**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and review of the policy titled Abuse Prohibition Policy and Procedures, the facility failed to ensure that four of 19 sampled residents (R) (R8, R14, R17, and R18) were free from physical, verbal, and sexual abuse. The allegations of abuse are identified to have been committed by R3, R5, and a Contracted Facility Staff. On 12/5/2023, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Administrator, Regional Administrator (RA), Director of Nursing (DON) and Regional Nurse Consultant (RNC) were informed of two Immediate Jeopardy's (IJ) on 12/5/2023 at 3:45 pm. The noncompliance related to the first Immediate Jeopardy was identified to have existed on 7/5/2022 when the facility failed to protect four residents (R) (R8, R14, R17 and R18) from physical, verbal, and sexual abuse. A Credible Allegation of Compliance was received on 12/13/2023. Based on observations, record review, resident and staff interviews, and review of facility policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed as of 12/14/2023. Findings include: Review of the facility policy titled Abuse Prohibition Policy and Procedures revised January 2017 revealed the facility believes that each resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. The purpose of these identified procedures is to assure that we are doing all that is within our control to create a standard of intolerance and to prevent any occurrences of any form of mistreatment, neglect, abuse, or misappropriation of any resident and/or their property. The procedures herein establish standards and practices for screening and training employees, protection of residents and for prevention, identification, investigation and reporting of abuse, neglect, mistreatment, and misappropriation of property. 1. Review of the clinical record revealed R3 was admitted to the facility on [DATE] with diagnoses including Alzheimer's dementia, hypertensive heart disease, and atrial fibrillation (A-fib). Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed R3 presented with a Brief Interview of Mental (BIMS) score of 12, indicating moderate cognitive impairment. 2. Review of the clinical record revealed R5 was admitted to the facility on [DATE] with diagnoses including hypertension, diabetes, and dementia. Review of the quarterly MDS assessment dated [DATE] revealed R5 presented with a BIMS score of 99, indicating severe cognitive impairment. Review of the electronic medical records (EMR) revealed documentation of 13 allegations of potential physical, sexual, and verbal abuse as follows: 1. Progress Note dated 7/5/2022 at 5:52 pm documented that R5 speaking loudly in his room. I enter room and he is standing over his roommate (R18) yelling cuss words and shaking his fist in the direction of the resident. I entered the room and tried to get between the two residents. 2. Progress Note dated 10/24/2022 documented an allegation of physical abuse in which R3 grabbed R8's arm and pushed her into the nurses' station. The note indicated the action had caused R8 to hit the right side of her body against the nurses' station. 3. Progress Note dated 11/5/2022 documented R3 had to be constantly redirected from going into other residents' rooms. The notes documented R3 had become combative towards the staff and other residents. 4. Progress Note dated 11/14/2022 documented several witnesses observed R3 approach a defenseless female resident and without provocation, grabbed the female resident by the head and shook her head around. The female resident was in a geriatric chair, with her eyes closed, before R3 had grabbed her. R3 let go of the female resident when he was confronted by the staff. 5. Progress Note dated 11/27/2022 documented R3 entered another resident's room (R8) and tried to take her belongings. The CNA tried to redirect R3, but he hit the CNA in the face. The nurse escorted R3 out of R8's room and administered a PRN (as needed) medication. 6. Progress Note dated 11/29/2022 at 1:48 pm documented that R5 entered (R8) room, walked up to the bed, and (R8) told him to leave. He then grabbed her wrist pushing on her. 7. Progress Note dated 12/1/2022 at 2:23 am documented that R5 was observed in another residents room (R18), and both residents were hollering at each other - was able to redirect R5 back to his room and back to bed. 8. Progress Note dated 1/6/2023 at 12:10 am documented that R5 wandered into (R8) room - heard residents in the room hollering out, and when staff entered the room, noted R5 and female resident (R8) holding each other's hands tugging on each other - was able to redirect R5 with much encouragement back to his room but he was very agitated and cursing. 9. Progress Note dated 7/2/2023 at 1:58 am documented that on 7/1/2023 at 10:20 pm, R5 was up in his room when CNA entered the room, she noted R5 holding roommate (R17) leg while his roommate (R17) was in bed sleeping. 10. Review of the Progress Note dated 7/2/2023 at 6:47 am documented that R5 was observed in the bed with his roommate (R17). R5 had taken off all his clothes and threw his adult brief in the doorway. 11. Review of the Progress Note dated 7/16/2023 at 6:40 am revealed that R5 became very agitated and was fighting/slapping/cursing at staff while providing activities of daily living (ADL) care. He kicked one staff member in the abdomen. Staff left the room and approximately five minutes later, R5 was observed hitting his roommate (R17) in the face and arm with his bedroom shoe. R17 removed from room for his safety. 12. Review of the Progress Note dated 9/22/2023 at 2:47 pm documented that R5 slapped the other resident (R14) and pulled her hair. The other resident scratched at R5 and then the two were separated. Interview on 11/28/2023 at 3:53 pm, the Administrator acknowledged that If I didn't know about it, I didn't do an investigation in reference to the physical, sexual, and verbal abuse allegations that have been documented in the EMR. Interview on 11/29/2023 at 9:07 am, CNA EE stated R3 and R5 had a history of hitting other residents and would become combative when their medications wore off. CNA EE stated the staff had tried to keep both residents from hitting and/or becoming combative with other residents, but it had been difficult. During further interview, she stated everyone working at the facility knew R3 and R5 had been combative and had tendencies to hit other residents and staff. She stated she had reported aggressive behaviors, at different times, to three different nurses: LPN AA, LPN BB and LPN GG. 13. Review of a Police Report dated 11/13/2023 documented an allegation of sexual abuse which R8 reported was perpetrated by a Contracted Facility Staff. R8 alleged the Contracted Male Therapist asked her if she had ever had sexual relations with a man before. She stated that on another day he had offered to give her a back massage after she had complained about her back to him. R8 stated that while rubbing her back the perpetrator's hand traveled inside her buttock cheeks and near her anus. R8 indicated the Contract Male Therapist was constantly staring at her and adjusting his penis from outside his pants. She claimed the incident happened three - or - four weeks ago. The alleged sexual abuse allegation was not investigated. Review of R8's EMR revealed no documentation of the allegation of abuse by the Contracted Facility Staff. Interview on 11/29/2023 at 12:15 pm with R8, stated a Physical Therapist had touched her inappropriately during a therapy session. Interview on 11/29/2023 at 12:54 pm with the police officer, he reiterated his statement of the 11/13/2023 police report. Interview on 11/29/2023 at 1:03 p.m., the Administrator revealed that the Business Office Manager accompanied R8 to the Administrators office regarding the alleged sexual abuse by the Contracted Physical Therapist. When asked what the Administrator did with this information, the Administrator did not provide a response. Interview on 11/29/2023 at 1:30 pm, the Administrator confirmed that she did not report or investigate the allegation of sexual abuse between R8 and the Contracted Facility Staff to the State Agency (SA). Review of the facility document titled State Reportable Incident Log revealed that none of the allegations of physical, sexual, and verbal abuse were identified by the facility as a reportable offense to the State Agency. Interview on 11/29/2023 at 1:30 pm the Administrator/Abuse Coordinator confirmed that the allegations identified in the EMR progress notes were not reported or investigated. The Administrator's response to each identified entry was, I don't have that and that wasn't reported to me. The facility implemented the following actions to remove the Immediate Jeopardy: 1. The Regional Nurse Consultant provided education specific to identifying resident-to-resident physical abuse, specific to determining resident-to-resident sexual abuse, and specific to identifying sexual abuse from contracted facility staff using the Abuse, Neglect, and Exploitation Policy. This education was provided to the following Department Managers: Regional Administrator, AIT/MDS, Risk Manager, Activity Assistant, MDS, Director of Nursing, Housekeeping Supervisor, and the Human Resources Director. 2. The facility held an Ad Hoc QAPI meeting to review the Immediate Jeopardy findings. The following key personnel attended the Ad Hoc QAPI meeting: Regional Administrator, AIT/MDS, Risk Manager, Activity Assistant, MDS, Director of Nursing, Housekeeping Supervisor, and the Human Resources Director. The Medical Director was unable to attend in person, however, this information was reviewed via teleconference. The Medical Director visited 12/12/2023 and reviewed facility findings and plans and made no recommendations. The Abuse, Neglect, and Exploitation policy was reviewed during this meeting, and no policy changes were recommended. 3. The prevoius Administrator resigned effective immediately on 12/5/2023. The Regional Administrator assumed the role of Interim Administrator on 12/6/2023. 4. The identified progress notes dated 9/22/2023, 7/16/2023, 7/2/2023, 1/6/2023, 11/29/2022, 12/1/2022, 7/5/2022, 10/24/2022 that contain allegations of abuse for R5 as the perpetrator have been reported to the Department of Community Health Complaint Division. 5. R5 continues to reside at facility. R5 received inpatient geri-psych treatment from 9/1/2023 - 9/14/2023. R5 was being followed by facility psych services which were provided via telehealth. A new psych services contract has been initiated and visits will be conducted in person beginning 12/13/2023. 6. The allegation of sexual abuse for R8 has been reported to the Department of Community Health Complaint Division. 7. An audit was completed of Nurse's Notes dating back to April 2022 to identify allegations of abuse. The audit tool labeled Review of Nurse's Notes for Abuse and Potential Behavior Events Indicating a State Reportable was used. This audit resulted in forty-seven (47) abuse allegations reported to the Department of Community Health Complaint Division. 8. Nineteen (19) Residents were identified with a BIM score of 8 or higher and were interviewed using the Abuse Questionnaire for Interviewable Residents to identify potential allegations that indicate a State Reportable. This process resulted in one (1) abuse allegation reported to the Department of Community Health Complaint Division. This allegation was investigated and subsequently unsubstantiated. 9. A root cause analysis was completed; it was determined that a lack of thorough education related to the Abuse Prevention Program was a factor. Education for all staff related to the Abuse Prevention Program was started on 11/30/2023 and has continued through 12/12/2023. 10. The Regional Nurse Consultant conducted training using the Abuse, Neglect, and Exploitation policy for the following staff: a. 11 of 12 licensed staff members have received this training. b. 14 of 14 CNAs have received this training. c. 1 of 1 Activities Staff have received this training. d. 9 of 10 Dietary Staff have received this training. e. 7 of 7 Housekeeping/Laundry/Maintenance staff have received this training. f. 3 of the 3 Administrative Staff have received this training. Total Education: 45 of 47 Staff Members have received this training: 96% 11. All facility staff, including PRN staff, not in-serviced on the Abuse, Neglect, and Exploitation Policy will not work until the education is completed. The facility implemented the following actions to remove the Immediate Jeopardy: 1. Inservice topic Pre IJ inservice -QAPI meeting 11/30/23: Topics discussed include the following: Wandering & Elopement P/P, Grievance Policy and procedures, state reportable, Abuse policy and procedures (sexual abuse, physical abuse, mental abuse, verbal abuse, neglect, exploitation, injury-unknown origin. Individuals in attendance included medical director, administrator AIT, DON, MDS, SSD/Human resources, BOM, CDM, Housekeeping supervisor, Activities director, Regional Manager. Adhoc QAPI meetings - Review of immediate jeopardy findings. Verbal presentation 9:00 am to 9:45am by the Regional Administrator on 12/6/23. Attendance included Maintenance director, dietary manager, Business office Manager, AIT/MDS, Risk Manager, Activity Assistant, MDS, DON, Housekeeping supervisor, Human Resources. Medical director signed sign in sheet on 12/12/23. Phone interview on 12/15/2023 at 4:47 pm with the Regional Nurse Consultant (RNC) revealed that the facility employee roster was printed out on 11/30/2023 and began the first wave of in-services. The topics discussed included defining abuse, different types of abuse, who the abuse coordinator was and examples of different abuse scenarios, and timely reporting of abuse and neglect. The RNC continued to state the meeting discussing the IJs basically was a summary of abuse allegation were not getting reported. The RNC also stated that she initiated a daily clinical meeting to be done prior to the morning meetings. The clinical meetings require the MDS coordinator to pull the previous days' nurses notes and discuss possible issues to be brought up in the morning meetings. 2. Inservice topic: Adhoc QAPI meetings - Review of immediate jeopardy findings. All the IJs identified on 12/5/2023 were reviewed. Verbal presentation 9:00 am to 9:45am by the Regional Administrator on 12/6/2023 a. Attendance included Maintenance Director, Dietary Manager, Business Office Manager, AIT/MDS, Risk Manager, Activity Assistant, MDS, DON, Housekeeping Supervisor, Human Resources. Medical Director signed sign in sheet on 12/12/2023. b. Facility policy Abuse, Neglect and Exploitation revised and different from the abuse policy initially provided. This policy had been highlighted to identify the specific types of abuse. Abuse identification, reporting, investigation, implementation of corrective actions; Elopements identification; QAPI process related to abuse procedures and wandering. Interview on 12/14/2023 on 9:23 am, The Regional Administrator (RA) stated a QAPI meeting was held about the Immediate Jeopardy findings. The RA stated that the Medical Director was not personally there, but he was on the phone to be a part of the discussion. The Medical Director visited the facility on 12/12/2023 and signed the sign in sheet. 3. Upon arrival to the facility on [DATE] on 8:58 am, The Administrator's door was closed. This was unusual as the door had been open since entry of the facility on 11/27/2023. The Regional Administrator approached the Surveyor as she was setting up to inform her about the immediate resignation of the Administrator. The Regional Administrator (RA) stated she resigned yesterday evening, and we accepted it. I will be the acting administrator for this facility moving forward. Anything you need you can ask me. The previous administrator was not seen on the premises since that notification. The RA signed an Administrator job description for 12/6/2023. Interview on 12/15/2023 at 4:08 pm with the Regional Administrator (RA), stated the previous Administrator's resignation was verbal. The verbal resignation was accepted effective 12/5/2023. 4. The following Identified allegations of abuse about R5 a. 9/22/2023 - reviewed FRI- Date reported is 12/6/2023. b. 7/16/2023 - reviewed FRI- Date reported is 11/29/2023 c. 7/2/2023 - reviewed FRI- Date reported is 11/29/2023 d. 1/6/2023 - reviewed FRI- Date reported is 12/7/2023 e. 11/29/2022 - reviewed FRI- Date reported is 11/29/2023 f. 12/1/2022 - reviewed FRI- Date reported is 12/1/2023 g. 7/5/2022 - reviewed FRI- Date reported is 12/7/2023 h. 10/24/2022 - reviewed FRI- Date reported is 12/1/2023 Interview on 12/14/2023 at 9:23 am with the Regional Administrator (RA) revealed that the outcomes of these investigations were based on what was noted in the nurses' notes proceeding these events. Examples of the interventions that were implemented include the room changes for R5 and Psych evaluations. The RA stated they did what could be done with the information they had and due to the time that has lapsed between the potential allegation to current. 5. Observation on 12/14/2023 at 9:03 am, R5 was observed in the facility in his room. R5 was at the foot of the bed, sitting up. The resident was alert and orientated with no behaviors noted. Observation on 12/15/2023 at 6:15 am, R5 has been observed in his room asleep. No behaviors were noted. R5 was outside of his room several times throughout the survey and during the IJ time frame. R5 was assessed at [local hospital]. Review of R5's medical record documents an Interdisciplinary treatment plan was initiated 9/1/2023. The reason for this admission was noted to be aggressive. The DSM V diagnosis was noted to be Psychosis D/T organic and with brain disease. A Behavioral Health discharge assessment and social services discharge assessment were performed. Documents were provided of a visit to [local hospital]. A Master treatment plan for R5 was reviewed. R5 had daily progress notes from 9/1/2023 through 9/14/2023; his discharge on [DATE]. Subjective observations and objective observations were performed in addition to physical examinations and clinical treatment plan. R5's Psychiatric evaluation documents R5's Chief complaint, history of present illness, past psychiatric history, past medical history, current outpatient medications, allergies and social history were noted. 