had no complaints to make to the surveyor. Observation and interview on 03/03/23 at 11:14 AM, Resident #36 was in his room listening to music sitting on a wheelchair . The resident revealed no signs or symptoms of anger, fear, anxiety or sadness. The resident stated he felt happy because she is not here (Nurse X). The resident denied any other abuse by staff and would report any verbal abuse to the nursing staff. During an observation and interview on 03/03/23 at 11:21 AM, Resident # 27 was wondering the hallways sitting on her wheelchair. The resident revealed no signs or symptoms of anger, fear, anxiety or sadness. The resident smiled and stated ,I am happy and feel safe that Nurse (X) is not here. The resident added no other staff have verbally abused her and she would report abuse to the administrator and nursing staff. During an observation and interview on 03/03/23 at 11:28 AM, Resident #11 was in bed watching TV. The resident revealed no signs or symptoms of anger, fear, anxiety or sadness. The resident smiled and stated, I feel good that she (Nurse X) is not here and something had to be done. The resident added that there has been no other verbal abuse by other staff and she felt safe. During an observation and interview on 03/03/23 at 11:33 AM, Resident #3 was in his room. The resident revealed no signs or symptoms of anger, fear, anxiety or sadness. The resident stated, I feel good she is not here .staff needs to be kind to everyone .she was mean and never said anything nice . The resident responded that he felt safe. If abused occurred again the resident stated he would tell (a family member). Record review of facility's self report to HHS on 03/02/23 revealed HHS assigned the intake numbers. During an interview on 03/03/23 at 10:55 AM, the Administrator stated, with approval from his corporate headquarters his intention was to terminate Nurse (X). Record review of facility's interview of 67 residents on 03/01/23 revealed checklists were completed for 67 residents; and no resident made any new allegations of abuse to include verbal abuse. Record review of facility's Ad-Hoc QAPI meeting held on 3/1/2023 revealed signatures for Medical Director, NHA (Nursing Home Administrator), RDO (Regional Director of Operations) and DON. During an interview on 03/02/23 at 5:07 PM, the RDO stated the highlights of the training were: administrative staff to be familiar with reporting guidelines, verbal abuse, and all abuse. During a Joint interview on 03/02/23 at 5:10 PM with Admin, DON, and ADON, the DON stated: the highlight of the training was to report verbal abuse and any suspected abuse. The ADON added: the highlight to report and investigate all abuse. The Administrator: the main highlight was to report alleged or suspect abuse; and to adhere to the reporting guidelines. Record review of facility's in-service on 03/02/23 on the topic of Process for reporting abuse/Neglect revealed 46 paid employees signed the sign-in sheet, 100% completion rate. [total paid staff on 03/2/23 was 46] Record review of facility's in-service on 03/01/23 on the topic of Abuse/Neglect-Verbal Abuse revealed 45 paid employees signed the sign-in sheet, 98% completion rate. [total paid staff on 03/2/23 was 46; Nurse X was suspended and did not attend the training] 1.During an interview on 03/02/23 at 10:12 AM, LVN M stated: LVN M received training on Abuse/Neglect on 02/11/23. The highlights of the training included: bedside manners, voice tone, and identifying abuse and to report to the Administrator.[shift was 6AM-6PM] 2.During an interview on 03/02/23 at 10:25 AM, CNA N stated: received abuse/neglect training on 2/11/23 and the highlights of the tr [TRUNCATED]

Based on observation, interview, and record review, the facility failed to protect a resident's right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 4 of 5 residents (Resident # 3, #11, #27 and #36) reviewed for abuse, in that: 1. The facility failed to prevent Resident # 11 from being verbally abused by Nurse suffering psychosocial harm 2. The facility failed to prevent Resident #3 from being verbally abused by Nurse and suffering psychosocial harm 3. The facility failed to prevent Resident #36 from being verbally abused by Nurse and suffering psychosocial harm 4. The facility failed to prevent Resident #27 from being spoken to in a harsh, loud manner by Nurse X; and Resident # 27 suffered psychosocial harm These failures resulted in an IJ on 03/01/23 at 6:45 PM. While the IJ was removed on 03/03/23 at 12:40 PM., the facility remained out of compliance at a level of actual harm that is not immediate jeopardy with a scope of pattern due to facility's need to evaluate the effectiveness of their plan of removal. This deficient practice placed residents at risk of psychosocial harm, feeling disrespected or uncomfortable, decreased self-esteem, impaired quality of life; and abuse. The findings were: 1. Record review of Resident #11's face sheet reflected Resident #11 was a [AGE] year-old female admitted on [DATE] with diagnosis including rhabdomyolysis (condition of muscle deterioration and kidney damage), diabetes mellitus (disease that affects the body's ability to process glucose), and hypertensive heart disease (heart problems that occur with long term high blood pressure). RP was listed as the resident. Record review of Resident #11's MDS assessment reflected a BIMS of 10, indicating moderately impaired cognitive status. Also, record review of Resident #11's ADLs included: bed mobility-supervision with set-up; transfer-supervision with set-up; and eating was-supervision with set-up. Record review of Resident #11's care plan dated 12/13/22 listed the problem of Behavioral Systems which included the Approach .Approach and speak in a calm manner . Record review of Resident #11's signed HHS Form 4825-A (written statement), dated June 2005 read: She (Nurse X) is rude She said that I need to fast and not eat everything She (Nurse X) saw me trying to get past my wheelchair and she laughed at me. [There were no other witnesses to the alleged said incident.] Record review of Resident #11's EMR revealed weight of 313 pounds on 02/01/23. Record review of Resident #11's nurse note dated 02/20/23 authored by Nurse X read. [Resident #11] can be uncooperative with staff. resident will cover her food at meal time and tell [Nurse X] what are you looking at .resident is disrespectful to staff and other resident. In an observation on 2/10/2023 at 7:48 AM, breakfast was being served in the communal dining area with the TV on a loud volume. The communal dining area was brightly lit. In an interview on 2/10/2023 at 7:50 AM, Resident #11 stated she was upset because Nurse X refused to let her eat breakfast in her room that morning [A resident's right]. Resident #11 stated she advised Nurse X that she was not feeling well due to a migraine and wanted to eat in her room because it was not as loud or bright. Resident #11 stated she was upset because Nurse X was so rude about it. Resident #11 stated she had also asked the ADON to eat in her room. In an interview on 2/10/2023 7:55 AM, Nurse X stated she would prefer residents not eat in their room. Nurse X declined further interview and walked abruptly away from this surveyor and Resident #11. In an interview on 2/10/2023 at 7:56 AM, the ADON stated she was aware of the request, and did not know that Nurse X had refused Resident #11's request. The ADON stated she would find Resident #11's breakfast tray and take it to Resident 11's room immediately. The ADON stated some residents preferred to eat in the dining area, and it was unusual for Resident #11 to request to eat in her room. [The ADON honored the resident's request to eat in her room.] Observation and interview on 03/01/23 at 08:35 AM , Resident #11 was in room watching TV, cleaned and groomed, alert and oriented.; wheelchair present. The resident did not reveal signs or symptoms of sadness, fear, or anxiety (as a response to verbal abuse). The resident requested door be closed for the interview. Resident was eating her breakfast in the room. The Resident stated, .not that long ago (Nurse X) was rude to me .she said I could not eat in my room on 02/02/23 .I was upset she has always been rude to me .maybe she does not like me .she yells at me and laughs at me .yesterday (02/28/23) she laughed at me .as I