**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On July 15, 2025, 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 Director of Clinical Operations, and Director of Operations were informed of the Immediate Jeopardy (IJ) on July 15, 2025, at 3:48 pm. The noncompliance related to the IJ was identified to have existed on June 13, 2025.An acceptable Immediate Jeopardy Plan of Removal was provided on July 18, 2025, and included interviews and skin assessments, education on abuse policy, threatening or violent behavior in the workplace, policy review, no weapons signage, night receptionist and weekend managers' new addition. The survey team validated the implementation of the removal plan, and the Immediate Jeopardy was removed on July 24, 2025. After the removal of the Immediate Jeopardy, the deficiency remained at a scope and severity of an L, no actual harm, with potential for more than minimal harm widespread.Based on observations, interviews, record reviews, and review of the facility policies titled, Abuse, Neglect, and Exploitation, Work Place Violence, and Active Shooter, the facility failed to ensure residents were free from staff to resident abuse by not preventing two Certified Nursing Assistants (CNAs), BB and CC, from bringing a firearm into the workplace on the East Wing and threatening other employees in a resident-occupied environment for Resident (R) (R1, R2, R3, R4, and R5) on 7/1/2025. This failure placed all residents at serious risk of physical injury or death, as well as significant psychosocial trauma. Findings include:Review of the facility policy titled, Abuse Prevention dated 3/25/2025 stated, It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibited and prevent abuse, neglect, exploitation, and misappropriation of funds. Abuse means the willful infliction of injury, unreasonable confinement, intimidation or punishment, with resulting physical harm, pain or mental anguish, which can include staff to resident abuse, etc. VI.Protection of resident (F) providing emotional support and counseling to residents during the investigations and as needed.Review of the facility policy titled, Workplace Violent Prevention Program dated 7/1/2025 stated, It is the policy of this facility to promote a safe, respectful, and productive environment in which to deliver quality healthcare and administrative services. Violence in the workplace will not be permitted or tolerated. The facility will develop a workplace violence prevention program to identify and prevent episodes of workplace violence. Workplace violence is defined as any threat of physical violence, harassment, intimidation, or other threatening disruptive behavior that occurs at the worksite.Review of the facility policy titled, Active Shooter/Violent Incidents dated 9/16/2024 stated Our facility is committed to maintaining a safe environment, including a safety from violence and threats of violence. Intent of Policy: to minimize the potential to residents, employees, visitors, and property resulting from individuals brandishing firearms or other weapons or claiming to possess a firearm/weapon with the expressed intention of causing harms, expressed threats, bomb threaten, threatening individuals while under a restraining order, or hostage situation. All staff will receive training upon hire and annually to increase awareness of potential threat or violent incidents including, but not limited to, acts of terrorism, active shooters, bomb threats/explosives, assaults, hostage situations.Record review of the police incident report dated 7/1/2025 at 11:05 pm documented law enforcement was dispatched to the facility regarding 2 (two) employees with firearms in the east wing, threatening another employee, CNA DD. A continued review of the document revealed that the Administrator wanted all suspects formally trespassed from the property.Record review of the document titled Criminal Trespass Warning/Ban Form dated 7/1/2025 stated Employees advised CNA CC, and another female employee got into a verbal altercation where they announced they had firearms with them. Administrator advised that she wanted both subjects banned.1. Record review of the Electronic Medical Record (EMR) for R1 revealed diagnoses, including but not limited to Alzheimer's disease, unspecified psychosis not due to substances or known physiological conditions. The Quarterly Minimum Data Set (MDS) dated [DATE], Section C (Cognitive Patterns) assessed a Brief Interview Mental Status Score (BIMS) of eight, which indicates moderate cognitive impairment. Section GG (Functional Abilities) assessed dependent for care for all Activities of Daily Living Skills, nonambulatory, and no limitations for Range of Motion (ROM) regarding upper/lower extremities.On 7/1/2025, R1 was sitting in a geriatric chair in front of the nurses' station on the East Wing during the incident and was unable to remove himself, nor did staff remove R1when the incident occurred.Record review of the document titled Social Services Quarterly Evaluation dated 7/17/2025 for R1stated he was an established client receiving psychiatric counseling services. The document further revealed that on 7/1/2025, R1 witnessed staff with a firearm.2. Record review of the EMR for R2 revealed diagnoses, including but not limited to bipolar disorder, generalized anxiety disorder, and PTSD. The Quarterly MDS dated [DATE], Section C assessed a BIMS score of 15, which indicates little to no cognitive impairments.Record review revealed that R2 ‘s room was located directly in front of the nurse station on the East Wing. During an interview on 7/10/2025 at 11:01 am, R2 reported being awakened by staff arguing. She described the argument as being very loud with the use of profanity. She reported standing in the doorway and later returning to her bed. R2 revealed that when the police arrived at the hall, she learned about the firearms. She stated that it made her feel very