6. R8 Sexual abuse allegation was reported on 11/29/2023. Interview on 12/5/2023 at 12:30 pm with the previous Administrator confirmed the report was submitted to the State Agency after being questioned about the incident between R8 and the Contract employee. Interview on 12/5/2023 at 11:45 am the Regional Administrator confirmed that after the interview with the Administrator asking about the incidents R5 that were not reported, the RA decided an audit of all the nurses' notes since the last survey. The RA notified the Regional Director of an influx of state reportables will be coming through the pipeline. 7. Audit tool Review of nurse's notes for abuse and potential behavior events indicating state reportable. The accessors were the AIT, The DON and MDS coordinator. Tool reviewed by the DON beginning on 11/30/2023, 6 pages does not have accessor's name or date. The resident names are listed, and then checked yes or no. Yes, is in response to indicate potential problems for abuse. Total number of 71 residents were reviewed. Interview on 12/15/2023 at 4:39 pm with the Administrator in Training (AIT) stated the individuals involved in the audit included the AIT, the MDS coordinator, The director of Nursing (DON) and the Regional Administrator (RA). The AIT stated that all the nurses' notes dated after 4/10/2022 were printed out. There were a total of 1138 pages front and back. The 1138 pages were divided four ways, and each individual grabbed a stack and began to read. The AIT stated that each resident was reviewed, with their name on the audit tool. A yes indicated there was a problem and a no indicated no problems were detected. For all the yes responses, the group would discuss and review the notes and then figure out who the other indivdual named in the nurse's note was ie. Roommate. A report is then sent to the State Agency and documented on a log. 8. Record review of resident BIMS Audit dates 11/30/2023. 19 Residents with the BIMs of 8 and above were identified. All the resident's Historical assessment report was printed out on 11/30/2023 at 12:15 pm. An abuse questionnaire for the interviewable resident's. was included. a. The questionnaires were conducted by the Activities Director on 12/1/2023. b. 19 name questionnaires were found. c. Investigation that was identified for 12/20/2023. The FRI provided shows a reported date of 11/30/2023. Interview on 12/15/2023 at 5:10 pm with R19 revealed that the Activity Director did ask R19 a bunch of questions about any instances of abuse. R19 revealed that R19's roommate was in an altercation with a staff member. R19 stated a staff member puts hands on him. When asked who the staff member was, R19 couldn't recall. R19 noted that the Activity Director made notes of R19's statement. Interview on 12/15/2023 at 5:20 pm with R25 revealed that the Activity Director did speak with R25. R25 stated that the activity director asked about a situation that might have happened between R25 and a staff member. R25 stated no one put hands on me. R25 stated I told my roommate to stay out of my business. Interview on 12/15/2023 at 5:10 pm with R9 revealed the facility had conducted a survey and spoke with all the residents. R9 stated the staff member had asked her if there had been any concerns about abuse, neglect, or misappropriation. R9 stated there had not been any concerns about these issues. R9 stated the facility had treated her well and she had been satisfied with the results of the investigations. R9 stated if there had been any concerns brought up in the Resident Council Meeting, she would inform the Ombudsman and the Administrator. Interview on 12/15/2023 at 5:13 pm, R26 was observed seated in his room, he was well dressed, and well-groomed with no obvious signs of trauma or neglect. He stated he was well cared for and that he gets along well with staff and roommates he had no concerns regarding his care and stated concerns with his roommate were resolved and explained did not hit anyone just threw his plate on the floor and could not remember the incident. His roommate stated he felt safe around R26. An interview on 12/15/2023 at 5:16 pm with R8 revealed the facility had conducted a survey and spoke with all the residents. R8 stated the staff had treated her well and there had not been any complaints at this time. R8 stated if she had any concerns or complaints, she would contact the Ombudsman and/or the Administrator. Interview on 12/15/2023 at 5:23 pm, R27 was observed seated in her room, she was unable to recall the incident which occurred on 9/27/2023 regarding another resident popping the top of her hand while playing cards. She stated the administrator had previously talked to her but was unable to recall what the incident was about. R27 stated she felt safe and that she got along well with her roommates. 9. Plan was identified as the following. The facility will determine if/when the abuse occurred and investigate and report per the regulation. The start date was 11/30/2023 with an ongoing completion date. Team leader for this plan was Interim Administrator. The project goal: The facility shall show evidence that all alleged violations are thoroughly investigated. The point people were the DON, the Regional Administrator, the MDS coordinator and the AIT. The quality performance/peer review action plan outlined the actions they would take to correct issues for the identified problem areas. Actions to be taken for F600, a full house audit was conducted 11/30/2023 - 12/1/2023 to review the nurse notes dated back to April 2022 to current. Additional actions were outlined in the facility action plan/continuous quality improvement plan. Persons responsible were identified as DON, AIT, Maintenance, Social Services Designee and the Administrator. 10. Per the Regional Administrator (RA) the log of individuals names and their dates of participation of the in- services are included. Signatures of the in-services were used to confirm. During the confirmation period on 12/15/2023 at 10:30 am. There was a discrepancy.in the identification of staff. The total number of educated staff members are 45. The breakdown of the staff is as follows. Interview on 11:08 am on 12/15/2023 with the RA confirms the staff breakdown below is as follows. 11 of 12 licensed staff members have received this training. 15 of 15 CNAs have received this training. 1 of 1 Activities Staff have received this training. 9 of 10 Dietary Staff have received this training. 7 of 7 Housekeeping/Laundry/Maintenance staff have received this training. 2 of the 2 Administrative Staff have received this training. Facility policy Abuse, Neglect and exploitation looks revised and different from the abuse policy initially provided. This policy had been highlighted to identify and specify types of abuse, Abuse identification, reporting, investigation, implementation of corrective actions; Elopements identification; QAPI process related to abuse and procedures and wandering Inservice's provided. Inservice was presented verbally. 12/11/2023 at 2 pm - Abuse and wandering/elopements. 23 individuals were noted to have attended (signed) Inservice topic F600- Freedom from abuse neglect, 610- Investigation abuse, 609 abuse reporting. Start time was at 10:30-11:15 pm and 2pm - 2:45 pm o Verbal presentation on 12/6/2023 o 15 attended the 10:30 am class and 12 attended the 2:00 pm o Inservice topic 689 accidents-elopements; F656- Care plans provided at 10:30 am-11:15 am and 2:00 pm 2:45 pm Presented verbally on 12/6/2023. 15 attended the 10:30 am class and 12 attended the 2:00 pm - Inservice topic: Wandering/elopement plan; abuse prevention program plan. Started 9:00 am presented verbally. Presented by the Regional Administrator on 12/1/2023. 10 attended the 9:00 am presentation and 13 attended the 10:30 am Inservice topic was Wandering/elopement, Abuse prevention program plan. Provided by RN AAA. Paper and verbally presented at 9:00 am to 9:35 am with 10 people in attendance on 12/2/2023 Inservice topic: Freedom from abuse and neglect- sexual abuse. Provide on 11/30/2023 at 12:00 pm and 2:00 pm provided by RNC, 34 staff in attendance via signatures. Freedom from abuse and neglect- resident to resident physical abuse. Start time was 12:00 pm and 2:00 pm. Verbal presentation by RNC on 11/30/2023 with 35 in attendance. Inservice topic- Abuse prevention program- Reporting/investigation. Verbal presentation provided at 12:00 pm and 2:00 pm by RNC on 11/30/2023 with 34 people in attendance. To certify that all staff were educated, the survey team interviewed a sample of staff within each department. Each shift; first, second and third shifts were included in the interviews. Interview on 12/15/2023 with following employees revealed they received education: 6:43 am LPN BB; 6:56 am CNA LL; 7:00 am CNA MM; 7:09 am CNA KK; 7:20 am CNA DD; 7:34 am Dietary Aide NN; 7:42 am Dietary Aide OO; 7:50 am Laundry FF; 8:17 am Housekeeping PP; 8:24 am Dietary Manager; 9:04 am LPN AA; 9:15 am LPN RR; 9:27 am CNA EE; 9:34 am CNA SS; 9:44 am Director of Nursing (DON); 2:01 pm Administrator in Training (AIT); 2:09 pm MDS coordinator; 2:27 pm Housekeeping Supervisor; 2:34 pm Business Office Manager; 2:45 pm Human Resource Manager; 3:40 pm Dietary Aide VV; 3:45pm CNA II; and 3:53 pm CNA WW. 11. Interview on 12/14/2023 at 9:45 am, the Regional Administrator (RA) provided a list of all the employees at the facility, next to the employee's names, the RA included the dates of when each employee was in-serviced The RA stated that the last two staff listed on the employee list are RN Supervisors. They were PRN and will not be returning to the facility. A new employee was hired to take their place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and review of policy titled Abuse Prohibition Policy and Procedures, the facility failed to ensure allegations of sexual, physical and verbal abuse, were reported to the State Agency (SA) in a timely manner for four of 19 sampled residents (R) (R8, R14, R17 and R18). The allegations of abuse are identified to have been committed by R3, R5, and a Contracted Facility Staff. On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Administrator, Regional Administrator (RA), Director of Nursing (DON) and Regional Nurse Consultant (RNC) were informed of two Immediate Jeopardy's (IJ) on [DATE] at 3:45 pm. The noncompliance related to the Immediate Jeopardy was identified to have existed on [DATE] when the facility failed to protect four residents (R8, R14, R17, and R18) from physical, verbal, and sexual abuse. A Credible Allegation of Compliance was received on [DATE]. Based on observations, record review, resident and staff interviews, and review of facility policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed as of [DATE]. Findings include: Review of the policy titled Abuse Prohibition Policy and Procedures revised [DATE] revealed it is the intent of this facility to actively preserve each resident's right to be free from mistreatment, neglect, abuse, or misappropriation of resident property. Each resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. The purpose of these identified procedures is to assure that we are doing all that is within our control to create a standard of intolerance and to prevent any occurrences of any form of mistreatment, neglect, abuse, or misappropriation of any resident and/or their property. The procedures herein establish standards and practices for screening and training employees, protection of residents and for prevention, identification, investigation and reporting of abuse, neglect, mistreatment, and misappropriation of property. 1. Review of the clinical record revealed R3 was admitted to the facility on [DATE] with diagnoses including Alzheimer's dementia, hypertensive heart disease, and atrial fibrillation (A-fib). Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed R3 presented with a Brief Interview of Mental (BIMS) score of 12, indicating moderate cognitive impairment. 2. Review of the clinical record revealed R5 was admitted to the facility on [DATE] with diagnoses including hypertension, diabetes, and dementia. Review of the quarterly MDS assessment dated [DATE] revealed R5 presented with a BIMS score of 99, indicating severe cognitive impairment. 3. Review of the clinical record revealed R8 was admitted to the facility on [DATE] with diagnoses including hypertensive heart disease, anxiety, chronic obstructive pulmonary disease (COPD), and depression. Review of the annual MDS assessment dated [DATE] revealed R8 presented with a BIMS score of nine, indicating moderate cognitive impairment. Review of the Progress Note dated [DATE] documented an allegation of physical abuse in which R3 grabbed R8's arm and pushed her into the nurses' station. The note indicated the action had caused R8 to hit the right side of her body against the nurses' station. Review of the Progress Note dated [DATE] at 1:48 pm documented that R5 entered (R8's room) and walked up to (R8), and (R8) told (R5) to leave. (R5) then grabbed (R8's) wrist pushing on (R8). Review of the Progress Note dated [DATE] at 12:10 am documented that R5 wandered into (R8's Room) - heard residents (in the room) hollering out, and when staff entered the room, noted R5 and female resident holding each other's hands tugging on each other - was able to redirect R5 with much encouragement back to his room, but he was very agitated and cursing. Review of a police report dated [DATE] of an allegation of sexual abuse revealed R8 had reported an alleged sexual abuse allegation by a Contracted Physical Therapist, that was not investigated. Interview on [DATE] at 12:15 pm with R8, she confirmed the allegation that a Contracted Physical Therapist had made sexual comments to her and touched her inappropriately. Interview on [DATE] at 1:03 pm, the Administrator confirmed R8 made an allegation of abuse to her and to a police officer on [DATE]. The Administrator stated she did not report this allegation of abuse to the State Agency and verified that she should have reported the allegation of abuse but was unable to state the reason she had not reported the incident. 4. Review of the clinical record revealed R14 was admitted to the facility on [DATE] with diagnoses including hypertension, hyperlipidemia, and dementia. Review of the quarterly MDS assessment dated [DATE] revealed R14 presented with a BIMS score of four, indicating severe cognitive impairment. Review of the Progress Note dated [DATE] at 2:47 pm documented that R5 slapped the other resident (R14) and pulled her hair. The other resident (R14) scratched at R5 and then the two were separated. 5. Review of the clinical record revealed R17 was admitted to the facility on [DATE] with diagnoses including coronary artery disease, seizure disorder, traumatic brain injury, and depression. Review of the quarterly MDS assessment dated [DATE] revealed R17 presented with a BIMS score of 99, indicating cognition could not be determined. Review of the Progress Note dated [DATE] at 1:58 am documented that on [DATE] at 10:20 pm, R5 was up in his room when Certified Nursing Assistant (CNA) entered the room, she noted R5 holding roommate (R17) leg while his roommate (R17) was in bed sleeping. Review of the Progress Note dated [DATE] at 6:47 am documented that R5 was observed in the bed with his roommate (R17). R5 had taken off all his clothes and threw his adult brief in the doorway. Review of the Progress Note dated [DATE] at 6:40 am revealed that R5 became very agitated while CNA's were changing him due to his incontinence of urine- resident was fighting/and slapping/scratching staff and cursing and name calling staff vulgar names and kicked one of the CNA's in the stomach - difficulty to redirect - left room to allow resident to calm down, but about five minutes later, R5 was observed hitting roommate in the arm and face with his bedroom shoe - roommate (R17) removed from the room for safety. Interview on [DATE] at 3:30 pm, the Administrator in Training (AIT) confirmed that the altercations on [DATE], [DATE], and on [DATE] was between R5 (perpetrator) and R17 (victim). 6. Review of the clinical record revealed R18 was admitted to the facility on [DATE] with diagnoses including coronary artery disease, congested heart failure (CHF), urinary tract infection (UTI), asthma, and depression. Review of the Progress Note dated [DATE] at 2:23 am documented that R5 was observed in another residents room (R18), and both residents were hollering at each other - was able to redirect R5 back to his room and back to bed. Review of the Progress Note dated [DATE] at 5:52 pm documented that R5 was speaking loudly in his room. I enter the room and he is standing over his roommate (R18) yelling cuss words and shaking his fist in the direction of the resident. I entered the room and tried to get between the two residents. Review of the facility's State Reportable Incident Log revealed that none of the nine identified allegations above were identified as State reportable, and therefore, were not reported to the State Agency. Interview on [DATE] at 11:30 am with the Administrator/Abuse Coordinator revealed that allegations identified in the progress notes were not reported or investigated. The Administrator's response to each identified entry was, I don't have that and that wasn't reported to me. Interview on [DATE] at 1:53 pm, the Administrator acknowledged, If I didn't know about it, I didn't do an investigation, in reference to the allegations of sexual, physical, and verbal abuse that has been documented in the progress notes. Interview on [DATE] at 9:07 am, CNA EE revealed R3 and R5 had been combative in the past towards the other residents. She stated the staff had tried to keep them from hitting and/or becoming combative with other residents, but it had been difficult to do, when their medicine wore off. CNA EE stated she had reported the aggressive behaviors of R3 and R5 to three different nurses: LPN AA, LPN BB and LPN GG. She stated the nurses documented the incidents in the nurses' notes as behavioral problems. The facility implemented the following actions to remove the Immediate Jeopardy: 1. The Regional Nurse Consultant provided education on timely reporting of allegations of abuse using the Abuse, Neglect, and Exploitation Policy. This education was provided to the following Department Managers: Regional Administrator, AIT/MDS, Risk Manager, Activity Assistant, MDS, Director of Nursing, Housekeeping Supervisor, and the Human Resources Director. 