struggled with my wheelchair .I complained in the past to the Administrator and he let me eat in my room .I'm not afraid of her I want her to be polite. Record review of Resident Council Minutes for the past 9 months ( June 2022 to March 2023) read: on 02/16/23: night staff needs better communications [In reference to Nurse X]. During an interview on 03/01/23 at 2:13 PM, the ADON stated Nurse X tried to get Resident #11 to eat in the dining room for socialization reasons. Resident #11's tray was in the dining hall and taken to the resident. The ADON was not aware of verbal abuse by Nurse X towards Resident #11. The ADON stated that Resident #11, Resident #27, and Resident #3 told her (ADON) of instances where Nurse X could come across being load. The ADON stated the instances were never recorded as grievances; and she recalled the said residents saying not wanting to file a grievance against Nurse X; but their denial (Resident #11, #27 and #3) was not documented as a grievance or investigated. Regarding the Resident Council minutes dated 08/22/23, the ADON recalled speaking to Nurse X about modulating her volume when speaking to residents. The ADON did not consider the minutes on the concern over communications to be a grievance only to be a concern to be discussed with Nurse X. ADON described Nurse X, as a phenomenal and an excellent nurse in providing nursing care. 2. Record review of quarterly MDS dated [DATE], revealed Resident #3 was a [AGE] year-old-male admitted [DATE] with the diagnosis of diffuse traumatic brain injury (widespread traumatic injury to the tissues of the brain, usually mechanical forces such as those that are present in high velocity road traffic accidents). The summary BIMS score of 14 was indicative of intact cognition. ADLs revealed: transfer and bed mobility required limited assistance with one person physical assistance and supervision with set-up for eating. Record review of Resident #3's face sheet dated, 03/01/23, revealed the RP was a family member. Record review of Resident #3's care plan dated 2/15/23 read, the Problem .Behavioral Symptoms . Approach .maintain calm environment .anticipate behavior and re-direct .ensure staff is aware of resident('s) behaviors and successful interventions. Record review of Resident #3's written statement on HHS form 4825-A, [dated 03/01/23] read, (Nurse X) does not speak what is not true [resident had communication and writing deficits during the interview]. Record review of Resident # 3's nurse notes from 01/01/23 to 03/01/23 authored by Nurse X revealed no negative behaviors by Resident #3 directed at Nurse X. Record review of Resident #3's email to a Family Member K dated 11/22/2021 read, [ .(Nurse X)] .called me 'crazy'. In an interview on 2/08/2023 at 1:46 PM, Resident #3 stated he would like to talk about something but was afraid he may get in trouble. Resident #3 stated Nurse X treated many people, including him, like mud. He stated every time he came to Nurse (X) for something, she made sure her back was turned toward him so she could quickly walk away from him. Resident #3 stated Nurse X would go into a different room, so he would not know where she was when he needed something. He stated she was nice to some residents and obviously had her favorites. Resident #3 stated Nurse X embarrassed him in the past when she said something about his mother after he asked her a question. Resident #3 stated Nurse X exclaimed, your momma wouldn't like you screaming like that. Resident #3 stated he does not like to be around Nurse X. Resident #3 stated he had mentioned it to staff, but they don't care what I say about Nurse [X] because they like Nurse [X]. Observation and interview on 03/01/23 at 9:02 AM , Resident #3 was in bed watching TV, cleaned and groomed, alert and oriented but with communication deficits. No signs of anxiety, sadness or fear. The Resident stated, .[Nurse X] treats me like mud .she wants to talk to other residents not me .I want her to become better .I complained to everybody [Administrator and DON] but nothing happens . During an interview on 03/02/23 at 3:14 PM, Family Member K stated: Nurse X had been extremely rude to the Family Member K and to Resident #3. Family Member K stated that [Nurse X] threatened to withhold (Resident #3's) medication or give him (Resident #3) extra medication to control (Resident #3). [Family Member did not report the allegation to facility management] Family Member K stated that about 6 months ago (November 2022), she told former Administrator O about Nurse X's verbal abuse and former Administrator O said he would check; but never informed Family Member K of any internal investigation outcomes. Family Member K stated they received numerous emails from (Resident #3) complaining about Nurse X's behavior. [Record review of email from Resident #3 dated 11/22/21 read Nurse X called Resident #3 crazy. Record review of email from Resident #3 dated 03/02/23 read [Nurse X ] lied. During an interview on 03/02/23 at 3:48 PM, former Administrator O stated, I do not remember a verbal complaint from a family member about six months ago involving Nurse (X) and a resident (Resident #3) . The former Administrator O the residents may have mis-interpreted Nurse X's tone [speaking loudly]. 3. Record review of the quarterly Minimum Data Set, dated dated dated [DATE] revealed Resident #36 was a [AGE] year-old male admitted [DATE]. Active diagnosis included hip fracture; cerebral palsy (impaired muscle coordination); moderate intellectual disabilities; Lack of coordination. Brief Interview for Mental Status score of 13 indicative of intact cognition. ADL for bed mobility and transfer was limited assistance with one person physical help; eating was supervision with set-up. Record review of Resident #36's care plan, dated 09/03/21 read, Problem .Behavioral Symptoms .Approach .Provide opportunities for expression of feelings related to situational stressor . Record review of Resident #36's written statement, transcribed by the Surveyor L, on 03/01/23 at 09:47 AM read, I do not feel comfortable with [Nurse X]. She yells at me and screams at people. She tells me to sit down in a loud voice. Get rid of her (Nurse X) Hire someone else. Record review of Resident # 36' nurse notes from 01/01/23 to 03/01/23 authored by Nurse X revealed no negative behaviors by Resident #36 directed at Nurse X. In an interview on 2/08/2023 at 11:53 AM Resident #36 stated Nurse X was frequently rude to him and other residents. Nurse X frequently yells and hollers. Resident #36 stated he did not like to ask Nurse X for assistance. Resident #36 stated, It doesn't do any good to complain about staff here when asked to whom he had reported his concerns. Observation and interview on 03/01/23 at 9:38 AM , Resident #36 was in his room sitting on a wheelchair listening to country music. The resident displayed no signs of distress, anxiety, fear or sadness. Resident #36 stated, Nurse X had the habit of yelling at him. He complained the Administrator and the DON about Nurse X's yelling but no changed occurred. 4. Record review of quarterly MDS dated [DATE] revealed Resident #27 was a [AGE] year-old female with an admitted [DATE] . Active diagnosis included cerebral palsy (impaired muscle movements); cellulitis (bacterial skin infection) of left and right lower limb; lymphedema (swelling); and lack of coordination. The BIMS summary score of 13 was indicative of intact cognition. ADLs revealed: bed mobility and transfer were limited assistance with one person physical assist; eating was supervision with set-up. Record review of Resident #27's care plan, dated 01/03/23 revealed that Resident #27 had to be approached in a calmed manner. Record review of Resident #27's written statement on Form 4827-A dated 3/1/27 at 10:19 AM read, [Nurse X] talks to us like we are babies Don't do this like a slap on the hand Take a lot of food from peoples plates to feed her cats. Record review of Resident # 27' nurse notes from 01/01/23 to 03/01/23 authored by Nurse X revealed no negative behaviors by resident directed at Nurse X. In an interview on 02/08/2023 at 3:23 PM, Resident #27 stated Nurse X was often rude to her. Resident #27 stated Nurse X frequently speaks to her in a harsh tone. Resident #27 stated it made her feel bad and Resident #27 wished she was not at this facility when