uncomfortable because she has a history of substance abuse, drugs, domestic violence, and dealing with people with firearms. R2 stated that the next day, the Administrator confirmed in a meeting that the CNAs had brought firearms into the facility. R2 reported being afraid for her safety and others' safety. She stated, Just witnessing the number of police officers in the hallway which was uncomfortable for her.Record review of the facility document titled, Social Services Quarterly Evaluation for R2 dated 7/17/2025 revealed that on 7/1/2025, R2 witnessed staff with a firearm.3. Record review of the EMR for R3 revealed diagnoses, including but not limited to bipolar disorder, anxiety disorder, schizophrenia, and depression. The Quarterly MDS dated [DATE] assessed Section C, a BIMS score of 15, which indicates little to no cognitive impairments.During an interview on 7/10/2025 at 1:08 pm, R3 reported witnessing staff arguments. R3 reported ambulating in the hall at the time of altercations with another resident, R4. He described the nursing assistants' arguments as being very loud, the use of profanity, and disturbing. R3 reported being afraid for others' safety after learning about firearms being in the building. He reported being in the lobby when the police officers arrived on site.Record review of the facility document titled, Social Services Quarterly Evaluation for R3 dated 7/17/2025, revealed the resident was already an established client receiving psychiatric counseling services. The document also stated that on 7/1/2025, R3 witnessed staff with a firearm. The form stated that R3 stated he did feel he was in danger and felt safe being in the facility. 4. Record review of the EMR for R4 revealed the following diagnoses, including but not limited to Alzheimer ‘s disease, generalized anxiety disorder, and major depressive disorder. The Quarterly MDS dated [DATE] assessed a BIMS score of eight, which indicates moderate cognitive impairments.During the interview on 7/10/2025 at 1:12 pm, R4 was unable to recall the specifics of the events involving a firearm. R4 could recall being informed that people had firearms in the building from other people, and that her account of the event was cloudy. R4 stated she was afraid of firearms coming in and responded with the statement uggh.Record review facility document titled, Social Services Quarterly Evaluation dated 7/17/2025 stated that on 7/1/2025, R4 witnessed staff with a firearm.5. Record review of the EMR for R5 revealed the following diagnoses, including but not limited to paranoia, schizophrenia. The Quarterly MDS dated [DATE] Section C assessed a BIMS score of 15, which indicates little to no cognitive impairments.During an interview on 7/9/2025 at 4:20 pm, R5 reported that he was sitting in the front lobby of the building when police officers arrived. He stated there were firearms in the building brought in by CNAs. R5 further revealed being worried about CNAs returning to the building and being concerned about a shootout. R5 revealed he would not be able to run because he was in a motorized wheelchair and one hand was contracted.Record review of the facility document for R5 titled, Social Services Quarterly Evaluation dated 7/17/2025 stated that on 7/1/2025, R5 witnessed staff with a firearm. Interview on 7/8/2025 at 1:16 pm with CNA DD confirmed getting into a verbal altercation with CNA BB in the East Wing Hall of the facility. She reported that several residents were present at the time of the arguments. She revealed that R1 was sitting in a geriatric chair in front of the desk. R3 and R4 were observed walking in the hall. She reported that she removed herself from the nurse station prior to CNA BB and CNA CC displaying their firearm to CNA EE. CNA DD reported that she was not aware of contacting 911 immediately. She confirmed she did not receive any active shooter or workplace violence training until after the incident occurred.Interview on 7/8/2025 at 2:31 pm with CNA EE confirmed being in the East Wing hall during the time of the altercation between CNA DD and CNA BB. She reported that R1 was sitting in a geriatric chair in front of the nurse station, and R2 (room [ROOM NUMBER]) was standing in the doorway of her room, which is directly across from the nurse station. She reported that CNA BB was using profanity and speaking in a loud, angry voice tone. She reported witnessing CNA BB leaving the hall and later returning to the nurse station with a purse. She reported that CNA BB removed a firearm from her purse and waved the firearm in the air at the nurse station. She stated that R1 was still in front of the nurse station in a geriatric chair and witnessed the firearm. She stated that CNA BB placed the firearm back into her purse and began pacing the hall using profanity and continuing to speak in a loud, angry voice tone with the purse in her hand. CNA EE reported that several residents' room doors were open in the hall. CNA EE reported observing CNA CC sitting at the nurse station and opening her bookbag, revealing a firearm. She further revealed that she contacted the Administrator to inform her of the incident and did not contact 911. CNA EE stated that the Administrator contacted 911. CNA EE reported that she was not aware she needed to contact 911 immediately. CNA EE confirmed that she did not receive any active shooter or workplace violence training until after the incident occurred on 7/1/2025.Interview with the Administrator on 7/8/2025 at 3:31 pm revealed that the two CNAs(CNA BB and CNA CC) involved in the incident were agency staff and that 7/1/2025 was their first shift. The Administrator stated she was not familiar with the CNAs (CNA BB and CNA CC) work ethics or background checks, and the hiring agency is responsible for the completion of references or background checks. The Administrator reported being informed of firearms present in the facility by CNA EE, and that her