2. The facility held an Ad Hoc QAPI meeting to review the Immediate Jeopardy findings. The following key personnel attended the Ad Hoc QAPI meeting: the Regional Administrator, AIT/MDS, Risk Manager, Activity Assistant, MDS, Director of Nursing, Housekeeping Supervisor, and the Human Resources Director. The Medical Director was unable to attend in person, however, this information was reviewed via teleconference. The Medical Director visited [DATE] and reviewed facility findings and plans and made no recommendations. During this meeting, a review of the Abuse, Neglect, and Exploitation policy specific to timely reporting of allegations of abuse was conducted, and no policy changes were recommended. 3. The Administrator, resigned effective immediately on [DATE]. The Regional Administrator assumed the role of Interim Administrator on [DATE]. 4. The identified residents, R8, R14, R17, and R18, with allegations of abuse with R5 as the perpetrator, have been reported to the Department of Community Health Complaint Division. 5. R8 continues to reside at this facility. The last allegation involving R8 and R5 together occurred on [DATE]. 6. R14 continues to reside at this facility. The last allegation involving R14 and R5 together occurred on [DATE]. 7. R17 continues to reside at this facility. The last allegation involving R17 and R5 together occurred on [DATE]. 8. R18 discharged from the facility [DATE]. 9. R5 continues to reside at facility. R5 received inpatient geri-psych treatment from [DATE] - [DATE]. R5 was being followed by facility psych services which were provided via telehealth. A new psych services contract has been initiated and visits will be conducted in person beginning [DATE]. 10. The allegation of sexual abuse for R8 has been reported to the Department of Community Health Complaint Division. 11. R8 continues to reside at this facility and was included in the Interviews conducted of residents with BIM of 8 or higher and voiced no new concerns during this interview. 12. An audit was completed of Nurse's Notes dating back to [DATE] to identify allegations of abuse. The audit tool labeled Review of Nurse's Notes for Abuse and Potential Behavior Events Indicating a State Reportable was used. This audit resulted in forty-seven (47) abuse allegations reported to the Department of Community Health Complaint Division. 13. Nineteen (19) Residents were identified with a BIM score of 8 or higher and were interviewed using the Abuse Questionnaire for Interviewable Residents to identify potential allegations that indicate a State Reportable. This process resulted in one (1) abuse allegation reported to the Department of Community Health Complaint Division. This allegation was investigated and subsequently unsubstantiated. 14. A root cause analysis was completed; it was determined that a lack of thorough education related to the Abuse Prevention Program was a factor. Education for all staff related to the Abuse Prevention Program was started on [DATE] and has continued through [DATE]. 15. A Performance Improvement Plan related to Abuse Prevention Program was developed and will be followed through the facility's QAPI process. 16. The Regional Nurse Consultant conducted training using the Abuse, Neglect, and Exploitation policy specific to timely reporting of allegations of abuse for the following staff: a. 11 of 12 licensed staff members have received this training. b. 14 of 14 CNAs have received this training. c. 1 of 1 Activities Staff have received this training. d. 9 of 10 Dietary Staff have received this training. e. 7 of 7 Housekeeping/Laundry/Maintenance staff have received this training. g. 3 of the 3 administrative staff members have received this training. Total Education: 45 of 47 Staff Members have received this training: 96%. 17. All facility staff not in-serviced on the Abuse, Neglect, and Exploitation Policy specific to timely reporting of abuse allegations will not be allowed to work until the education is completed. The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows: 1. Inservice topic: Pre IJ inservice -QAPI meeting [DATE]: Topics discussed include the following: Wandering & Elopement P/P, Grievance Policy and procedures, state reportable, Abuse policy and procedures (sexual abuse, physical abuse, mental abuse, verbal abuse, neglect, exploitation, injury-unknown origin. Individuals in attendance included Medical Director, previous Administrator, AIT, DON, MDS, SSD/Human resources, BOM, CDM, Housekeeping Supervisor, Activities Director, Regional Manager, RN BBB. Adhoc QAPI meetings - Review of Immediate Jeopardy findings. Verbal presentation 9:00 am to 9:45am by the Regional Administrator on [DATE]. Attendance included Maintenance Director, Dietary Manager, Business Office Manager, AIT/MDS, Risk manager, Activity Assistant, MDS, DON, Housekeeping Supervisor, Human Resources. The Medical Director signed the sign in sheet on [DATE]. Phone interview on [DATE] at 4:47 pm with the Regional Nurse Consultant (RNC) revealed that the facility employee roster was printed out on [DATE] and began the first wave of in-services. The topics discussed included defining abuse, different types of abuse, who the abuse coordinator was and examples of different abuse scenarios, and timely reporting of abuse and neglect. The RNC continued with stating the meeting discussing the IJs basically was a summary of abuse allegation that were not getting reported. The RNC also stated that the RNC initiated a daily clinical meeting to be done prior ot the morning meetings. The clinical meetings require the MDS Coordinator to pull the previous days' nurses notes and discuss possible issues to be brought up in the morning meetings. 2. Inservice topic: Adhoc QAPI meetings - Review of Immediate Jeopardy findings. All the IJs identified on [DATE] were reviewed. Verbal presentation 9:00 am to 9:45am by the Regional Administrator on [DATE]. a. Attendance included Maintenance Director, Dietary Manager, Business Office Manager, AIT/MDS, Risk Manager, Activity Assistant, MDS, DON, Housekeeping Supervisor, Human Resources. Medical Director signed sign in sheet on [DATE]. b. Facility policy Abuse, Neglect and Exploitation looks revised and different from the abuse policy initially provided. This policy had been highlighted to identify and specify types of abuse. Abuse identification, reporting, investigation, implementation of corrective actions; Elopements identification; QAPI process related to abuse procedures and wandering. Interview on [DATE] on 9:23 am, the Regional Administrator (RA) stated a QAPI meeting was held about the Immediate Jeopardy finding. The RA stated that the Medical Director was not in person there, but he was on the phone to be a part of the discussion. The Medical Director visited the facility on [DATE] and signed the sign in sheet. 3. Upon arrival to the facility on [DATE] on 8:58 am, The Administrator's door was closed. This was unusual as the door had been open since entry of the facility on [DATE]. The Regional Administrator approached the Surveyor as she was setting up to inform her about the immediate resignation of the Administrator. The Regional Administrator stated she resigned yesterday evening, and we accepted it. I will be the acting administrator for this facility moving forward. Anything you need you can ask me. The previous Administrator was not seen on the premises since that notification. The Regional Administrator signed an Administrator job description for [DATE]. Interview on [DATE] at 4:08 pm with the Regional Administrator, revealed the previous Administrator's resignation was verbal. The verbal resignation was accepted effective [DATE]. 4. The facility Incident report indicates the following incidents were reported. a. [DATE] - reviewed FRI- Date reported is [DATE]. b. [DATE] - reviewed FRI- Date reported is [DATE] c. [DATE] - reviewed FRI- Date reported is [DATE] d. [DATE] - reviewed FRI- Date reported is [DATE] e. [DATE] - reviewed FRI- Date reported is [DATE] f. [DATE] - reviewed FRI- Date reported is [DATE] g. [DATE] - reviewed FRI- Date reported is [DATE] h. [DATE] - reviewed FRI- Date reported is [DATE] Interview on [DATE] at 9:23 am with the Regional Administrator, revealed that the outcomes of these investigations were based on what was noted in the nurses' notes proceeding these events. Examples of the interventions that were implemented include the room changes for R5 and Psych evaluations. The Regional Administrator stated they did what could be done with the information they had due to the time that has lapsed between the potential allegation to current and the outcomes of the investigations. 5. Record review of FRI confirms that the incident between R5 and R8 on [DATE] was reported on [DATE]. Observation on [DATE] at 9:03 am, R5 was observed in the facility in his room. R5 was at the foot of the bed, sitting up. The resident was alert and orientated with no behaviors noted. Observation on [DATE] at 6:15 am, R5 has been observed in his room asleep. No behaviors were noted. R5 was outside of his room several times throughout the survey and during the IJ time frame. Observation on [DATE] at 9:25 am, R8 was observed in her room, alert and orientated. R8 keeps to self and eats several meals in R8's room. Interview on [DATE] at 5:16 pm with R8 revealed the facility had conducted a survey and spoke with all the residents. R8 stated the staff had treated her well and there had not been any complaints at this time. R8 stated if she had any concerns or complaints, she would contact the Ombudsman and/or the Administrator. 6. Observation on [DATE] at 2:44 pm, R14 was observed interacting with the Activities Director. R14 was alert and orientated with no behaviors noted. Observation on [DATE] at 11:55 am, R14 was observed in the room, laying in bed. Review of the FRI documents a reported date of [DATE]. The resident is still in the facility. 7. Record review of FRI confirms that the incident for [DATE] was reported on [DATE]. Observation of [DATE] at 11:50 am, R17 was observed in the room. R17 was in bed, asleep and appears clean. 8. Per the resident's MDS and Discharge sheet, R18 is deceased . 9. Observation on [DATE] at 9:03 am, R5 was observed in the facility in his room. R5 was at the foot of the bed, sitting up. Resident was alert and orientated with no behaviors noted. Observation on [DATE] at 6:15 am, R5 has been observed in his room asleep. No behaviors were noted. R5 was outside of his room several times throughout the survey and during the IJ time frame. R5 was assessed at [name] Hospital. Review of R5's medical record documents an Interdisciplinary treatment plan was initiated [DATE]. The reason for this admission was noted to be aggressive. The DSM V diagnosis was noted to be Psychosis D/T organic and with brain disease. A Behavioral Health discharge assessment and social services discharge assessment were performed. (Hospital) A Master treatment plan for R5 was reviewed. R5 had daily progress notes from [DATE] through [DATE]; his discharge on [DATE]. Subjective observations and objective observations were performed in addition to physical examinations and clinical treatment plan. R5's Psychiatric evaluation documents R5's Chief complaint, history of present illness, past psychiatric history, past medical history, current outpatient medications, allergies and social history were noted. 10. The Facility Incident Report form indicates this incident [DATE] - reviewed FRI- Date reported is [DATE]. Per RN CCC, it appears someone had started the report. 11. R8 has been observed in her room throughout the survey and during the IJ period. The resident keeps to herself and eats several of her meals in her room. R8 was observed in her room at 9:25 am on [DATE]. R8 participated in the abuse questionnaire for interview-able residents on [DATE]. R8 was noted to have BIMS of 9. No additional allegations were noted. Some of R8's answers included refusal to answer. The Activities Director conducted the interview. 12. Audit tool Review of nurse's notes for abuse and potential behavior events indicating state reportable. The accessors were the AIT, The DON and MDS Coordinator. Tool reviewed by the DON beginning on [DATE], 6 pages does not have the accessor's name or date. The resident names are listed, and then checked yes or no. Yes, is in response to indicate potential problems for abuse. Total number of 71 residents were reviewed. Interview on [DATE] at 4:39 pm with the Administrator in Training (AIT) stated the individuals involved in the audit included the AIT, the MDS coordinator, The director of Nursing (DON) and the Regional Administrator. The AIT stated that all the nurses' notes dated after [DATE] were printed out. There were a total of 1138 pages front and back. The 1138 pages were divided four ways, and each individual grabbed a stack and began to read. The AIT stated that each resident was reviewed, with their name on the audit tool. A yes indicated there was a problem and a no indicated no problems were detected. For all the yes responses, the group would discuss and review the notes and then figure out who the other individual named in the nurse's note was ie. Roommate. A report is then sent to the State Agency and documented on a log. 13. Record review of resident BIMS Audit dates [DATE]. 19 Residents with the BIMs of 8 and above were identified. All the resident's Historical assessment report was printed out on [DATE] at 12:15 pm. An abuse questionnaire for the interviewable resident's was included. a. The questionnaires were conducted by Activities Director on [DATE]. b. 19 name questionnaires were found. c. Investigation that was identified for [DATE]. The FRI provided shows a reported date of [DATE]. Interview on [DATE] at 5:10 pm with R19 revealed that the Activity Director did ask R19 a bunch of questions about any instances of abuse. R19 revealed that R19's roommate was in an altercation with a staff member during R25's brief change. R19 stated a staff member puts hands on him. When asked who the staff member was, R19 couldn't recall. R19 noted that the activity director made notes of R19's Statement. Interview on [DATE] at 5:20 pm with R25 revealed that the Activity Director did speak with R25. R25 stated that the Activity Director asked about a situation that might have happened between R25 and a staff member. R25 stated no one put hands on me. R25 stated I told my roommate to stay out of my business. Interview on [DATE] at 5:10 pm with R9 revealed the facility had conducted a survey and spoke with all the residents. R9 stated the staff member had asked her if there had been any concerns about abuse, neglect, or misappropriation. R9 stated there had not been any concerns about these issues. R9 stated the facility had treated her well and she had been satisfied with the results of the investigations. R9 stated if there had been any concerns brought up in the Resident Council Meeting, she would inform the Ombudsman and the Administrator. Interview on [DATE] at 5:13 pm, R26 was observed seated in his room, he was well dressed, and well-groomed with no obvious signs of trauma or neglect. He stated he was well cared for and that he gets along well with staff and roommates he had no concerns regarding his care and stated concerns with his roommate were resolved and explained did not hit anyone just threw his plate on the floor and could not remember the incident. His roommate stated he felt safe around R26. Interview on [DATE] at 5:16 pm with R8 revealed the facility had conducted a survey and spoke with all the residents. R8 stated the staff had treated her well and there had not been any complaints at this time. R8 stated if she had any concerns or complaints, she would contact the Ombudsman and/or the Administrator. Interview on [DATE] at 5:23 pm, R27 was observed seated in her room, she was unable to recall the incident which occurred on [DATE] regarding another resident popping the top of her hand while playing cards. She stated the administrator had previously talked to her but was unable to recall what the incident was about. R27 stated she felt safe and that she got along well with her roommates. 14. Plan was identified as the following. a. The facility will determine if/when the abuse occurred and investigate and report per the regulation. The start date was [DATE] with an ongoing completion date. Team leader for this plan was the Regional Administrator. The project goal: The facility shall show evidence that all alleged violations are thoroughly investigated. The Point people were the DON, the Regional Administrator, the MDS coordinator and the AIT. b. The quality performance/peer review action plan outlined the actions they would take to correct issues for the identified problem areas. c. Actions to be taken for F600, a full house audit was conducted [DATE] - [DATE] review the nurse notes dated back to [DATE] to current. Additional actions were outlined in the facility action plan/continuous quality improvement plan. d. Persons responsible were identified as DON, AIT, Maintenance, Social Services Designee, and the Administrator. 15. QAPI meeting [DATE] i. topics discussed include the following: Wandering & Elopement P/P, Grievance Policy and procedures, state reportable, Abuse policy and procedures (sexual abuse, physical abuse, mental abuse, verbal abuse, neglect, exploitation, injury-unknown origin. Individuals in attendance included Medical Director, Administrator, AIT, DON, MDS, SSD/Human Resources, BOM, CDM, Housekeeping Supervisor, Activities Director, Regional Manager, RN BBB. A performance improvement project worksheet was reviewed. The project title is F-tag 600 freedom from abuse; F tag 610 failure to investigate, report, prevent and correct alleged abuse. Plan: The facility will determine if/when the abuse occurred and investigate and report per the regulation. The start date for this project is [DATE] with the completion date is ongoing. Regional Administrator is leading the charge. A root cause analysis was conducted to develop and approach the problem. The implement the approaches of the plan include at the following. A full house audit was conducted between [DATE] through [DATE] of the nurses' notes dates back to the prior survey [DATE] to current. Any identified allegations of abuse will be reported. Education will be provided to the employees except two as they will not be returning to work Abuse education will be provided upon hire and on throughout the calendar year. The Administrator or designee will take care of the investigations and report in the time frame required. Individuals identified to be responsible for these efforts was the MDS coordinator, AIT, DON and the Regional Administrator. 