spoken to in that manner. Resident #27 further stated [Nurse X] does not pay my bills, and I am not her child so she shouldn't speak to me like that! Resident #27 stated it made her feel bad and she would return to her room to cry when Nurse X spoke to her condescendingly. Resident #27 stated she had previously told other aides and the ADON that she did not like Nurse X, but Nurse X continued to act bossy over me. Observation and interview on 03/01/23 at 10:12 AM , Resident #27 was attending a church service; sitting on a wheelchair, alert and oriented. There were no signs of sadness, anxiety or fear . The Resident stated, she told the surveyor that Nurse X treated her like a child. Resident #27 added that she once cried after being treated as a child by Nurse X. Resident #27 complained to the Administrator about Nurse X's tone and behaviors but no actions were taken against Nurse X. Record review of Resident # 27's nurse notes from 01/01/23 to 03/01/23 authored by Nurse X revealed no negative behaviors by Resident#27 directed at Nurse X. In a group interview on 2/09/2023 at 9:30 AM, with the DON, the Regional Nurse, and the ADON, the ADON stated she did the facility staffing. She further revealed Nurse X was the only full-time nurse on staff, other than the DON. The ADON stated Nurse X worked 12 hour shifts 6:00 AM to 6:00 PM Monday through Saturday and Sundays off. When asked if she felt this was ok for RN to work this many hours, ADON stated, yes, she is one of our best nurses. She does just fine. When the DON was asked if she was aware of any issues or complaints concerning Nurse X being rude to residents, she replied No, that's just the way Nurse X talks to people. The DON stated Nurse X knew which residents needed a firmer approach. The DON stated that Nurse X really cared for the residents at the facility. When asked if the DON felt Nurse X was able to maintain a therapeutic relationship working that many hours each week she replied yes. The DON further explained that Nurse X had been offered more money to go to another facility but would not leave her people. In an interview on 2/10/2023 at 4:00 PM, Nurse X stated she was the primary (nurse) that worked Monday through Saturday 6:00 a.m. to 6:00 p.m. When asked if she knew what abuse and neglect of a resident was, she stated yes, this can be verbal or physical abuse like talking ugly to a person. She further revealed that staff including herself should speak respectfully to residents. She stated the facility had presented many in-services about abuse and neglect and she had attended several of them. When asked how she would feel if she was spoken to in an aggressive or disrespectful way she stated, I would not like that. When asked if she ever recalled speaking disrespectful or less than polite to a resident or family member, she stated no. During the interview, Nurse X was asked what the negative outcome would be if a resident was spoken to in a harmful or disrespectful manner. Nurse X revealed the resident could become agitated, frustrated, or even depressed. She said she felt it could hurt the resident mentally. When asked if residents are allowed to decline services, Nurse X stated yes, they do have the right. She stated they should be encouraged to proceed with the service if it benefits them. Nurse X further revealed she wanted all of her residents to get the services that they needed. She stated she felt that they needed to get out of their rooms and be social. When asked if the resident did not want to go out of their room and you were their nurse, what would you do. She stated, I would ask them questions like 'why do you not want to go?' and then go from there, meaning see what was wrong. During an interview on 03/01/23 at 10:59 AM, the facility physician stated: Nurse X was direct .and does not cuddle residents. The physician added this was the first time he heard about Nurse X possibly verbally abusing residents. Nurse X was described as a dedicated nurse that was sometimes misunderstood by residents because of her directness and need for a different bedside manner. The physician stated he never received any complaints of verbal abuse from residents or families about Nurse X when he visited the facility. During an interview on 03/01/23 at 2:43 PM, The DON stated: Nurse X was outstanding and you would not find a better nurse. The DON stated that Nurse X was sometimes firm with residents; meaning more direct but not abusive. The DON added that at staff meetings, administration addressed communications and speaking to a resident in a better tone. No resident filed a complaint about verbal abuse involving Nurse X or any other staff to the DON. No formal investigations were done or HHS was not contacted. I have verbally counseled [Nurse X about one month ago in February 2023, but did not document it as part of the disciplinary process. The QAPI monthly minutes, per DON, had not developed an action plan dealing with communication. Per the DON, Nurse X was allowed to continue to work after the survey entrance (02/07/23) until the present because she (DON) did not believe that verbal abuse was present perpetrated by Nurse X.[Procedure for allegation of abuse was to report to the Abuse Coordinator, document the allegation or grievance and investigate. The DON was made aware in the interview that four residents and a family member had alleged verbal abuse by Nurse X.] During an interview on 03/01/23 at 3:02 PM, the Administrator stated: he assumed the role of administrator on 01/16/23. He stated that there had been no documented grievances for the past 9 months involving verbal abuse or staff speaking loudly or rudely to residents. The Administrator was made aware of alleged rude tones by Nurse X by the Activity Director in the month of February 2023. The Administrator stated his response to the allegation of rudeness by Nurse X in February 2023 was: I am encouraging structure in meetings .I have visited with the residents and heard their concerns about rudeness .just information as I was transitioning not an official complaint .no actions plans have been developed and have not reported to HHS any verbal abuse by any staff or done any formal investigations. The Administrator stated that no action plan at the monthly QAPI meeting had been developed for communications. The Administrator stated that per abuse policy if there was an allegation of abuse the alleged perpetrator would be suspended pending an investigation. The Administrator stated, I did not suspend her (Nurse X) because rude tone did not rise to verbal abuse level requiring a suspension and a formal investigation .I read the minutes from the Resident Council meeting but did not see it as formal grievance . During an interview on 03/01/22 at 3:25 PM, Nurse X stated: she worked Monday to Saturday 6:00 AM to 6:00 PM. She received abuse training on 02/11/23 and the highlights of the training were: report abuse to the Administrator, keep residents safe, and not engage in any abuse. Verbal abuse was defined as belittling the resident and being disrespectful. Nurse X stated that a loud voice or tone is not abuse. For residents that cannot hear, Nurse X stated that 'sometimes you need to raise voice to be heard. Regarding Resident # 27, Nurse X stated: she might have spoken loud to Resident #27 but not in a rude manner. Nurse X there were no issues of communication between her/him and Resident #3 except Resident #3 had communication deficits. As for Resident #36, Nurse X stated there were no issues. Nurse X added that Resident #11 had a weight problem; but she (Nurse X denied ever laughing or belittling the resident. Nurse X stated she was not soft spoken and the residents might misunderstand her tone as abuse. Nurse X stated that the ADON spoke to her about her loud tone; and encouraged her to use a softer tone. Nurse X recalled that after the state visit (02/10/23) the DON spoke to her about her tone and that residents might misunderstand; and to speak softer. I have apologized to [Resident #3] around January (2023) because we could not understand each other . Nurse X concluded that she had not verbally abused any resident and denied her interactions with any resident constituted willful verbal abuse or rudeness. During an interview on 03/01/23 at 1:58 PM, Activity Director stated: regarding the Resident Council