16. Per the Regional Administrator the log of individuals names and their dates of participation of the in- services are included. Signatures of the services were used to confirm. During the confirmation period on [DATE] at 10:30 am. There was a discrepancy in the identification of staff. The total number of educated staff members are 45. The breakdown of the staff is as follows. Interview on 11:08 am on [DATE] with the Regional Administrator confirms the staff breakdown below is as follows. 11 of 12 licensed staff members have received this training. 15 of 15 CNAs have received this training. 1 of 1 Activities Staff have received this training. 9 of 10 Dietary Staff have received this training. 7 of 7 Housekeeping/Laundry/Maintenance staff have received this training. 2 of the 2 Administrative Staff have received this training. Facility policy Abuse, Neglect and exploitation looks revised and different from the abuse policy initially provided. This policy had been highlighted to identify the specific types of abuse, Abuse identification, reporting, investigation, implementation of corrective actions; Elopements identification; QAPI process related to abuse procedures and wandering Inservice's provided. Inservice was presented verbally. [DATE] at 2:00 pm - Abuse and wandering/elopements. 23 individuals were noted to have attended (signed) Inservice topic F600- Freedom from abuse neglect, 610- Investigation abuse, 609 abuse reporting. Start time was at 10:30 am -11:15 am and 2:00 pm - 2:45 pm o Verbal presentation by RN BBB on [DATE] o 15 attended the 10:30 am class and 12 attended the 2:00 pm o Inservice topic 689 accidents-elopements; F656- Care plans provided at 10:30 am-11:15 am and 2:00 pm -2:45 pm Presented verbally on [DATE]. 15 attended the 10:30 am class and 12 attended the 2:00 pm Inservice topic: Wandering/Elopement plan; abuse prevention program plan. Started 9:00 am presented verbally. Presented by Regional Administrator on [DATE]. 10 attended the 9:00 am presentation and 13 attended the 10:30 am presetation Inservice topic was Wandering/Elopement, Abuse prevention program plan. Provided by RN AAA. Paper and verbally presented at 9:00 am to 9:35 am with 10 p[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and review of policy titled Abuse Prohibition Policy and Procedures, the facility failed to investigate, correct, and prevent allegations of abuse for four of 19 sampled residents (R) (R8, R14, R17, and R18) with multiple documented incidences of physical, sexual, and verbal abuse by R3, R5, and a Contracted Physical Therapist. On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Administrator, Regional Administrator (RA), Director of Nursing (DON) and Regional Nurse Consultant (RNC) were informed of two Immediate Jeopardy's (IJ) on [DATE] at 3:45 pm. The noncompliance related to the IJ was identified to have existed on [DATE] when the facility failed to protect four residents (R8, R14, R17, and R18) from physical, verbal, and sexual abuse. A Credible Allegation of Compliance was received on [DATE]. Based on observations, record review, resident and staff interviews, and review of facility policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed as of [DATE]. Findings include: Review of the policy titled Abuse Prohibition Policy and Procedures revised [DATE] revealed it is the intent of this facility to actively preserve each resident's right to be free from mistreatment, neglect, abuse, or misappropriation of resident property. Each resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. The purpose of these identified procedures is to assure that we are doing all that is within our control to create a standard of intolerance and to prevent any occurrences of any form of mistreatment, neglect, abuse, or misappropriation of any resident and/or their property. The procedures herein establish standards and practices for screening and training employees, protection of residents and for prevention, identification, investigation and reporting of abuse, neglect, mistreatment, and misappropriation of property. 1. Review of the clinical record revealed that R3 was admitted to the facility on [DATE] with diagnoses including Alzheimer's dementia, hypertensive heart disease, and atrial fibrillation (A-fib). Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that R3 presented with a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. 2. Review of the clinical record revealed that R5 was admitted to the facility on [DATE] with diagnoses including hypertension, diabetes, and dementia. Review of the quarterly MDS assessment dated [DATE] revealed that R5 presented with a BIMS score of 99, indicating the resident was not able to cognitively be screened due to impairment. 3. Review of the clinical record revealed that R8 was admitted to the facility on [DATE] with diagnoses including hypertensive heart disease, anxiety, chronic obstructive pulmonary disease (COPD), and depression. Review of the admission MDS assessment dated [DATE] revealed that R8 presented with a BIMS score of nine, indicating moderate cognitive impairment. 4. Review of the clinical record revealed that R14 was admitted to the facility on [DATE] with diagnoses including hypertension, hyperlipidemia, and dementia. Review of the admission MDS assessment dated [DATE] revealed that R14 presented with a BIMS score of four, indicating severe cognitive impairment. 5. Review of the clinical record revealed that R17 was admitted to the facility on [DATE] with diagnoses including coronary artery disease (CAD), seizure disorder, traumatic brain injury, and depression. Review of the admission MDS assessment dated [DATE] revealed that R17 presented with a BIMS score of 99, indicating the resident was not able to cognitively be screened due to impairment. 6. Review of the clinical record revealed that R18 was admitted to the facility on [DATE] with diagnoses including CAD, congested heart failure (CHF), urinary tract infection (UTI), asthma, and depression. Review of the admission MDS assessment dated [DATE] revealed that R8 presented with a BIMS score of 12, indicating moderate cognitive impairment. During a review of the clinical records, it was noted there was five documented incidences involving R5 for potential physical abuse, two incidences of potential verbal abuse, and one incident of potential sexual abuse: * On [DATE], R5 was standing over his roommate (R18) yelling and cursing while shaking his fist at R18. * On [DATE], R5 wandered into R8's room and as R8 was telling him to leave, R5 grabbed R8's wrist and started pushing her. * On [DATE], R5 was in R18's room yelling at him. Staff redirected R5 from R18's room. * On [DATE], R5 wandered into R8's room and was yelling at her and pulling on her hands. R5 was very agitated and cursed at staff as he was redirected from R8's room. * On [DATE], staff observed R5 holding his roommate (R17) leg, while R17 was in bed sleeping. * On [DATE], R5 was observed in bed with his roommate (R17). R5 had taken off all his clothes and threw the pull-up in the doorway. * On [DATE], R5 became very agitated and was fighting/slapping/cursing at staff while providing activities of daily living (ADL) care. He kicked one staff member in the abdomen. Staff left the room and approximately five minutes later, R5 was observed hitting his roommate (R17) in the face and arm with his bedroom shoe. R17 removed from room for his safety. * On [DATE], R5 slapped R14 and pulled her hair. During a review of the clinical records, it was noted there was two documented incidences involving R3 for potential physical abuse: * On [DATE], R3 grabbed R8's arm and pushed her into the nurse's station, causing R8 to hit the right side of her body against the nurses' station. * On [DATE], R3 grabbed a defenseless female resident by the head and shook her head around, before being confronted by staff, and then let go of the residents head. During a review of the clinical records, it was noted there was one incident for potential sexual abuse by a Contracted Physical Therapist: * On [DATE], R8 reported an allegation of potential sexual abuse by a Contracted Physical Therapist, to the Business Office Manager, the Administrator, and the Police Department. Review of the facility's State Reportable Incident Log revealed that none of the 11 identified allegations were identified as State reportable, and therefore, were not reported to the State Agency (SA), nor investigated by the facility. Interview on [DATE] at 11:30 am with the Administrator, who serves as the facility's Abuse Coordinator, revealed that the allegations identified in the progress notes were not reported to the State Agency and was not investigated. The Administrator's response to each identified entry was, I don't have that and that wasn't reported to me. Interview on [DATE] at 12:41 pm, the Administrator revealed there had not been any difference between a Grievance and a Facility Reported Incident. Interview on [DATE] at 1:53 pm, the Administrator stated, If I didn't know about it, I didn't do an investigation. This was in reference to sexual, physical and verbal abuse that have been documented in the progress notes. Interview on [DATE] at 9:07 am, Certified Nursing Assistant (CNA) EE stated R3 and R5 had been combative in the past, and had tendencies to hit other residents, and even staff members. She stated the staff tried to keep R3 and R5 from hitting and/or becoming combative with other residents, but it had been difficult, especially when their medications wore off. CNA EE stated the last incident involving R5 was approximately two weeks ago, when staff heard yelling and screaming and went to R8's room, and noted R5 grabbing R8 by both shoulders, shaking the resident and yelling at her. During further interview, CNA EE stated there had not been any in-services on how to care for R3 or R5 when the aggressive behaviors were exhibited. CNA EE stated she had reported aggressive behaviors to three different nurses: Licensed Practical Nurse (LPN) AA, LPN BB and LPN GG. Interview on [DATE] at 1:03 pm, the Administrator confirmed that R8 made an allegation of abuse to herself and the police officer on [DATE]. The Administrator stated she did not report this allegation of abuse to the State Agency. The Administrator stated she should have investigated the allegation of abuse and was unable to state the reason she had not investigated the incident. Interview with the Administrator on [DATE] at 1:30 pm, it was revealed that the Business Office Manager accompanied R8 to the Administrators office regarding the alleged sexual abuse by the Contracted Physical Therapist. When asked what the Administrator did with this information, the Administrator did not provide a response. The facility implemented the following actions to remove the Immediate Jeopardy: 1. The Regional Nurse Consultant provided education on thorough investigations and corrective action implementation to decrease the likelihood of alleged abuse using the Abuse, Neglect, and Exploitation Policy. This education was provided to the following Department Managers: Regional Administrator, AIT/MDS, Risk Manager, Activity Assistant, MDS, Director of Nursing, Housekeeping Supervisor, and the Human Resources Director. 2. The facility held an Ad Hoc QAPI meeting to review the Immediate Jeopardy findings. The following key personnel attended the Ad Hoc QAPI meeting: Regional Administrator, AIT/MDS, Risk Manager, Activity Assistant, MDS, Director of Nursing, Housekeeping Supervisor, and the Human Resources Director. The Medical Director was unable to attend in person, however, this information was reviewed via teleconference. The Medical Director visited [DATE] and reviewed facility findings and plans and made no recommendations. During this meeting, a review of the Abuse, Neglect, and Exploitation policy specific to timely reporting of allegations of abuse was conducted, and no policy changes were recommended. 3. The Administrator, resigned effective immediately on [DATE]. The Regional Administrator assumed the role of Interim Administrator on [DATE]. 4. The allegations of physical abuse of R8, R14, and R17 have been investigated, and necessary corrective actions have been implemented. 5. The allegations of sexual abuse for R8 and R17 have been investigated, and necessary corrective actions have been implemented. 6. The allegations of verbal abuse for R18 have been investigated, and necessary corrective actions have been implemented. 7. R8 continues to reside at this facility. The last allegation involving R8 and R5 together occurred on [DATE]. 8. R14 continues to reside at this facility. The last allegation involving R14 and R5 together occurred on [DATE]. 9. R17 continues to reside at this facility. The last allegation involving R17 and R5 together occurred on [DATE]. 10. R18 discharged from the facility [DATE]. 11. R5 continues to reside at the facility. R5 received inpatient geri-psych treatment from [DATE] - [DATE]. R5 was being followed by facility psych services which were provided via telehealth. A new psych services contract has been initiated and visits will be conducted in person beginning [DATE]. 12. An audit was completed of Nurse's Notes dating back to [DATE] to identify allegations of abuse. The audit tool labeled Review of Nurse's Notes for Abuse and Potential Behavior Events Indicating a State Reportable was used. This audit resulted in forty-seven (47) abuse allegations reported to the Department of Community Health Complaint Division. 13. Nineteen (19) Residents were identified with a BIM score of 8 or higher and were interviewed using the Abuse Questionnaire for Interviewable Residents to identify potential allegations that indicate a State Reportable. This process resulted in one (1) abuse allegation reported to the Department of Community Health Complaint Division. This allegation was investigated and subsequently unsubstantiated. 14. A root cause analysis was completed; it was determined that a lack of thorough education related to the Abuse Prevention Program was a factor. Education for all staff related to the Abuse Prevention Program was started on [DATE] and has continued through [DATE]. 15. A Performance Improvement Plan related to Abuse Prevention Program was developed and will be followed through the facility's QAPI process. 16. The Regional Nurse Consultant conducted training using the Abuse, Neglect, and Exploitation policy specific to thorough investigations and corrective action implementation to decrease the likelihood of occurrence of alleged abuse for the following staff: a. 11 of 12 licensed staff members have received this training. b. 14 of 14 CNAs have received this training. c. 1 of 1 Activities Staff have received this training. d. 9 of 10 Dietary Staff have received this training. e. 7 of 7 Housekeeping/Laundry/Maintenance staff have received this training. f. 3 of the 3 Administrative Staff have received this training. Total Education: 45 of 47 Staff Members have received this training: 96% 17. All facility staff not in-serviced on the Abuse, Neglect, and Exploitation Policy specific to thorough investigations and corrective action implementation will not be allowed to work until the education is completed. The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows: 1. Inservice topic/adhoc QAPI meetings - Review of Immediate Jeopardy findings a. Verbal presentation 9:00 am to 9:45am by the Regional Administrator on [DATE] b. Attendance included Maintenance Director, Dietary Manager, Business Office Manager, AIT/MDS, Risk Manager, Activity Assistant, MDS, DON, Housekeeping Supervisor, Human Resources. Medical Director signed the sign in sheet on [DATE]. QAPI meeting [DATE]. c. Topics discussed include the following: Wandering & Elopement P/P, Grievance Policy and procedures, State Reportable, Abuse policy and procedures (sexual abuse, physical abuse, mental abuse, verbal abuse, neglect, exploitation, injury-unknown origin. Individuals in attendance included Medical Director, Administrator AIT, DON, MDS, SSD/Human Resources, BOM, CDM, Housekeeping Supervisor, Activities Director, Regional Manager, Regional Nurse Consutant BBB, Observation on [DATE] at 2:25 pm, several staff members were gathered in the dining room as an in-service was being presented. The surveyor heard the Regional Nurse Consultant presenting the inservice. Phone interview on [DATE] at 4:47 pm with the Regional Nurse Consultant (RNC) revealed that the facility employee roster was printed out on [DATE] and began the first wave of in-services. The topics discussed included defining abuse, different types of abuse, who the abuse coordinator was and examples of different abuse scenarios, and timely reporting of abuse and neglect. 2. Inservice topic/adhoc QAPI meetings - Review of Immediate Jeopardy findings. All the IJs identified on [DATE] were reviewed. a. Verbal presentation 9:00 am to 9:45am by the Regional Administrator on [DATE] b. Attendance included Maintenance Director, Dietary Manager, Business Office Manager, AIT/MDS, Risk Manager, Activity Assistant, MDS, DON, Housekeeping Supervisor, Human Resources. Medical Director signed sign in sheet on [DATE]. Facility policy Abuse, Neglect and Exploitation looks revised and different from the abuse policy initially provided. This policy had been highlighted to identify the specific types of abuse. Abuse identification, reporting, investigation, implementation of corrective actions; Elopements identification; QAPI process related to abuse and procedures and wandering. Interview on [DATE] on 9:23 am, The Regional Administrator stated a QAPI meeting was held about the Immediate Jeopardy finding. The RA stated that the Medical Director was not there in person, but he was on the phone to be a part of the discussion. The Medical Director visited the facility on [DATE] and signed the sign in sheet. 