Minutes (February 2023) , communication involved the tone of staff at night; and the staff were loud. The Activity Director could not comment on the 08/11/22 and 06/09/22 minutes because she was not an employee at the facility. She attended training on abuse and neglect. She added, I told the Administrator and DON about the tone issue (raised at the February 2023 Resident Council Minutes in morning meeting around 02/17/23 and no new interventions were instituted .we just talked about having better communications . During an interview on 03/03/23 at 8:36 AM, Anonymous Party P stated they heard about allegations of verbal abuse involving Nurse X in January 2023 and conveyed the allegation to the DON. The DON did not contact Anonymous Party P with results involving any investigation of Nurse X. At a resident council meeting in February, Anonymous Party P heard allegations of verbal abuse by staff and Nurse X. The verbal abuse was not intentional by Nurse X, but she would come across as verbally abusing residents and not caring. Record review of Nurse X's training record revealed Nurse X attended Abuse/Neglect training on 02/23/23. Record review of facility's sign-in sheet on facility's Abuse and Neglect policy revised April 2013 revealed Nurse X signed the sheet. Record review of Nurse X's time card revealed she worked 6 days per week (Monday to Saturday) 06:00 AM to 6:00PM from 01/29/23 to 03/01/23. Record review of Nurse X's annual competency evaluation dated 09/01/2019 revealed she was rated as satisfactory for Knowledge of Abuse/Neglect Protocol; and Nurse X signed the evaluation on 09/01/2019. Record review of Nurse X's Skills checklist dated 01/03/23 read, the Role of Charge Nurse .Receives and gives pertinent care reports to .the DON .Documents and reports changes of condition and unusual occurrences to the MD, Family, and DON . Nurse X was rated as demonstrating said competencies on 01/03/23. Record review of facility's in-service sign in sheet for the training on Abuse & Neglect dated 02/23/23 revealed Nurse X attended the training and signed the attendance sheet. Record review of facility's Reporting Abuse to Facility Management revised February 2014 read, Abuse is defined as the willful infliction of injury, unreasonable confinement. intimidation, or punishment with resulting physical harm, pain or mental anguish . Further the said policy defined verbal abuse as .any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents . The policy further read, .The staff, with the physician's input (as needed), will investigate alleges occurrences of abuse and neglect to clarify what happened and identify possible causes. The Administrator was given the IJ template and was notified of the Immediate Jeopardy {IJ} on 03/01/23 at 6:45 PM; and a plan of removal was requested. On 03/02/23 at 4:45 PM, the facility's provided a plan of removal that was accepted. It was documented as follows: SURVEY TYPE: Annual Survey SURVEY DATE: 3/1/2023 Plan for REMOVAL Plan to remove immediate jeopardy. F600 Residents #3, 11, 27, and 36 were assessed by DON and support was provided as accepted, physician was notified of the alleged deficiency on 3/1/23. There were no new orders obtained. Affected residents' responsible parties were notified by DON and ADON of alleged deficiencies and plan of correction. On 3/1/2023 Administrator reported allegations of abuse to THHS and initiated investigation immediately. Nurse X was immediately suspended by DON and Administrator on 3/1/23. On 3/1/2023 the DON (director of nursing) and Administrator interviewed all residents in the facility to determine if any other residents experienced any psychosocial harm from verbal abuse from Nurse X or from any other staff. There was no concern identified. The interviews were completed before midnight on 3/1/2023. Ad-Hoc QAPI meeting was held on 3/1/2023, with the Medical Director, NHA (Nursing Home Administrator), RDO (Regional Director of Operations) and DON to review the alleged deficiencies, policy and procedure, and the plan for removal of immediacy. On 3/1/2023 the RDO completed 1:1 in-service on Abuse, grievances, and communication with Administrator, DON, and ADON. Starting on 3/1/2023, the facility leadership (Administrator, DON, and ADON) will complete education with all staff on Verbal Abuse, grievances process, and communication, to ensure that each resident receives the services consistent with the professional standards of practice, comprehensive person-centered care plan and the residents' goals and preferences. The training was initiated on 3/1/2023 and will be completed on 3/2/2023. Staff will not be allowed to work until they receive the training. The policy pertaining to Abuse and Grievances were reviewed on 3/1/2023 by the DON, NHA (Nursing Home Administrator) and Medical Director. Starting on 3/1/2023, IDT (Interdisciplinary team), including Administrator, DON, ADON, Activity Director, MDS Coordinator, HR, BOM) will meet with residents daily Monday to Friday, and Manager on Duty Saturday and Sunday to determine if any allegations of abuse or grievances toward staff members arise. The findings will be immediately brought up to Administrator for further action, if necessary. Grievances will be reviewed during morning meeting with Administrator and IDT team members for any follow up needed. All grievances will be entered into Grievance log by Administrator and investigation form will be filled out accordingly. On 3/2/2023 the RDO will start reviewing Grievance log and investigation forms weekly for four (4) weeks followed by monthly reviews after. 3/2/2023 RDO will provide physical oversight at facility weekly x4 weeks and then monthly reviews after. The DON/designee will monitor compliance by completing audit of ten (10) residents per week for four (4) weeks. This was initiated on 3/2/2023. Any identified concern will be addressed immediately and if trends and patterns are identified, the facility will conduct an Ad-Hoc QAPI meeting to discuss if additional interventions are needed to ensure compliance. The Administrator will be responsible to ensure this plan is completed on 3/2/2023. The RDO will provide oversight of DON and Administrators to ensure that the items on the plan of removal are reviewed and completed. Monitoring of the implementation of the POR: Plan to remove immediate jeopardy. Observation and interview on 03/02/23 at 2:57 PM, Resident #3 was in his room listening to music waiting for his smoke break. The resident stated he had no fears, did not feel anxious, was not sad, and felt happy. The resident had no complaints to make to the surveyor. Observation and interview on 03/03/23 at 11:14 AM, Resident #36 was in his room listening to music sitting on a wheelchair . The resident revealed no signs or symptoms of anger, fear, anxiety or sadness. The resident stated he felt happy because she is not here (Nurse X). The resident denied any other abuse by staff and would report any verbal abuse to the nursing staff. During an observation and interview on 03/03/23 at 11:21 AM, Resident # 27 was wondering the hallways sitting on her wheelchair. The resident revealed no signs or symptoms of anger, fear, anxiety or sadness. The resident smiled and stated ,I am happy and feel safe that Nurse (X) is not here. The resident added no other staff have verbally abused her and she would report abuse to the administrator and nursing staff. During an observation and interview on 03/03/23 at 11:28 AM, Resident #11 was in bed watching TV. The resident revealed no signs or symptoms of anger, fear, anxiety or sadness. The resident smiled and stated, I feel good that she (Nurse X) is not here and something had to be done. The resident added that there has been no other verbal abuse by other staff and she felt safe. During an observation and interview on 03/03/23 at 11:33 AM, Resident #3 was in his room. The resident revealed no signs or symptoms of anger, fear, anxiety or sadness. The resident stated, I feel good she is not here .staff needs to be kind to everyone .she was mean and never said anything nice . The resident responded that he felt safe. If abused occurred again the resident stated he would tell (a family member). Record review of facility's self report to HHS on 03/02/23 revealed HHS assigned the intake numbers. During an interview on 03/03/23 at 10:55 AM, the Administrator stated, with approval from his corporate headquarters his intention was to terminate Nurse (X). Record review of facility's interview of 67 residents on 03/01/23 revealed checklists were completed for 67 residents; and no resident made any new allegations of abuse to include verbal abuse. Record review of facility's Ad-Hoc QAPI meeting held on 3/1/2023 revealed signatures for Medical Director, NHA (Nursing Home Administrator), RDO (Regional Director of Operations) and DON. During an interview on 03/02/23 at 5:07 PM, the RDO stated: the highlights of the training were: administrative staff to be familiar with reporting guidelines, verbal abuse, and all abuse. During a Joint interview on 03/02/23 at 5:10 PM with Admin, DON, and ADON, the DON stated: the highlight of the training was to report verbal abuse and any suspected abuse. The ADON added: the highlight to report and investigate all abuse. The Administrator: the main highlight was to report alleged or suspect abuse; and to adhere to the reporting guidelines. Record review of facility's in-service on 03/02/23 on the topic of Process for reporting abuse/Neglect revealed 46 paid employees signed the sign-in sheet, 100% completion rate. [total paid staff on 03/2/23 was 46] Record review of facility's in-service on 03/01/23 on the topic of Abuse/Neglect-Verbal Abuse revealed 45 paid employees signed the sign-in sheet, 98% completion rate. [total paid staff on 03/2/23 was 46; Nurse X was suspended and did not attend the training] 1.During an interview on 03/02/23 at 10:12 AM, LVN M stated: LVN M received training on Abuse/Neglect on 02/11/ [TRUNCATED]

Based on observation, interview and record review the facility failed to ensure the resident environment remained free of accident hazards as is possible and that each resident received adequate supervision to prevent accidents for 2 of 22 Residents (Resident #10 and Resident #65) reviewed for accidents and supervision. There was not adequate supervision for Residents #65 who had a history of wandering and was at risk for elopement and there were inadequate interventions in place while the facility's exit door to the women's secured unit did not function properly. The facility failed to repair or replace the exit door in the women's secured unit and to provide the necessary supervision to prevent Resident #65 from eloping from the secured unit. An Immediate Jeopardy (IJ) was identified on 11/10/21. While the IJ was removed on 11/12/21, the facility remained out of compliance at no actual harm with potential for more than minimal harm that was not an immediate jeopardy and a scope was a pattern while they continued to monitor their Plan of Removal. These deficient practices could place residents at risk for avoidable avoidable incidents and injury. The findings were: Review of a facility policy, Safety and Supervision of Residents revised December 2007 read in part as follows: Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Facility-Oriented Approach to Safety. 1. Our facility-oriented approach to safety addresses risk for groups of residents. 2. Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring,, and reporting processes; QA&A reviews of safety and incident/accident reports; and a facility-wide commitment to safety at all levels of the organization. 3. When accident hazards are identified, the QA & A/Safety Committee shall evaluate and analyze the causes(s) of the hazards and developer strategies to mitigate or remove the hazards to the extent possible. 4. Employees shall be trained and inserviced on potential accident hazards and how to identify and report accident hazards and try to prevent avoidable accidents. 5. The QA&A Committee and staff hall monitor intervention to mitigate accident hazards inn the facility and modify as necessary. Systems Approach to Safety. 1. The facility-oriented and resident-oriented approaches to safety are used together to implement a systems approach to safety, which considers the hazards identified inn the environment and individual resident risk factors, and then adjusts interventions accordingly. 2. Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individuals resident's assessed needs and identified hazards in the environment. 3. The type and frequency of resident supervision may vary among residents and over time for the same resident. For example, resident supervision may need to be increased when there are temporary hazards in the environment (such as construction) or if their is a change in the resident's condition. Resident Risks and Environment hazards: 1. Due to their complexity and scope, certain resident risk factors and environmental hazards are addressed in dedicated policies and procedures. These risk factors and environmental hazards include: e. unsafe wandering. Review of a work order from a local fire and safety company dated 9/13/21 revealed they checked secure unit doors. Review of notes revealed A hall left side hall door into secure unit was unlocking when force applied to door from inside the unit adjusted armature and tested hard locked. No comments were noted. Review of Resident #65's face sheet, dated 11/12/21 revealed she was admitted to the facility on [DATE] with diagnoses which included [CONDITION(S)] (disorder of the central nervous system that affects movement, including tremors), Type 2 diabetes mellitus with diabetic polyneuropathy, Alzheimer's disease, unspecified, [CONDITION(S)] disorder, [CONDITION(S)] type, Major depressive disorder, recurrent, unspecified and Generalized anxiety disorder, Review of Resident #65's admission MDS, dated [DATE], revealed her BIMS was 2 indicating severe cognitive impairment; she exhibited verbally and physically aggressive towards others; wandered; had a fall since her admission and was receiving anti-depressant, anti-anxiety and anti-psychotic medications. Review of Resident #65's Care Plan, dated 10/25/21, revealed Resident resided in secure unit and was at risk for injury from wandering in an unsafe environment related to impaired safety awareness. One of the Interventions included included to keep environment free from possible hazards. Further review revealed the CP was updated on 11/3/21 after Resident #65 was identified as potential/ high risk for injury related to identified elopement risk factors and or exit seeking behavior. One of the interventions included to supervise the Resident closely and make regular compliance rounds whenever resident is in room. Review of an event report dated 11/1/21 revealed that Resident #65 was found by local police down the street. It was noted that Resident #65 had been repeatedly opening doors/setting off alarms of secured doors; resisting redirection, wandering with no rational purpose and attempting to open doors. Her mental status was noted as confused and restless; possible contributing factors were Dementia, Psychiatric Diagnosis of [CONDITION(S)]. Further review revealed Resident #65 was taken to the ER. Review of Provider Investigation Report dated 11/5/21 revealed that on 11/1/21 at 1:02 PM the facility received a phone call from local police department that Resident #65 was across the street at a nearby restaurant. The DON went across the street to meet with local police department and Resident #65. The DON observed Resident #65 to have a scrape to her right knee. Resident #65 was taken to the ER and returned to the facility on the same date and had a bandage to her right knee as a result of a fall during her elopement. Further review revealed after investigation staff last saw Resident #65 in the TV room about 12:30 PM. The facility believed Resident #65 opened the window to her room, removed the screen, went out the window, replaced the screen and walked about 50 yards from the facility and was found at a nearby restaurant. Review of the time sheets for the CNA's from 11/1/21 to 11/10/21 revealed that the following aides working the women's secured unit: 11/1/21, CNA L was the only aide working from 6 AM to 6 PM. The Housekeeping Supervisor was added to the schedule as floating because she was a CNA as well. On 11/2/21 CNA G was the only aide assigned to the unit from 6 AM to 6 PM. Management was also added as floating. CNA O was the only aide working the night shift 6 PM to 6 AM. On 11/3/21 revealed CNA G worked alone in the unit from 