3. Upon arrival to the facility on [DATE] on 8:58 am, The Administrator's door was closed. This was unusual as the door had been open since entry of the facility on [DATE]. The Regional Administrator approached the Surveyor as she was setting up to inform her about the immediate resignation of the Administrator. The Regional Administrator (RA) stated she resigned yesterday evening, and we accepted it. I will be the acting Administrator for this facility moving forward. Anything you need you can ask me. The Administrator was not seen on the premises since that notification. The RA signed an Administrator job description for [DATE]. Interview on [DATE] at 4:08 pm with the Regional Administrator (RA), stated the previous Administrator's resignation was verbal. The verbal resignation was accepted effective [DATE]. 4. The following allegations of physical abuse were investigated and with necessary correction actions implemented. [DATE] at 2:47 pm (R5 and R14): Both residents were assessed, and no injuries occurred. R5's medication regimen was reviewed by the Medical Doctor. It was determined that R5 will be followed by psych services that will be in person at the facility. [DATE] at 6:40 am (R5 and R17): The outcome of the investingation was that R17 was moved to another room for safety after several attempts were made to redirect R5. On call Physician was notified and new orders medication (IM injection). Staff continue to monitor. [DATE] at 1:58 am (R5 and R17). The outcome of the investigation was that R17 was moved to a different room while R5's medication had changed per MD orders. [DATE] at 12:10 am (R5 and R8): Since the incident occurred, R5 has been on medication reviewed by the Medical Director/PCP. A room change was initiated and R5 received Inpatient psych services related to behaviors. [DATE] at 1:48 pm - (R5 and R8)- the final investigation was submitted on [DATE]. R5's medication has changed since the incident occurred per doctor's orders. Staff will continue to redirect R5 while in the facility. [DATE]. (R3 and R8): The outcome of this investigation was that per nurses notes, the Medical Director was contacted in regard to resident R3's behaviors with order to transfer resident to ER if R3 continued with aggression. Interview on [DATE] at 9:23 am the Regional Administrator (RA) revealed that a lot of the outcomes were based on some interventions that were previously done based on the nurses' notes and where the residents currently are in the facility. 5. The following allegations of sexual abuse were investigated and with necessary correction actions implemented. [DATE] at 6:47 am (R17 and R5) Outcome of the investigation was that a room change was initiated on [DATE]. [DATE] (R8 and physical therapist/contract employee UU): Outcome included the review of other female residents the Physical therapist/Contract employee UU case load were interviewed. Physical Therapist/Contract employee UU was banned from the facility. The investigation was unsubstantiated by the facility. Interview on [DATE] at 9:23 am the Regional Administrator (RA) revealed that a lot of the outcomes were based on some interventions that were previously done based on the nurses' notes and where the residents currently are in the facility. 6. The following allegations of verbal abuse were investigated and with necessary correction actions implemented. [DATE] at 2:23 am (R18 and R5) The LPN that made this nurse note entry is no longer employed at the facility and R18 is now deceased as of [DATE]. R5 is continued to be seen by psych services. [DATE] at 5:52 pm (R18 and R5): Outcome of the investigation is that there were no injuries. Room changes for R5 was initiated, medication for R5 was reviewed. R5 is still a resident at the facility however, R18 is now deceased as of [DATE]. Interview on [DATE] at 9:23 am the Regional Administrator (RA) revealed that a lot of the outcomes were based on some interventions that were previously done based on the nurses' notes and where the residents currently are in the facility. 7. Record review of FRI confirms that the incident of [DATE] with R5 and R8 was reported on [DATE]. Observation on [DATE] at 6:15 am, R5 has been observed in his room asleep. No behaviors were noted. and outside of his room several times through the survey and during the IJ time frame. Observation on [DATE] at 9:25 am, R8 was observed in her room, alert and orientated. R8 keeps to self and eats several meals in R8's room. Interview on [DATE] at 5:16 pm with R8 revealed the facility had conducted a survey and spoke with all the residents. R8 stated the staff had treated her well and there had not been any complaints at this time. R8 stated if she had any concerns or complaints, she would contact the Ombudsman and/or the Administrator. 8. Observation on [DATE] at 2:44 pm, R14 was observed interacting with the Activities Director. R14 was alert and orientated with no behaviors noted. Observation on [DATE] at 11:55 am, R14 was observed in the room, laying in bed. Review of the FRI documents a reported date of [DATE]. The resident is still in the facility. 9. Record review of FRI confirms that the incident for [DATE] was reported on [DATE]. Observation of 12/15/ 2023 at 11:50 am, R17 was observed in R17's room. R17 was in bed, asleep and appears clean. 10. Per the resident's MDS and Discharge sheet, R18 is deceased . 11. Observation on [DATE] at 9:03 am, R5 was observed in the facility in R5's room. R5 was at the foot of the bed, sitting up. Resident was alert and orientated with no behaviors noted. Observation on [DATE] at 6:15 am, R5 has been observed in R5's room asleep. No behaviors were noted. and outside of his room several times through the survey and during the IJ time frame. R5 was assessed at [name] Hospital. Review of R5's medical record documents an Interdisciplinary treatment plan was initiated [DATE]. The reason for this admission was noted to be aggressive. The DSM V diagnosis was noted to be Psychosis D/T organic and with brain disease. A Behavioral Health discharge assessment and Social Services discharge assessment were performed. Master treatment plan for R5 was reviewed. R5 had daily progress notes from [DATE] through [DATE]; his discharge on [DATE]. Subjective observations and objective observations were performed in addition to physical examinations and clinical treatment plan. R5's Psychiatric evaluation documents R5's Chief complaint, history of present illness, past psychiatric history, past medical history, current outpatient medications, allergies and social history were noted. 12. Audit tool Review of nurse's notes for abuse and potential behavior events indicating state reportable. The accessors were the AIT, The DON and MDS coordinator. Tool was reviewed by the DON beginning on [DATE]. Six pages does not have the accessor's name or date. The resident names are listed, and then checked yes or no. Yes, is in response to indicate potential problems for abuse. Total number of 71 residents were reviewed. Interview on [DATE] at 4:39 pm with the Administrator in Training (AIT) stated the individuals involved in the audit included the AIT, the MDS Coordinator, The Director of Nursing (DON) and the Regional Administrator (RA). The AIT stated that all the nurses' notes dated after [DATE] were printed out. There were a total of 1138 pages front and back. The 1138 pages were divided four ways, and each individual grabbed a stack and began to read. The AIT stated that each resident was reviewed, with their name on the audit tool. A yes indicated there was a problem and a no indicated no problems were detected. For all the yesresponses, the group would discuss and review the notes and then figure out who the other individual named in the nurse's note was ie. Roommate. A report is then sent to the State Agency and documented on a log. 13. Record review of resident BIMS Audit dates [DATE]. 19 Residents with the BIMs of 8 and above were identified. All the resident's Historical assessment report was printed out on [DATE] at 12:15 pm. An abuse questionnaire for the interviewable resident's was included. a. The questionnaires were conducted by Activities Director on [DATE]. b. 19 name questionnaires were found. c. Investigation that was identified for [DATE]. The FRI provided shows a reported date of [DATE]. Interview on [DATE] at 5:10 pm with R19 revealed that the Activity Director did ask R19 a bunch of questions about any instances of abuse. R19 revealed that R19's roommate was in an altercation with a staff member during R25's brief change. R19 stated a staff member puts hands on him. When asked who the staff member was, R19 couldn't recall. R19 noted that the Activity Director made notes of R19's Statement. Interview on [DATE] at 5:20 pm with R25 revealed that the Activity Director did speak with R25. R25 stated that the Activity Director asked about a situation that might have happened between R25 and a staff member. R25 stated no one put hands on me. R25 stated I told my roommate to stay out of my business. Interview on [DATE] at 5:10 pm with R9 revealed the facility had conducted a survey and spoke with all the residents. R9 stated the staff member had asked her if there had been any concerns about abuse, neglect, or misappropriation. R9 stated there had not been any concerns about these issues. R9 stated the facility had treated her well and she had been satisfied with the results of the investigations. R9 stated if there had been any concerns brought up in the Resident Council Meeting, she would inform the Ombudsman and the Administrator. Interview on [DATE] at 5:13 pm, R26 was observed seated in his room, he was well dressed, and well-groomed with no obvious signs of trauma or neglect. He stated he was well cared for and that he gets along well with staff and roommates he had no concerns regarding his care and stated concerns with his roommate were resolved and explained did not hit anyone just threw his plate on the floor and could not remember the incident. His roommate stated he felt safe around R26. Interview on [DATE] at 5:16 pm with R8 revealed the facility had conducted a survey and spoke with all the residents. R8 stated the staff had treated her well and there had not been any complaints at this time. R8 stated if she had any concerns or complaints, she would contact the Ombudsman and/or the Administrator. Interview on [DATE] at 5:23 pm, R27 was observed seated in her room, she was unable to recall the incident which occurred on [DATE] regarding another resident popping the top of her hand while playing cards. She stated the Administrator had previously talked to her but was unable to recall what the incident was about. R27 stated she felt safe and that she got along well with her roommates. 14. Plan was identified as the following. a. The facility will determine if/when the abuse occurred and investigate and report per the regulation. The start date was [DATE] with an ongoing completion date. Team leader for this plan was the Regional Administrator. The project goal: The facility shall show evidence that all alleged violations are thoroughly investigated. The Point people were the DON, the Regional Administrator, the MDS Coordinator and the AIT. b. The quality performance/peer review action plan outlined the actions they would take to correct issues for the identified problem areas. c. Actions to be taking for a for F600, a full house audit was conducted [DATE] - [DATE] review the nurse notes dated back to [DATE] to current. Additional actions were outlined in the facility action plan/continuous quality improvement plan. d. Persons responsible were identified at DON, AIT, Maintenance, Social Services Designee, and the Administrator. 15. QAPI meeting [DATE]. i. Topics discussed include the following: Wandering & Elopement P/P, Grievance Policy and procedures, State Reportable, Abuse policy and procedures (sexual abuse, physical abuse, mental abuse, verbal abuse, neglect, exploitation, injury-unknown origin. Individuals in attendance included Medical Director, Administrator AIT, DON, MDS, SSD/Human Resources, BOM, CDM, Housekeeping Supervisor, Activities Director, Regional Manager, Regional Nurse Consultant. A performance improvement project worksheet was reviewed. The project title is F-tag 600 freedom from abuse; F tag 610 failure to investigate, report, prevent and correct alleged abuse. Plan: The facility will determine if/when the abuse occurred and investigate and report per the regulation. The start date for this project is [DATE] with the completion date is ongoing. The Regional Administrator is leading the charge. A root cause analysis was conducted to develop and approach the problem. The implement the approaches or the plan include at the following. A full house audit was conducted between [DATE] through [DATE] of the nurses' notes dates back to the prior survey [DATE] to current. Any identified allegations of abuse will be reported. Education will be provided to the employees except two as they will not be returning to work. Abuse education will be provided upon hire and on throughout the calendar year. The administrator or designee will take charge of the investigations and report in the time frame required. Individuals identified to be responsible for these efforts was the MDS coordinator, AIT, DON, and Regional Administrator. 16. Per the Regional Administrator (RA) the log of individuals names and their dates of participation of the in- services are included. Signatures of the services were used to confirm. During the confirmation period on [DATE] at 10:30 am. There was a discrepancy in the identification of staff. The total number of educated staff members are 45. The breakdown of the staff is at follows. Interview on 11:08 am on [DATE] with the RA confirms the staff breakdown below is as follows. 11 of 12 licensed staff members have received this training. 15 of 15 CNAs have received this training. 1 of 1 Activities Staff have received this training. 9 of 10 Dietary [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, interviews, and review of the policy titled Care Plans, Comprehensive Person-Centered the facility failed to develop and implement the person- centered care plan that focused on risks for wandering and elopement for two residents (R) (R6 and R10) from a sample of 19 residents. On 12/5/2023, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Administrator, Regional Administrator (RA), Director of Nursing (DON) and Regional Nurse Consultant (RNC) were informed of two Immediate Jeopardy's (IJ) on 12/5/2023 at 3:45 pm. The second Immediate Jeopardy (IJ) was identified to have existed on 7/14/2023 when the facility failed to provide protective oversight for residents at risk for elopement when R6 eloped three times and R10 eloped in a three-month timeframe. A Credible Allegation of Compliance was received on 12/13/2023. Based on observations, record review, resident and staff interviews, and review of facility policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed as of 12/14/2023. Findings include: Review of the policy titled Care Plans, Comprehensive Person- Centered revised December 2016, revealed a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation: number 1. The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. Number 2. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. Number 8. The comprehensive person-centered care plan: g. incorporates identified problem areas. H. incorporates risks factors associated with identified problems. 1. Review of the clinical record revealed R6 was admitted to the facility on [DATE] with diagnoses including dementia, agitation, and depression. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview Mental Status (BIMS) score of 99, indicating the resident had severe cognitive impairment. Section E revealed the resident exhibited wandering behaviors daily and the behaviors put the resident at significant risk of getting outside the facility. Section GG revealed resident ambulated independently. Review of the Elopement Risk Assessment dated 6/30/2023 revealed R6 wanders aimlessly and verbally expresses a desire to leave the facility. A wander guard was applied to left wrist. Review of R6's comprehensive care plan initiated on 7/9/2023 and revised on 10/4/2023 revealed resident is at risk for wandering/elopement due to attempting to exit the building. Interventions to care include provide distraction, provide simple commands, and promptly checking exit doors when the alarm sounds. Interventions added after the 7/14/2023 elopement include assess residents whereabouts every 15 minutes and check residents wander guard at each exit to ensure it is functioning properly each shift. There is no evidence of interventions added for the 8/18/2023 or the 8/29/2023 elopements. Review of the Progress Note dated 7/2/2023 at 1:49 am written by Licensed Practical Nurse (LPN) HH, documented R6 was being monitored due to wandering and voiced the desire to go home and tried to find a way out, wander guard intact to left wrist. Review of the Progress Note dated 7/14/2023 at 4:22 pm written by the Administrator in Training (AIT), documented at 10:30 am Activities Director (AD) answered the phone with a woman stating she saw a man in a light blue shirt walking on the highway. Review of the Progress Note dated 8/19/2023, written by LPN HH, documented on 8/18/2023 at 11:15 pm Certified Nursing Assistant (CNA) TT observed R6 going out the laundry door near the maintenance shed. Review of a handwritten note dated 8/29/2023 written by CNA EE, documented R6 walked out through the back door, and she tried to redirect him back inside the building, but resident refused. There is no documentation in the resident electronic medical record regarding this incident. Interview on 11/27/2023 at 10:59 am, the Activities Director (AD) stated the facility doors used to stay unlocked all the time. She stated residents were able to go in and out. The AD stated R6 was missing from the facility for approximately one hour. During continued interview, she stated lock pads were installed to the doors on 9/14/2023. Interview on 11/27/2023 at 4:07 pm, the Director of Nursing (DON) revealed interventions on care plans were communicated to all staff by word of mouth. According to the DON, the facility had not been initiating quarterly elopement assessments as required by facility policy. She stated elopement assessments were only being completed on admission. During further interview, the DON stated she expects the care plan coordinator to document residents identified as risk for elopement. The DON stated care plan interventions are mostly carried out to staff by word of mouth, and that interventions are to be developed and implemented after each elopement. Interview on 11/27/2023 at 4:45 pm, the AIT said the wander guard system was not loud enough for staff to hear, and when the doors are open, the alarm does not sound. She stated the Maintenance Director was made aware, but nothing has changed. During further interview, she stated the current system was unsafe and explained if a resident walked out behind a family member staff would not be able to detect and hear the alarm sound. She stated care plans should be updated after each elopement. Interview on 12/15/2023 at 9:04 am, LPN AA revealed care plans should be updated to include the interventions specifically related to wandering. She verified the wandering interventions for R2 on his care plan, and confirmed there were no additional interventions added for the 8/16/2023 and 8/29/2023 incidents when R2 was found outside the facility. 