6 AM to 11:30 AM until CNA P reported to work. On 11/4/21 CNA O was the only staff working the unit from 6 PM to 6 AM. On 11/9/21 CNA O was the only staff working the unit from 6 PM to 6 AM. On 11/10/21 CNA G and CNA Q were assigned to work from 6 AM to 6 PM. CNA Q had not submitted her time sheet for verification as of 11/12/21 at 6 PM. Observation on 11/8/21 at 9:35 AM revealed the nurse's station for the women's secured unit was located outside the unit. Upon entering the secured unit, CNA G was the only staff in the women's unit. Further observation revealed CNA G entered the shower room with a resident. CNA G remained in the shower with the resident about 5 minutes. CNA G then escorted a 2nd resident into the shower room and where she remained for 6 minutes. Observation on 11/8/21 at 9:40 AM revealed six residents in the TV room; three residents were asleep and two other residents were sitting in their wheelchairs in the hallway. Interview on 11/8/21 at 9:47 AM with CNA G confirmed she was the only staff on duty at the time. She stated CNA L was on break. CNA G confirmed she toileted two residents in the main shower room and that she was unable to supervise the other residents in the unit while assisting residents in the bathroom. CNA G stated she often worked alone in the unit and and it was impossible to provide care and supervise the remaining residents at the same time. CNA G stated that the nurse's would come into the unit to pass out medications but would then leave the unit again. She stated she did not get support from anyone else. Observation on 11/8/21 at 9:56 AM revealed CNA L returned from break and entered the women's secured unit. Interview on 11/8/21 at 10:15 AM with CNA L revealed she worked when Resident #65 eloped. She stated she was working alone in the unit and providing pericare for another resident in the shower room. She stated she heard the alarm but could not leave the resident because the resident was full of feces. CNA L stated the alarm sounded for about 15 to 20 minutes. When she stepped out of the shower room she saw LVN N running down the hall. CNA L stated she saw the back door was opened and when she went outside she saw a blue A frame ladder by the fence right outside the women's unit. She stated she walked the inside parameter of the courtyard and did not see any broken slats and then checked the 2 gates and they were both locked. CNA L stated she heard Resident #65 was across the street at a restaurant. She stated the problem was that the back door did not close properly and would open on it's own. CNA L pushed out on the door and showed how the door remained open (ajar) and did not return to the closed position. The 3 second warning alarm sounded, after 3 seconds it activated the 15 second alarm and it released the door. CNA L stated there were a few residents including Resident #65 who would often push on the door. She stated she often worked alone and if she was busy with another resident she would not be able to get to the alarm fast enough and the resident could get out. CNA L stated the charge nurses were also supposed to respond to the alarm but would not always respond. CNA L stated she was agency and she had been working the door had been a problem. She stated nursing staff was aware the door did not close properly. Review of a picture sent to Surveyor's work cell phone on 11/10/21 at 6:12 PM revealed a blue 5 or 6 foot A frame aluminum ladder in the open position located by the fence on the right side exiting the door. Interview on 11/09/21 at 9:37 AM with Resident #65 revealed she did not remember leaving the facility. Resident #65 repeatedly stated she did not know when asked about her leaving the unit, the facility or walking across the street. Resident #65 was not interviewable. Interview on 11/10/21 at 8:35 AM with the MS revealed he had been in his position for about 4 weeks and with the company for about 1 year. He stated the back door to both the women's and men's unit were warped. He stated they were mag doors and there was too much spacing between the magnet components. The door would not stay locked/latched when there was any movement (wind blows) or when a resident pushed on the door it would open. The MS stated any movement or push would activate the 3 sec alarm and then then the 15 sec egress alarm opened the door. The MS stated a fire and safety company went out to the facility 2 to 3 weeks prior. They recommended the facility replace the door because they had adjusted the mag hardware as much as they could by bringing the mag hardware as close together as possible. The MS stated the closer the mag hardware was the greater the magnetic pull which was kept the door closed. The MS stated staff told him that the residents often triggered the alarm and that the door would open. He stated that there was nothing that he could do and stated staff was supposed to respond to the alarm making sure the residents did not get out. The MS confirmed this would be difficult if there was only one aide working the women's unit. Observation on 11/10/21 at 8:45 AM of the courtyard enclosing the back of the women's and men's unit revealed a table base with a table top that was detached from the base located right outside the women's unit by the door. Interview with the MS at this same time revealed he did not know who put the table base and table top outside and did not know how long it had been outside. Further observation revealed the fence pickets were all in intact and the gates were locked and secured. Observation outside the fence parameter revealed the women's unit backed up to a walking trail. The walking trail was enclosed with trees, tall grass and rock terrain. Further interview with the MS revealed the walking trail lead to the restaurant across an intersection where Resident #65 was located. The distance from the back door of the women's unit to the restaurant across the street was approximately 1/4 mile. Resident #65 had to cross a 3 lane lane busy intersection. The MS stated he was not involved in the investigation related to Resident #65's and did not know anything or anyone saying anything about a ladder located in the courtyard. The MS stated the facility would be renovating the women's secured unit and they would be replacing the door at that time but stated it was still in the planning phase. In the mean time, he stated there was not a contingency plan other than the assigned aide or aides would have to respond to the alarm to ensure residents did not get out. The MS again stated it would be difficult for one aide to provide care and the necessary supervision for the other residents. Interview on 11/10/21 at 9:19 AM with LVN K revealed she was the charge nurse from 6 AM to 2 PM Monday through Friday for the women's secured unit. LVN K stated she was not on duty when Resident #65 eloped. She stated staff suspected that Resident #65 got out through a window although she stated the windows did not open more than about 6 inches. LVN K confirmed that the back door did not work properly. She stated staff had to pull on the back door to close it and then enter the code to lock it. LVN K stated the door would open on windy days or if a resident pushed on the door. She stated the alarm would sound and if it was quiet she could hear it from the nurse's station. LVN K stated she and the aides on the unit would use their personal cell phones to communicate or one of the aides would holler from the door. LVN K stated two CNA's usually worked the unit but there were times when only 1 CNA worked the unit. She stated they would try to get a second aid and if not she would help as much as possible. Although, she stated she was the charge nurse for the women's and men's unit. Observation on 11/10/21 at 9:50 AM revealed LSC Surveyor and the MS were testing the exit door in the women's unit for functionality. LSC Surveyor demonstrated the egress component on the door worked properly meaning, when the release bar was pushed out or any part of the door was pushed out it activated the 3 second warning alarm. The 15 second alarm followed and then the door was released and opened. LSC Surveyor stated the problem was the door was warped so when the door was pushed out, if a resident leaned on it, if the wind caused movement, the door would get stuck and would remain ajar instead of returning to the closed position once the pressure when pushing on it was released. He stated the 3 second alarm would shut off when pressure was released, the door would return to the closed position and it would remain locked. He stated, in this case, because the door remained ajar, it automatically activated the 3 second alarm and then the 15 second alarm to release the door. The LSC Surveyor stated if staff was not available or did not immediately respond to the alarm sounding residents would be able to exit the door. Interview with the MS at this same time confirmed these findings. Observation on 11/10/21 at 10:32 AM revealed two yellow barrels, an orange ladder and a blue ladder located right outside the main dining room. Interview on 11/10/21 at 10:42 AM with LVN N revealed he was the charge nurse over the women's and men's unit when Resident #65 eloped from the facility. He stated he had been back and forth between the men's and women's unit during lunch and he last saw Resident #65 about 12:30 PM. She had finished eating her lunch. LVN N stated he was sitting at the nurse's station located outside the women's unit and the ADON told him she thought the alarm to the exit door to the women's unit was sounding. He stated the sound of the alarm from the nurse's station was faint. He stated he went to check the unit and noticed the back door was opened. He went outside and saw a ladder right outside the women's unit. It was propped up against the fence and thought it was green in color. LVN N stated he checked the parameters of the inside of the courtyard and did not see any broken fence pickets and made sure the doors were secured. He stated he went back to the nurse's station and found out that local police department notified the DON and reported they possibly had one of their resident's; Resident #65. The police were with Resident #65 across the street at a local restaurant. He stated Resident #65 had to cross a busy intersection to get to the restaurant. LVN N stated he returned to the unit, completed a head count and confirmed Resident #65 was not in the unit. LVN N stated he and CNA L were the only staff working the women's unit and stated there was usually only one aide assigned to the unit. He stated he would make routine rounds about every 2 hours or so and believed one aide could manage the unit unless the aide was busy with a resident providing care. Then she would not be able to supervise the other residents. LVN N also confirmed the back door was not working properly and Resident #65 and at least 2 other residents would often push on the back door activating the alarm. He re-iterated the problem they had with the exit door as reported by CNA L and stated all administrative staff was aware the door was not working properly. LVN N stated Resident #65 was in the last room on the left side by the exit door. He stated other staff reported Resident #65 had tried getting out before through a window. She had torn the screen. LVN N stated the problem with the back door not working made it challenging for the staff to work the unit. Interview on 11/10/21 at 11:37 AM with the DON confirmed the events provided in the Provider Investigation Report related to Resident #65's elopement. The DON stated they speculated Resident #65 got out through a window because staff reported Resident #65 had previously torn or cut the screen to another room and staff believed Resident #65 wanted to get out. In reviewing progress notes the DON confirmed that staff had not documented on this incident. The DON confirmed local police called her about 1:02 PM on the date of the incident and reported they possibly had one of their residents at a restaurant across the street. The DON stated she met the police and confirmed it was Resident #65. She noted Resident #65 had a superficial scrape to her right knee and did not seem to have any other injuries but was taken to the local ER for evaluation. The DON stated Resident #65 returned to the facility from the ER later that afternoon and no other injuries were noted. The DON stated she and the ADM walked the parameter of the inside of the courtyard and did not see anything propped up against the fence, any broken fence pickets and stated the gates were secured/locked. She stated they could not figure out how Resident #65 got out other than through a window. The DON confirmed the exit door to the women's unit was not working properly and reiterated what all other staff had reported including that a gust of wind would open the door. The DON stated they had a couple of companies look at the door within the last several months but did not know the outcome. She stated the MS had been in charge of that and she did not ask him about any recommendations if any had been made about fixing the exit door. The DON stated she started working for the facility since March 2021 and the doors had been a problem since that time. She further stated the windows in the women's unit only opened about 6 inches and they had been like that the entire time she worked. They had the MS ensure that all windows were secured with a screw only allowing the window to open about 6 inches. She stated since Resident #65's elopement their contingency plan to ensure the residents did not elope from the women's unit. was to assign two aides to the women's unit during the day so they could monitor the back door and provide the supervision as needed. The DON stated that one other resident had got out through the exit door into the courtyard but staff redirected the resident inside. She stated no other residents had eloped from the unit. Interview on 11/10/12 at 12:01 PM with the ADM confirmed the exit door to the women's unit was warped but stated the egress door worked properly. He stated the door only opened when someone continuously pushed on the handle for 15 seconds. The ADM stated they speculated Resident #65 got out through a window because she had previously poked or cut a hole through a window screen and then opened the window in another resident's room. He stated he met with department heads after Resident #65's elopement and they could not figure out how else she could have got out. The ADM stated he had the MS secure all windows in the unit adding a screw on the frame which only allowed the window to open about 6 inches. The ADM stated he had a company come out on 9/13/21 and they adjusted the mag locks on the door as much as possible. He stated they planned to renovate the women's unit and would be replacing the door at that time. He stated the Corporate engineer was in the process of securing contractors for the job. Interview on 11/10/12 at 12:25 PM with the ADM revealed he checked the exit door to the women's secured unit for functionality. He confirmed the egress alarm was activated without continuously pushing out on the handle. He stated when he pushed on the door it did not return to the closed position because the door was warped and the door remained ajar. The ADM confirmed the egress door would release and open and stated it posed a threat for the residents because they could exit the door if staff did not respond to the alarm on a timely basis. Interview on 11/10/21 at 2:45 PM with the DON revealed all 15 residents in the women's unit were in the unit because they were wanderers and an elopement risk. Interview on 11/10/21 at 2:46 PM with the ADM revealed they had cameras in the women's unit but stated he did not know how long it recorded. He stated he had looked at the footage because he would have to have an approximate time for the date he was searching. The ADM confirmed the last time staff saw Resident #65 on 11/1/21 in the unit was approximately 12:30 PM and the local police called the DON about 1:02 PM. The ADM stated he would review the footage and would get back with Surveyor. The ADM never returned with any information before exit on 11/12/21. Interview on 11/10/21 at 6:16 PM with LVN N revealed on 11/1/21 he, the ADM, the DON and the MS walked the women's secured unit after Resident #65 eloped. He stated he showed them the exit door was opened and the ladder was located right outside the women's unit propped up by the fence. LVN N stated he took a picture and clarified that the ladder was blue and not green. LVN N stated he did not know why staff speculated that Resident #65 got out through a window because