2. Review of the clinical record revealed R10 was admitted to the facility on [DATE] with diagnoses including dementia with psychotic disturbance, hypertensive heart disease, and stage four chronic kidney disease (CKD). Review of the admission Minimum Data Set (MDS) dated [DATE] revealed a BIMS score of 11, indicating moderate cognitive impairment. Section E revealed the resident did not exhibit wandering behavior Section GG revealed resident ambulated independently. Review of the Elopement Risk Assessment dated 9/7/2023 for R10 revealed section for wandering was not completed, but indicated his photo was added to the wanderer list. Further review revealed resident has not shown any signs of leaving facility, and wander guard was removed. Review of R10's comprehensive care plan initiated on 7/31/2023 and revised on 9/7/2023 revealed resident is at risk for wandering/elopement with wander guard in place. Interventions to care include photo taken and placed in designated areas, diversional activities to reduce wander/elopement behavior, observe for wander/elopement behavior, psych consult as needed, and notify physician (MD) as needed (PRN). The goal was for R10 not to exit the facility unplanned and or unattended. Review of Progress Note revealed a late entry dated 9/16/2023 at 2:23 pm written by LPN GG, documented at approximately 10:20 am, she received a call from R10's representative. The representative stated R10 expressed the desire to leave the facility immediately. Review of Progress Note dated 9/16/2023 at 2:15 pm written by DON documented R10 was found safe by the sheriff department on the highway around 1:50 pm. Further review revealed documentation that resident will not be returning to the facility due to safety hazard. Interview on 11/27/2023 at 4:07 pm, the DON revealed care plan interventions were communicated to all staff by word of mouth. She stated the interventions were not supported by documentation, and revealed the wander guards are monitored once a month. The DON stated staff are expected to take residents equipped with the wander guard to the exit doors and test if the system responded as required and expects staff to document in the nursing notes that they monitored the wander guard. During further interview, she stated the facility had not been completing quarterly elopement assessments as required by facility policy. She stated elopement assessments were only done on admission. She stated she expected the care plan coordinator to document residents identified as risk for elopement. Interview on 11/27/2023 at 4:45 pm, the AIT revealed the wander guard system was not loud enough for staff to hear, and when the doors are open, the alarm does not sound. She stated the current system was unsafe and explained if a resident walked out behind a family member, staff would not be able to detect and hear the alarm sound. She stated care plans should be updated after each elopement. She confirmed the care plan was not updated after the elopement for R10, because he was not returning to facility. Observation on 11/27/2023 at 4:50 pm, the AIT tested the wander guard system with a wander guard bracelet in her hand, and the door opened. The audible alarm sound was faint. The AIT stated, the door should not have opened, and the alarm sound could barely be heard. The alarm system was not detected, and the sound was faint. Interview on 12/5/2023 at 9:50 am, the DON indicated that the Quality Assurance and Performance Improvement (QAPI) meetings were designed to discuss areas needed for improvement and to discuss residents who were potentially at risk. The DON concluded the meetings in QAPI are a waste of time, and added discussions are never put in to practice, such as the discussions about care plan interventions. The facility implemented the following actions to remove the Immediate Jeopardy: 1. The facility held an Ad Hoc QAPI meeting to review the Immediate Jeopardy findings. The following key personnel attended the Ad Hoc QAPI meeting: Regional Administrator, AIT/MDS, Risk Manager, Activity Assistant, MDS, Director of Nursing, Housekeeping Supervisor, and the Human Resources Director. The Medical Director was unable to attend in person, however, this information was reviewed via teleconference. The Medical Director visited 12/12/2023 and reviewed facility findings and plans and no recommendations were made. During this meeting, a review of the Care Plan policy was completed, and no policy changes were recommended. 2. The Administrator resigned effective immediately on 12/5/2023. The Regional Administrator, assumed the role of Interim Administrator on 12/6/2023. 3. All Residents were assessed using the Elopement Risk Assessment to determine residents at high risk for elopement. These assessments resulted in three (3) additional residents at high risk, bringing the facility total to five (5) residents at high risk for elopement. 4. Care Plans have been reviewed and updated for five Residents determined to be at High Risk for Elopement. 5. Five (5) residents determined to be at High Risk for Elopement have been updated in the Elopement Binder. All staff have been educated on the location of the Elopement Binder (Admin office, dietary (kitchen), and nurse's station. The elopement binders will be updated as any additional residents are identified as high risk for elopement. The Director of Nursing will be responsible for updating the binders. 6. Resident R6 Care Plan review was completed, and appropriate updates were made specific to the risk for wandering/elopement and specific to suicidal ideations. 7. R6 continues to reside at the facility and is being followed by contracted psych services. R6 was seen by psych services on: 8/10/2023, 9/7/2023, and 11/16/2023. R6 has no elopements since 8/29/2023. 8. Resident R10 is no longer a Resident at this facility, discharge date of 9/16/2023. 9. The Wander Guard devices on residents identified as high risk for elopement are monitored every 12 hours by a Nursing Manager using the handheld Wander Guard Universal Tester noted in the electronic Medication Administration Record (MAR). The Universal Tester device was ordered and was delivered to the facility on [DATE]. All Staff are educated on 12/12/2023 on the use of the Universal Tester. 10. A root cause analysis was completed; it was determined that a lack of training related to Wandering and Elopements was a factor. Training for all staff related to Wandering and Elopements started on 11/30/2023 and has continued through 12/12/2023. 11. A Performance Improvement Plan related to Wandering and Elopements was developed and will be followed through the facility's QAPI process. 12. The Corporate MDS consultant provided education to the DON, MDS/AIT, and the MDS. The Regional Nurse Consultant conducted training related to Care Plan updates specific to those residents determined to be at high risk for elopement and for residents with suicidal ideations for the following staff: a. 11 of 12 licensed staff members have received this training. Total Education: 11 of 12 Staff Members have received this training: 92% 13. All Licensed staff not in-serviced on Care Plan updates specific to wandering/elopement will not be allowed to work until the education is completed. The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows: 1. A QAPI meeting was held on 12/6/2023 from 9:00 am and ended at 9:45 am. The following staff attended the QAPI meeting- Business Office Manager, Maintenance, Director, Dietary Manager, Administrator in Training AIT/MDS, Risk Manager Activity Assistant, MDS, Director of Nursing, Housekeeping Supervisor, and Human Resource Director. The QAPI meeting was held for the following Tags F835, F867, F689 and F689. And signatures were documented regarding completion of the inservice. 2. Resignation of the Administrator was verified per observation 12/6/2023 at 8:58 am. The Regional Administrator stated Administrator resigned yesterday evening and the resignation was accepted. He stated he will the acting Administrator moving was forward. The following interview verified the above information: During an interview on 12/15/2023 at 9:44 am, the DON revealed that in-services were held regarding elopement, wandering and abuse. Abuse should be reported within two hours to the state. QAPI meetings are addressed monthly, and clinical meetings are held every morning. When interventions are discussed during the QAPI we will start the in-service the same day if possible. The DON was not sure how much CNA's can see on care plans regarding the interventions. CNA's can access the elopement book. There are pictures of the identified as elopement risk residents and daily sign out sheets. LPN's can document in the MAR about the location of the resident as they are monitored. Facility now has a louder system, and it can be heard at a further range and if the door is open the sound is even much louder and at a rapid pace. DON was responsible for the education on the wander guard tester and she in-serviced staff regarding the tester. Alarm education was done by the Maintenance Director. 3. Residents R6, R10, R19, R20, R21, and R 22 are assessed for elopement risks. 4. Residents R6, R10, R19, R20, R21, and R 22 care plans updated for elopement risks. During an interview on 12/15/2023 at 9:14 am, LPN RR revealed she works the first shift, we did in-service about elopement and facility identified additional residents and added wander guards to the residents. The sound of alarms is audible and it can be heard from the nurse's station, and they sound when the wander guards are checked once a shift, the residents are checked hourly only by staff have the access codes to the door. The elopement book has all the intervention at the nurses stationand all staff have access to the book. During an interview on 12/15/2023 at 9:27 am, CNA EE revealed the in-service discussed elopement and abuse. And what to do when a resident elopes. CNA EE stated facility identified six residents as risk for elopement and the identified residents all have wander guards on their ankles. We take them to front door and the alarm goes off and they are working on it to get louder. We check on the resident elopement we check on them constantly. Only the staff have the access codes to exit the building. During an interview on 12/15/2023 at 9:34 am CNA SS revealed the in-service was done regarding elopement during the in-service and that it should be reportable to the administrator immediately. We do check on the resident that have been identified every few fifteen minutes. R6 is alert and oriented. Now we are doing regular checks, and we are checking more residents, we do check the wander guards every morning. Some have wander guard on the wrist. The alarm sounds can be heard from the hallway when the sound is heard you go and investigate. Observations on 12/14/2023 at 11:30 am showed residents R6, R10, R19, R20, R21 and R 22 had wander guards on their wrist and the wander guard functioned as required. 5. Observations on 12/14/2023 at 11:30 am, showed residents R6, R10 R19, R20, R21- and R 22, had wanderguards on their wrist and the wander guard functioned as required. During an interview on 12/15/2023 at 9:44 am, the DON revealed that in-services were held and additional residents identified as at risk for elopement were identified regarding elopement, wandering. QAPI meetings are addressed monthly, and clinical meetings are held every morning. When interventions are discussed during the QAPI we will start the in-service the same day if possible. The DON was not sure how much CNA's can see on care plans regarding the interventions. CNA's can access the elopement book there are pictures of the identified as elopement risk residents and daily sign out sheets. LPN's can document in the MAR about the location of the resident as they are monitored. Facility now has a louder system, and it can be heard at a further range and if the door is open the sound is even much louder and at a rapid pace. DON was responsible for the education on the wander guard tester and she in serviced staff regarding the tester. Alarm education was done by the Maintenance Director. 6. Documentation revealed R6's care plan was updated and showed specific interventions related to wandering/elopement and specific to suicidal ideations 12/6/2023. Record review showed facility implemented specific intervention in R6's care plan and documented directions. Record review showed facility reassessed R6 elopement risk assessment on 11/27/2023. The following interviews verified the care plan was updated. During an interview on 12/15/2023 at 9:04 am, LPN AA revealed she had done in-service regarding elopement and care plans were updated to include the interventions specifically related to wandering. We are now monitoring residents with bracelets before they have a tester, now it has a high pitch sound and its loud and clear I feel. The elopement book is accessible to all and they can access it for certain measures. The care plans are now updated to indicate they are at risk for elopement on the care plan they will be interventions all CNA are conveyed verbally through communications on what interventions are in place. All wander guards are checked on the MAR. During an interview on 12/15/2023 at 9:14 am, LPN RR revealed she works the first shift, we did in-service about elopement and abuse and when observed abuse that is reported to the administrator. Additional residents were identified. They added wander guards to those residets identified, and they fixed the sound alarm, its audible it can be heard from the nurse's station, and they sound we the wander guards are checked once a shift, the residents are checked hourly only the staff have the access codes to the door. The elopement book has all the intervention at the nurses and all staff have access to the book. 7. Record review showed psych services were established for the resident and R6 had no observed or recorded elopements since 8/29/20203. During an interview on 12/15/2023 at 6:45 am, LPN BB revealed knowledge of the six identified residents for risk of elopement. Licened Practical Nurse BB stated she received in-service regarding abuse and elopement. She explained codes were changed for the front door and will be changed daily. She stated the alarm was loud enough for staff to hear when inside the facility. Observations on 12/14/2023 at 11:30 am showed R6 had wanderguard on their wrist and the wanderguard functioned as required. 8. Record review and interviews showed R10 was discharged from the facility on 9/16/2023. 9. According to the daily door lock checks, documentation showed daily door checks were started on 12/4/2023. The following interviews were conducted and verified the above information: During an interview on 12/15/2023 at 6:45 am, LPN BB revealed knowledge of the six identified residents for risk of elopement. BB stated she in-serviced regarding abuse and elopement. BB explained codes were changed for the front door and will be changed daily. BB stated the alarm was loud enough for staff to hear when inside the facility. During an interview on 12/15/2023 at 9:44 am the DON revealed that in-services were held regarding elopement, wandering and abuse. Abuse should be reported within two hours to the state. QAPI meetings are addressed monthly, and clinical meetings are held every morning. When interventions are discussed during the QAPI we will start the inservice the same day if possible. The DON was not sure how much CNA's can see what is on care plans regarding the interventions. CNA's can access the elopement book, there are pictures of the identified as elopement risk residents and daily sign out sheets. LPN's can document in the MAR about the location of the resident as they are monitored. Facility now has a louder alarm system, and it can be heard at a further range and if the door is open the sound is even much louder and at a rapid pace. The DON was responsible for the education on the wander guard tester and she in-serviced staff regarding the tester. Alarm education was done by the Maintenance Director. Observations on 12/14/2023 at 11:30 am showed R6 had wanderguard on their wrist and the wanderguard functioned as required 10. A full house audit was conducted on 11/30/2023 and continued through 12/12/2023. Documentation showed five additional residents were identified as Risk for Elopement. 11. Record review showed on 11/30/2023 a full house audit was conducted and a total of five residents were identified for potential risk for elopement. The elopement Binder was updated with pictures of those residents. A list would be kept in the elopement binder with expiration dates of the wander devices for replacement. Education was provided to all staff regarding the elopement wandering policy and process. The care plans were updated to reflect elopement risk. The clinical team will ensure the orders are on the Medication Administration Record (MAR). The families were notified of the assessment results and informed that a wanderguard bracelet would be placed. The Mag locks are to be checked for placement by the nurse on every shift and additional wanderguards were ordered for additional residents and were placed on the residents. 12. a. 11 of 12 licensed staff members have received this training. b. 14 of 14 CNA's have received this training. c. 1 of 1 Activities Staff have received this training. d. 9 of 10 Dietary Staff have received this training. e. 7 of 7 Housekeeping/Laundry/Maintenance staff have received this training. f. 3 of the 3 administrative staff members have received this training. Evidence of the in-service showed that on 12/6/2023 at 12:00 pm to 1:00 pm and from 1:00 pm to 2:00 pm regarding Wandering, Elopement and Resident Safety and was dated on 11/30/2023 in all a total of thirty-six (36) staff were in-serviced signed on the inservice sheet. Another inservice sheet was completed on 12/1/2023 at 9:00 am ten staff (10) and on 12/1/2023 at 10:30 am a total of (13) thirteen. 13. Interview with the Regional Administrator revealed that all staff had been in-serviced regarding wandering and elopement. Interviews with staff showed in-service was completed regarding wandering and elopement, the DON supported with the following interview: During an interview on 12/15/2023 at 9:44 am the DON revealed that in-services were held regarding elopement, wandering and abuse. Abuse should be reported within two hours to the state. QAPI meetings are addressed monthly, and clinical meetings are held every morning. When interventions are discussed during the QAPI we will start the inservice the same day if possible. The DON was not sure how much CNA's can see on care plans regarding the interventions. CNA's can access the elopement book, there are pictures of the identified as elopement risk residents and daily sign out sheets. LPN's can document in the MAR about the location of the resident as they are monitored. Facility now has a louder alarm system, and it can be heard at a further range and if the door is open the sound is much louder and at a rapid pace. The DON was responsible for the education on the wanderguard tester and she in-serviced staff regarding the tester. Alarm education was done by the Maintenance Director. During an interview on 12/15/2023 at 6:55 am CNA LL revealed stealing and sexual inappropriate touching, mental and restraint is considered abuse and reportable to the administrator immediately, and all is reported when the administrator is not available, she would report to the DON. If a resident combative she would report first and then check on them, we have six residents with wanderguards. We check on those residents every two hours. I completed elopement in-services, abuse, and all types and how to report. We were told if the wanderguard resident exited it would sound an alarm. I was not here when they did the demonstration about sounding the alarm. If a resident disappears, we search the area and call 911. Interview on 12/15/2023 at 7:04 am, CNA MM stated abuse can be mental physical and dignity and if observed I would report it, I would notify the charge nurse if observed abuse, I would calm the residents down, we completed the F tags, abuse and elopement, we are supposed to make rounds making sure residents are in their rooms the ones that have wanderguard. Always check the residents throughout the nights. We have six residents with wanderguards. The alarm is loud enough to be heard. Interview on 12/15/2023 at 7:13 am, CNA KK we have learned abuse topic and forms of abuse and what to do when it occurs. Physical, mental, isolation, financial, verbal and I will inform the charge nurse if I observe the staff stealing money, the administrator is the abuse coordinator, during care when a resident becomes combative, I will separate them so they can calm down. I came in on one with the administrator, we talked about the elopement and were told to search all the rooms when they are missing contact the police and the administrator The maintenance guy sounded the alarm, and it could be heard and was loud. During an interview, 12/15/2023 at 7:23 am, CNA DD revealed we have learned all types of abuse including financial. Administrator is the abuse coordinator and any abuse would be reported to him immediately if he not here DON would be the next person to report to. We talked about abuse and elopement we now have six identified residents. That alarm sounding was demonstrated, I am not able to hear the alarm. Resident cant gets out because we have mega locks and codes. The resident does not know the codes. During an interview 12/15/2023 at 7:24 am, Dietary Aide NN revealed we learned about abuse and that it was reportable to the administrator immediately. Including verbal abuse which is reportable to the administrator. Elopement we were told when the alarm sounds the patient is trying to get, the alarm sound can be heard while I am in the kitchen.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, and review of the facility policy titled Elopements, the facility failed to provide adequate monitoring and protective oversight of the elopement prevention program and failed to ensure the mechanisms of the electronic alert system was functioning properly to prevent residents at risk for elopement to exit the facility undetected. In addition, the facility failed to have a process in place for the four remaining exit doors not equipped with the electronic alert system. Specifically, resident (R) R6 and R10, both wearing electronic alert system devices, eloped from the facility for approximately three hours, before being spotted by local citizens, and reported to the facility that they were missing. The sample size was 19. On 12/5/2023, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Administrator, Regional Administrator (RA), Director of Nursing (DON) and Regional Nurse Consultant (RNC) were informed of two Immediate Jeopardy's (IJ) on 12/5/2023 at 3:45 pm. The noncompliance related to the the second Immediate Jeopardy (IJ) was identified to have existed on 7/14/2023 when the facility failed to provide protective oversight for residents at risk for elopement when R6 eloped three times and R10 eloped once in a three-month timeframe. A Credible Allegation of Compliance was received on 12/13/2023. Based on observations, record review, resident and staff interviews, and review of facility policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed as of 12/14/2023. Findings include: Review of the policy titled Elopements revised 2008, indicated staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the Charge Nurse or the Director of Nursing (DON). When a departing individual returns to the facility, the DON or Charge Nurse shall examine the resident for injuries, notify the attending physician, notify the residents legal representative of the incident, complete and file Report of Incident/Accident, and document the event in the resident's medical record. 1. Review of the clinical record revealed R6 was admitted to the facility on [DATE] with diagnoses including dementia, agitation, and depression. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview Mental Status (BIMS) score of 99, indicating the resident had severe cognitive impairment. Section E revealed the resident exhibited wandering behaviors daily and the behaviors put the resident at significant risk of getting outside the facility. Section GG revealed resident ambulated independently. Review of the Elopement Risk Assessment dated 6/30/2023 documented the following: --Is the resident cognitively impaired with poor decision-making skills? (i.e., intermittent confusion, cognitive) - staff documented Yes and documented the resident had dementia, agitation, and confusion. --Does the resident verbally express the desire to go home? Staff documented, Yes. --Does the resident wander aimlessly? staff documented, Yes and documented frequently wandering- wander guard intact to left wrist. Review of R6's care plan revised on 10/4/2023 documented R6 was at risk for wandering/elopement due to attempting to exit the building. The care plan directed staff to provide distraction, provide simple commands and promptly check exit doors when the alarm sounds. Interventions added after the 7/14/2023 elopement include assessing resident whereabouts every 15 minutes and check residents wander guard at each exit to ensure it is functioning properly each shift. There is no evidence of interventions added for the 8/18/2023 or the 8/29/2023 elopement incidents. Review of the Progress Note dated 7/2/2023 at 1:49 am written by Licensed Practical Nurse (LPN) HH, documented R6 was being monitored due to wandering and voiced the desire to go home and tried to find a way out, electronic alert system device intact to left wrist. Review of the Progress Note dated 7/14/2023 at 4:22 pm written by the Administrator in Training (AIT), documented at 10:30 am Activities Director (AD) answered the phone with a woman stating she saw a man in a light blue shirt walking on the highway. Staff started looking throughout the building. The AD walked down the road and found resident approximately one and a half a miles from the facility. Resident was returned to the facility; assessment was completed, and no injuries noted. Resident had electronic alert system device intact and functioning properly upon re-entry to the facility. Review of the weather status in the area, according to Accuweather.com, showed the temperature on 7/14/2023 ranged from 71 degrees Fahrenheit (F) to 91 degrees F. Review of the Follow-up Report dated 7/21/2023 revealed on 7/14/2023, the AD received a call to the facility at approximately 10:30 am from an outside caller stating, she believed we might have a resident in a light blue shirt on the highway by her house. R6 had an electronic alert system device in place on the right wrist. Facility findings of the investigation showed the electronic alert system alarm on the back door was noted not functioning properly. The back gate by the broiler was not functioning properly and was replaced immediately. Review of the Progress Note dated 8/19/2023, written by LPN HH, documented on 8/18/2023 at 11:15 pm Certified Nursing Assistant (CNA) TT observed R6 going out the laundry door near the maintenance shed. CNA TT approached R6 to redirect him back into the facility and he stated, he was going to kill himself and end it and added, he didn't know he was going to be at the facility forever. R6 stated he didn't want to be at the facility. Resident was redirected back into the facility and later that afternoon, he tried to go out the front door when staff were trying to leave. LPN HH redirected resident back to his room and allowed him to vent his feelings. Resident showed no harm or threat to himself and will continue to monitor closely with 15-minute visual/safety checks. Review of a handwritten statement dated 8/29/2023 written by CNA EE, documented R6 walked out through the back door, and she tried to redirect him back inside the building, but resident refused. She documented that R6 was not supposed to be outside, but he got out on his own. CNA EE attempted to lead R6 back to the facility and R6's foot went off the concrete sidewalk and R6 fell and hit his head. She notified LPN GG. There is no evidence of documentation of this incident in the residents' electronic medical record (EMR). Interview on 11/27/2023 at 10:59 am, the Activities Director revealed on 7/14/2023, she received a phone call from a local citizen, who suspected a resident from the facility was walking along the highway. The AD asked the caller about the residents' description, and she concluded the description fitted that of R6. She stated she walked towards the highway and located R6 a mile and half from the facility. She notified the facility and the AIT drove to the location and transported R6 back to the facility. The AD stated the facility doors used to stay unlocked all the time, and residents were able to get in and out. She stated the lock pads were installed on 9/14/2023. Interview on 11/27/2023 at 11:25 am, LPN AA revealed she was familiar with R6 and stated he was slick, sneaky, and understood what was going on. She stated R6 was familiar with his surroundings and always looked for a way out. LPN AA stated the current electronic alert system was unsafe and placed residents at risk. Interview on 11/28/2023 at 9:43 am, LPN GG stated that R6 had attempted to leave the facility on multiple occasions. She revealed at that time when R6 eloped, the facility doors stayed unlocked. During further interview, LPN GG stated she does not recall the incident which occurred on 8/29/2023, when R6 exited the building. She stated it was impossible to monitor residents who were at risk for elopement on regular basis due to staffing concerns. Interview on 11/28/2023 at 4:59 pm, CNA FF revealed that R6 had attempted to leave the facility on several occasions. She revealed there was no electronic alarm system on any of the doors, except the front door, but that alarm sound was faint and could not be heard. During further interview, she stated residents had been able to get in and out of the facility before the maglocks were installed. 2. Review of the clinical record revealed R10 was admitted to the facility on [DATE] with diagnoses including dementia with psychotic disturbance, hypertensive heart disease, and stage four chronic kidney disease (CKD). Review of the admission MDS assessment dated [DATE] revealed a BIMS score of 11, indicating moderate cognitive impairment. Section E revealed the resident did not exhibit wandering behavior. Section GG revealed resident ambulated independently. Review of the Elopement Risk Assessment dated 9/7/2023 documented the following: --Is the resident cognitively impaired with poor decision-making skills? (i.e., intermittent confusion, cognitive) - staff documented Yes and documented the resident had dementia, agitation, and confusion. --Does the resident verbally express the desire to go home? Staff documented, No. --Does the resident wander aimlessly? staff documented, No. Resident re-evaluated and noted to no longer be an elopement risk as he has shown no signs of leaving the facility with wander guard removed. Review of the care plan for R10 revised on 9/7/2023 revealed resident was at risk for elopement/wandering with electronic alert system device in place. The goal was for R10 not to exit the facility unplanned and or unattended. The care plan directed staff to use diversional activities and to observe wandering and elopement behavior. Review of the Follow-up Report dated 9/22/2023 revealed on 9/16/2023, LPN GG received a call from R10's sister stating resident called her earlier saying he was going to leave the facility and go home. After the call ended, LPN GG went to the residents room and resident was not in his room. She alerted the staff of Code Pink and staff began looking in the facility and on the facility grounds, but resident was not located. Local authorities were notified, including the Administrator. Resident responded to facility via phone call and mobile text messages, and resident was located approximately two miles from the facility. Resident was noted to have superficial scratches to face from briars, but no complaints of pain. Emergency Medical Services (EMS) dispatched and transported R10 to the hospital for evaluation. Resident left the hospital against Medical Advice (AMA) after having eloped from the ER and being returned by local police department. Facility findings of the investigation revealed that resident had been pacing outside the facility in the smoking area. Smoke breaks are now scheduled and supervised by staff during set times throughout the day, door locks checked every shift. Review of a written statement from the AIT dated 9/16/2023, the AIT documented at 10:55 am she drove and searched the area for R10. At 1:52 pm the AD called and stated R10 had been located and was seated in AD's personal car. Record review of the weather status in the area, according to Accuweather.com, showed the temperature on 9/16/2023 ranged from as low as 61 degrees Fahrenheit (F) to 78 degrees F. Record review of R10's progress notes showed a late entry dated 9/16/2023 at 2:23 pm LPN GG documented, at approximately 10:20 am, she received a call from R10's representative. The representative stated R10 expressed the desire to leave the facility immediately. LPN GG told R10's representative she last saw R10 at 10:00 am walking down the hall. She was unable to locate R10, after a perimeter search around the facility, LPN GG notified the supervisor R10 was missing. Entire staff searched the facility and were unable to locate R10 and GG notified the police department. Review of a hand written statement from LPN GG dated 9/16/2023, revealed she spoke with residents sister at 10:20 am, who was concerned because R10 called her and stated he was going to leave the facility. LPN GG went to residents room and the smoking area and was unable to locate the resident. Staff started searching the surrounding woods and the highway. Called and texted resident encouraging him to return to the facility. Resident stated he did not want to return to the facility. LPN GG continued to communicate with R10 until 1:19 pm. Review of Progress Note dated 9/16/2023 at 2:15 pm written by the DON, documented R10 was found safe by the sheriff's department on the highway around 1:50 pm. EMS arrived at the scene and transported R10 to the hospital for evaluation. DON notified representative that resident had been found and documented R10 will not be returning to the facility due to safety concerns. Interview on 11/27/2023 at 2:40 pm, the Maintenance Director revealed the front entrance was the only door equipped with an electronic alert system. He stated the sensor system was supposed to beep when