the windows only opened up about 6 inches. LVN N stated there was no way Resident #65 would fit through an opening that size. Interview on 11/10/21 at 2:47 PM with Resident #23 (who was located about 4 to 5 rooms away from the back door) revealed the alarm on the exit door in the women's secured unit went off all the time and the staff would slam it shut. Resident #23 stated sometimes the alarm would go off and staff was not available to respond to it right away. She stated there were 2 or 3 residents that would often push on the door. She stated she had seen two residents exiting the unit into the courtyard but staff was able to redirect them back into the unit. Resident #23 stated the alarm would go off and then the door would open so if staff was not available then the residents could walk out of the unit. Interview on 11/12/21 at 5:05 p.m. with the ADM revealed the issue with the door had been addressed during QAPI meetings since November 2020. He stated they identified the exit doors to the women's and men's unit were warped and it affected their functionality. The ADM stated the exit doors had become warped over time by the weather; rain and wind. The ADM stated they had a plan to fix the doors as of July 2020 but it was placed on hold after the onset of the COVID pandemic. An IJ was identified on 11/10/21 at 5:09 PM per the above findings. The ADM, the DON, and the Corporate Nurse were provided with a copy of the IJ Template and a Plan of Removal was requested. Review of the Plan of Removal, dated 11/12/21, revealed: Immediate Action Residents #65 is safely residing in the facility female locked and secured unit. Resident #65 was taken to the emergency room after the incident to make sure she had no injuries requiring treatment and returned shortly thereafter without further incidence. Resident #65 and both the male and female secured units had their elopement assessments completed in the month of October 2021, all were identified to have wandering/exit seeking behaviors and a diagnosis of dementia. Resident #65's elopement assessment was again completed on 11/10/21 and no changes were identified. The doors exiting the secured unit into the courtyard were checked by HHSC Life Safety Surveyor and facility contract engineer technician at 2:00 PM on 11/10/2021 and the door was found to be functioning properly. Contract Fire Technician from Total Fire and Safety came to the facility at 7:30 PM on 11/10/2 and checked all secured unit doors and documented they were all functioning correctly. Staff was posted at the exit door on the women ' s secured unit until the door was checked and cleared by Total Fire and Safety. The staff monitoring the door has the responsibility to monitor those residents do not exit the door unseen until Total Fire and Safety can clear as functioning properly. Staff education, directed to all staff was started by the Director of Nursing on 11/10/21 with 95% completion as of 11/11/21 at 5:00 PM. There are three (3) staff that will require the education and they will receive it tonight 11/11/21, this will conclude all that work on the secured units. The POR/education will pertain to both the female and male units. All staff need to understand the process if an alarm on the secured unit is sounding. Staff not attending the initial education will be required to receive it before starting their next assigned shift. The expected completion date for this education is 11/13/21 by 11:00 PM. It is the charge nurse ' s responsibility to immediately go onto the secured unit to investigate any sounding alarm. The outside courtyard area will then be swept to identify if a resident is present. If no resident is found, a head count will be done by the charge nurse to validate all residents are accounted for. If a resident is missing, the outside area will be swept to see if the resident is found and the administrator will be immediately notified. A facility created log will be completed by the charge nurse to check that all aspects of the sweep have been completed. The administrator will review logs for completion in the morning and discuss in the morning interdisciplinary team meeting. This is an enduring plan. The logs will be brought to the monthly quality assurance performance improvement meeting for tracking, trending, and further interdisciplinary team recommendations. The log information contains; the date and time of the alarm sounding, the sweep of the courtyard, the head count to identify all residents are accounted for, the notification of the administrator. Continued Compliance and Monitoring: The facility will staff the male and female secured unit with (2) two staff members. If a staff member calls in/off, the director of nursing/designee will evaluate the needs for staffing and that adequate staff is in place on the secured units to meet the needs of the residents If staff is needed then the administrator will assign oversight assistance from the interdisciplinary staff. The Director of Nursing/designee will be responsible for reviewing staffing sheets every day to validate that adequate staffing is in place based on the needs of the secured unit. Any concerns will be reported to the administrator for further interventions. The maintenance director/designee will monitor the secured unit courtyards daily to identify any concerns with the gates or equipment left in that area. Any concerns will be immediately reported to the Administrator. The administrator will monitor the facility alarm log for completion after any report of the alarm sounding on the secured unit. Any concerns will be corrected immediately and brought to the attention of the Regional Director of Operations. Concerns will be brought to the monthly Quality Assurance Performance Improvement meeting for tracking, trending, and further interdisciplinary team recommendations. The verification of the facility's Plan of Removal revealed: Review of the Alarm Log revealed 4 entries between 11/10/21 to 11/11/21. Review of work order acknowledgement from a local fire and safety company dated 11/10/21 revealed: checked and tested both secure unit door locks both locks function properly. Each lock was tested for egress. Both release in 15 seconds. Gates are not egress locks and both of them are functioning properly. Review of Report of Employee Education on Elopement dated 11/10/21 revealed 49 staff signatures. Review of In-service dated 11/12/21 for breaks for secured unit/coverage revealed 13 staff signatures. Review of email dated 11/12/21 from AC Doors Specialties revealed they will take dimensions on the doors and provide a price on Monday, 11/15/21. Review of elopement assessments for residents in the women's secured unit revealed all 15 residents were wanderers and an elopement risk. In an interview on 11/12/2021 09:43 am with Housekeeping supervisor, she stated she was in-serviced in the last 24-hours on fire and elopement alarms and what her role and responsibility would be in those situations. She stated that when an alarm sounds, she was to surveil the area to ensure any resident attempting elopement was redirected back to the correct area. If there were no residents in the area she was to report to the area where the elopement alarm was sounding to assist with conducting head count procedures. She stated she was also a certified nurse aide (CNA). In an interview on 11/12/2021 09:46 am with RN B, she stated she was in-serviced in the last 24-hours on fire and elopement alarms and what her role and responsibility would be in those situations. She stated that when an alarm sounded, she was to surveil the area to ensure any resident attempting elopement was redirected back to the correct area. If there were no residents in the area she was to report to determine if any resident was missing based on the reported head count. If the head count indicated a resident was missing, an exterior search would be initiated, the DON, administrator and the local police depart would be notified. In an interview on 11/12/2021 09:47 am Assistant Business Office Manager, she stated she was in on the same in-servicing. She stated her task was to surveil her area to ensure any resident attempting elopement was redirected back to the correct area. If there were no residents in the area, she was to report to the nurses' station for further instructio [TRUNCATED]