a resident with an electronic alert system device gets close to the door. He revealed the rest of the facility exit doors were not equipped with the electronic alert system. During further interview, he stated staff informed him the front door electronic alert system alarm was not loud enough. He stated the electronic alert system was discontinued, obsolete and could not be repaired. The Maintenance Director revealed the facility installed all the exit doors with a mega lock system on 9/14/2023, which requires an access code to be entered to exit the building. He stated he checked the mega lock system daily but does not check the electronic alert system. He stated he relied on the mega lock system which, he stated did not have a sound feature to alert staff when a resident equipped with an electronic alert system device exits the building. Interview on 11/27/23 at 4:07 pm, the Director of Nursing (DON) stated staff are expected to take residents equipped with the electronic alert system device to the exit doors and test if the system responded as required. The system was supposed to sound an alarm, when a resident equipped with an electronic alert system device moved closer to the door. She stated she expected staff to document in the nursing chart that they monitored the wander guard. The DON confirmed the front door was the only door fitted with the electronic alert system and verified the current alarm system was not loud enough for staff to hear. During further interview, she stated prior to 9/13/2023, the rear doors stayed unlocked during the day. According to the DON, facility staff were supposed to review current procedures after each elopement and the resident is supposed to be sent out for evaluation. For the 7/14/2023 elopement, R6 was not sent out for evaluation, but staff monitored R6 every fifteen minutes. The fifteen-minute monitoring checks were discontinued, but she did not recall when and why the monitoring was discontinued. The DON stated elopement assessments were only done on admission, and not quarterly, as required by facility policy. Interview on 11/27/2023 at 4:45 pm, the AIT revealed the electronic alert system was not loud enough for staff to hear, and when the doors are open, the alarm does not sound. She stated the current system was unsafe and explained if a resident walked out behind a family member, staff would not be able to detect and hear the alarm sound. Observation on 11/27/2023 at 4:50 pm, the AIT tested the wander guard system with an electronic alert system bracelet in her hand, and the door opened. The audible alarm sound was faint. The AIT stated, the door should not have opened, and the alarm sound could barely be heard. The alarm system was not detected, and the sound was faint. Interview on 11/28/2023 at 8:53 am, the Administrator revealed she was unaware how R6 and R10 exited the building without staff noticing. She stated R6 and R10 were not adequately supervised, and the wander guard system did not sound the alarm when they exited. During further interview, she stated when R6 and R10 eloped from the facility, the doors were not equipped with the maglock system. She stated the maglock key codes are only given to staff members. She stated she expected staff to provide protective oversight for all residents. The facility implemented the following actions to remove the Immediate Jeopardy: 1. The Regional Nurse Consultant provided education related to the Wandering and Elopements policy, location of Elopement Binders, identifying residents at high risk for elopement, and Magnetic Door Lock Mechanism functionality to the following Department Managers: Regional Administrator, AIT/MDS, Risk Manager, Maintenance Director, Activity Assistant, MDS, Director of Nursing, Housekeeping Supervisor, and the Human Resources Director. 2. The facility held an Ad Hoc QAPI meeting to review the Immediate Jeopardy findings. The following key personnel attended the Ad Hoc QAPI meeting: Regional Administrator, AIT/MDS, Risk Manager, Maintenance Director, Activity Assistant, MDS, Director of Nursing, Housekeeping Supervisor, and the Human Resources Director. The Medical Director was unable to attend in person, however, this information was reviewed via teleconference. The Medical Director visited 12/12/2023 and reviewed facility findings and plans and no recommendations were made. During this meeting, a review of the Wandering and Elopement policy was completed, and no policy changes were recommended. 3. The Administrator resigned effective immediately on 12/5/2023. The Regional Administrator assumed the role of Interim Administrator on 12/6/2023. 4. All Residents were assessed using the Elopement Risk Assessment to determine residents at high risk for elopement. These assessments resulted in three (3) additional residents at high risk, bringing the facility total to five (5) residents at high risk for elopement. 5. Care Plans have been reviewed and updated for five residents determined to be at High Risk for Elopement. 6. Five (5) residents determined to be at High Risk for Elopement have been updated in the Elopement Binder. All staff have been educated on the location of the Elopement Binder (Admin office, dietary (kitchen), and nurse's station. The elopement binders will be updated as any additional residents are identified as high risk for elopement. 7. Magnetic Door Locking mechanisms have been installed on all entry/exit doors that require a code for entry and exit. 8. Magnetic Door Locking mechanisms are monitored and checked for functionality daily by the Maintenance Director (Monday-Friday) and the Weekend RN Supervisor (Saturday-Sunday) using the Daily Door Lock Checks form. 9. The Main Entrance is equipped with a functioning Wander Guard system because all Visitors and Vendors are required to enter and exit at the Main Entrance. The Wander Guard system delivers an audible announcer if a Resident identified at High Risk for Elopement breaches the Main Entrance doorway with a Wander Guard intact device. 10. The Wander Guard devices on residents identified as high risk for elopement are monitored every 12 hours by a Nursing Manager using the handheld Wander Guard Universal Tester noted in the electronic Medication Administration Record (MAR). The Universal Tester device was ordered and was delivered to the facility on [DATE]. All Staff are educated on 12/12/2023 on the use of the Universal Tester. 11. A root cause analysis was completed; it was determined that a lack of training related to Wandering and Elopements was a factor. Training for all staff related to Wandering and Elopements started on 11/30/2023 and has continued through 12/12/2023. 12. A Performance Improvement Plan related to Wandering and Elopements was developed and will be followed through the facility's QAPI process. 13. The Regional Nurse Consultant conducted training using the Wandering and Elopements policy, locations of the Elopement Binders, identifying residents at high risk for elopement, and regarding Magnetic Door Lock mechanism functionality for the following staff: a. 11 of 12 licensed staff members have received this training. b. 14 of 14 CNAs have received this training. c. 1 of 1 Activities Staff have received this training. d. 9 of 10 Dietary Staff have received this training. e. 7 of 7 Housekeeping/Laundry/Maintenance staff have received this training. f. 3 of the 3 administrative staff members have received this training. Total Education: 45 of 47 Staff Members have received this training: 96% 14. All facility staff not in-serviced on the Wandering and Elopements Policy, location of elopement binders, and identifying residents at high risk for elopement will not be allowed to work until the education is completed. The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows: 1. Evidence of the Wander Guard Training and in-services was verified in the in-service signup sheet dated 12/12/2023 located in the binder provided by the facility and 23 staff were in-serviced. An inservice meeting verified an inservice meeting held on 12/12/2023 was held regarding Maglock doors and how to check them. New Door codes. Door checks to ensure lock was engaged. The Wander guard system. Providing security to at risk residents and using proper tools to check door bracelets and checking residents' bracelets. (23 staff were in serviced). Observations on 12/14/2023 at 10:30 am showed the mega locks was installed with new door codes and the wander guard sound was audible and loud enough for staff to hear from all angles of the facility. 2. Evidence of the inservice showed that on 12/6/2023 at 10:30 am fifteen (15) staff were in serviced regarding Accidents and Elopements and care plans. On 12/6/2023 at 2:00 pm fourteen (14) staff were in serviced regarding Accidents and Elopements and care plans. A QAPI meeting was held on 12/6/2023 from 9:00 am and ended at 9:45 am the following staff attended the QAPI meeting- Business Office Manager, Maintenance, Director, Dietary Manager, Administrator in Training AIT/MDS, Risk Manager, Activity Assistant, MDS, Director of Nursing, Housekeeping Superisor, and Human Resource Director. The QAPI meeting was held for the following Tags F600, F609, F610, F835, F867, F689, and F656. And signatures were documented regarding completion of the inservice. A defined reassessment showed five residents were identified on the Elopement Risk assessment dated [DATE]. During an interview on 12/15/2023 at 9:44 am the DON revealed that in-services were held regarding elopement, wandering and abuse. She verified all abuse should be reported within two hours to the state. QAPI meetings are addressed monthly, and clinical meetings are held every morning. When interventions are discussed during the QAPI, in-service starts the same day if possible. DON is responsible for in-services. CNA's can access the elopement book. In the book, there are pictures of the identified as elopement risk residents and daily sign out sheets. LPN's can document in the MAR about the location of the resident as they are monitored. Facility now has a louder system, and it can be heard at a further range and if the door is open the sound is much louder and at a rapid pace. DON was responsible for the education on the wander guard tester and she in-serviced staff regarding the tester. Alarm education was done by the Maintenance Director. 3. The resignation of the Administrator was verified per observation on 12/6/2023 at 8:58 am, the Regional Administrator stated the Administrator resigned yesterday evening and that was accepted, and he will be the acting administrator moving forward. During an interview on 12/15/2023 at 9:44 am the DON revealed there was an Administrator change and the Regional Administrator was now the interim Administrator. When staff are unable to reach him regarding reportable, they are required to report to her. Observations on 12/14/2023 at 10:30 am through 10:40 am revealed the previous Administrator was not in the facility. 4. Evidence of the in-service showed that on 12/6/2023 at 12:00 pm to 1:00 pm and from 1:00 pm to 2:00 pm regarding Wandering, Elopement and Resident Safety and was dated on 11/30/2023 in all a total of thirty-six (36) staff were in-serviced signed on the inservice sheet. Another in-service sheet was completed on 12/1/2023 at 9:00 am ten staff (10) and on 12/1/2023 at 10:30 am a total of (13) thirteen. The following interviews verified interventions were in place: During an interview on 12/15/2023 at 9:14 am, LPN RR revealed she works the first shift, we did in-service about elopement and facility identified additional residents and added wander guards to the residents. The sound of alarms is audible it can be heard from the nurse's station, and the alarm sounds when the wander guards are checked once a shift, the residents are checked hourly only the staff have the access codes to the door. The elopement book has all the intervention at the nurses station and all staff have access to the book. During an interview on 12/15/2023 at 9:27 am, CNA EE revealed the in-service discussed elopement and abuse. And what to do when a resident elopes. CNA EE stated facility identified six residents as risk for elopement and the identified residents all have wander guards on their ankles. We take them to front door and the alarm goes off and they are working on it to get louder. We check on the resident elopement we check on them constantly. Only the staff have the access codes to exit the building. During an interview on 12/15/2023 at 9:34 am, CNA SS revealed the in-service was done regarding elopement and that it should be reportable to the Administrator immediately. We do check on the resident that have been identified every few fifteen minutes. R6 is alert and oriented, now we are doing regular checks, and we are checking more residents, we do check the wander guards every morning the rest have wander guard on the wrist. The alarm sounds can be heard from the hallway when the sound is heard you go and investigate. Observations on 12/14/2023 at 11:30 am showed residents R6, R10, R19, R20 and R21, and R 22 had electronic alert devices on their wrist and the electronic alert system functioned as required. Care plans have been reviewed and updated for five residents determined to be at High Risk for Elopement. Documentation showed care plans were updated for residents identified as elopement risk and was reviewed and interventions were put in place. The following interviews verified the interventions were conducted and were in place: During an interview on 12/15/2023 at 9:04 am, LPN AA revealed she had done in-service regarding elopement and that if anything that we were not sure should be reported to the Administrator including all types of abuse. Now residents with bracelets before they had a tester, now it has a high pitch sound and its loud and clear I feel. The elopement book is accessible to all CNA's and they can access it for certain measures, measures that will help. The care plans are now updated to indicate they are at risk for elopement and will have interventions. CNA conveyed verbally through communications on what interventions are in place. All wanderers are checked on the MAR. During an interview on 12/15/2023 at 9:14 am, LPN RR revealed she works the first shift, we did in-service and care plans were updated for five additional residents identified as risk for elopement. Wander guards were added to the residents they sound an alarm, which is audible it can be heard from the nurse's station, and they sound. The wander guards are checked once a shift, the residents are checked hourly only the staff have the access codes to the door. The elopement book has all the intervention at the nurses station and all staff have access to the book. During an interview on 12/15/2023 at 9:27 am, CNA EE revealed the in-service discussed elopement and abuse. And what to do when a resident elopes, when residents are fighting, we would separate, we now have elopement residents, and they all have wander guards on their ankles. We take them to front door and the alarm goes off and they are working on it to get louder. We check on the resident elopement we check on them constantly. Only the staff have the access codes to exit the building. 5. Residents R6, R10, R19, R20, R21, and R22 were identified to be at risk for elopement. Observations on 12/15/2023 at 11:50 am showed an elopement book at the nurses station and staff verified the resident were being monitored. 6. Documentation showed that the Magnetic Locking Mechanisms was installed on 9/14/2023. Observations from 11/29/2023 through 12/14/2023 revealed the Magnetic Locking Mechanisms worked as required. 7. According to the daily door lock checks, documentation showed daily checks were started on 12/4/2023. Observations on 12/15/2023 at 11:05 am showed that the magnetic locking mechanism was functioning as required. 8. Documentation showed the system was ordered on 12/7/2023 from [provider] and was installed on 12/12/2023. During an interview with the Regional Administrator on 12/12/2023 at 1:05 pm, a Wander Guard Universal Tester was ordered and was received by facility on 12/12/2023. 9. During an interview on 12/15/2023 at 9:44 am, the DON revealed that in services were held regarding elopement, wandering and abuse. Abuse should be reported within two hours to the state. QAPI meetings are addressed monthly, and clinical meetings are held every morning. When interventions are discussed during the QAPI, we will start the in-service the same day if possible. The DON was not sure how much CNA's can see on care plans regarding the interventions. CNA's can access the elopement book, there are pictures of the identified as elopement risk residents and daily sign out sheets. LPN's can document in the MAR about the location of the resident as they are monitored. Facility now has a louder system, and it can be heard at a further range and if the door is open the sound is much louder and at a rapid pace. The DON was responsible for the education on the wander guard tester and she in-serviced staff regarding the tester. Alarm education was done by the Maintenance Director. During an interview, 12/15/2023 at 7:23 am, CNA DD stated we have learned all types of abuse including financial. Administrator is the abuse coordinator and any abuse would be reported to him immediately if he not here DON would be the next person to report to. We talked about abuse and elopement. We now have six identified residents. That alarm sounding was demonstrated, I am not able to hear the alarm. Resident can't get out because we have mega locks and codes. The resident does not know the codes. During an interview 12/15/2023 at 7:24 am, Dietary Aide NN stated we learned about abuse and that it was reportable to the administrator immediately, including verbal abuse which is reportable to the administrator. Elopement we were told when the alarm sounds the patient is trying to get, the alarm sound can be heard while I am in the kitchen. 10. During an interview on 12/15/2023 at 6:45 am, LPN RR revealed in-services regarding abuse and elopements and and codes were changed the front door codes were changed, the codes have been changed daily. We have identified 6 residents and named them. When I get on th[TRUNCATED]