actions to contact 911 and file a no trespass ban were solely based on CNA EE‘s statement. She reported being unaware of any residents being present to witness a firearm or being in the lobby or smoke porch until made aware by the survey team. She reported that she did not follow up with the staff to inquire if any residents were up during the incident. The Administrator revealed that the day after the incident, she placed a sign up No Firearms Prohibited in the front entrance of the facility to ensure all staff and visitors are aware not to bring firearms in the building. The Administrator further stated that she serves as the Human Resources (HR) personnel and is solely responsible for the training and hiring of new staff in her building. She reported that all newly hired facility staff are oriented to the facility handbook during their orientation, and the handbook discusses prohibiting firearms. The Administrator further revealed that agency staff do not receive training or a copy of the facility handbook.Interview with the Director of Nursing (DON) on 7/9/2025 at 3:00 pm revealed that she was made aware of an active shooter incident at 4:00 am on 7/2/2025 by another staff member. She reported having staff only complete assessments for cognitive residents, not all residents in East Hall. The DON stated that she did not interview or follow up with any of the CNAs to determine if any residents witnessed the events or were awake in the East Hall, as this information was not made known to her. She reported that she received information from the Administrator that no residents were up or awake. She was only informed of rumors of staff threatening to have a firearm. The DON stated that if she had been made aware of or heard anything indicating a loud argument, residents witnessing a firearm, or a resident feeling uncomfortable or felt threatened, her interventions and response as the DON would have been different. She reported that interventions would have included ensuring that residents received follow-up psychiatric services immediately. She would have focused more on the residents who witnessed the firearm, R1, to ensure no negative or adverse effects. The DON reported that her expectations for the staff to ensure resident safety in the case of a workplace violence/ active shooter incident are for staff to remove the resident and close the room door immediately in the hall, and call 911, then call the Administrator and herself. If a staff member feels threatened, they should call the charge nurse. Staff should not have waited to call 911. Interview on 7/9/2025 at 4:37 pm with Receptionist HH reported observing CNA BB exiting the lobby and building, walking towards her car in the parking lot at least twice or more during the shift. She observed CNA BB exiting the lobby and later returning to the facility with food (pizza). Additionally, she observed CNA BB going to the parking lot again, almost close to 11:00 pm. She recalled seeing the CNA BB with a purse in her hand. She reported that R5 and some other unidentified residents were present in the lobby area and the smoke area (located off the lobby) throughout the incident, including the time of the active shooter incident. She also stated that the residents were present in the lobby when the officers entered the building. Receptionist HH reported that she was not aware of contacting 911 immediately. She confirmed she did not receive any Active Shooter or Workplace Violence Training until after the incident occurred.Interview on 7/9/2025 at 11:57 am, Licensed Practical Nurse (LPN) AA reported being unaware of CNA BB and CNA CC's behavior of threatening staff until after the incident had occurred. He recalled earlier during the shift, prior to taking his break, witnessing CNA BB and CNA CC speaking about their disagreement with their resident assignment, and making complaints of not having enough staff to work the floor. He confirmed that several residents were in the smoke area during the time the incident occurred. LPN AA confirmed that when CNA EE approached him to inform him of both CNA BB and CNA CC having firearms. He stated that CNA EE appeared upset and spoke to him in French so as not to alarm the residents. He reported that CNA EE stated she would call the Administrator. He reported that he approached CNA BB and CNA CC and asked them to leave the facility. He observed both CNAs (CNA BB and CNA CC) leaving the building, going to their cars. CNA CC had a bookbag, and CNA BB had a purse. LPN AA confirmed that he did not receive Active Shooter or Workplace Violence Training until after the incident occurred.Interview with CNA BB on 7/10/2025 at 11:15 am, CNA BB reported exiting the building and going to the parking lot on several occasions during her shift. She confirmed having a firearm in her possession in her vehicle on the premises. She confirmed having a verbal altercation with CNA DD about assignments. She confirmed making a statement. CNA BB confirmed not receiving any training from the facility on workplace violence and active shooters. Interview on 7/10/2025 at 12:13 pm CNA CC reported having a bookbag at the nurse station. She confirmed having a firearm in her possession in her vehicle but denied bringing a firearm into the facility. CNA CC confirmed not receiving any training from the facility on workplace violence and active shooters. CNA confirmed that R1 was sitting at the nurse station during the verbal altercation between CNA BB and CNA DD. She confirmed witnessing R3 and R4 walking the hall at the time of the verbal altercation.Interview on 7/9/2025 at 3:44 pm with the Social Service Director (SSD) reported being instructed in the morning meeting on 7/2/2025 by the Administrator that, due to two certified nursing assistants bringing firearms into the building to follow up with interviewing cognitive residents in the East Hall for any concerns or trauma. The Administrator wanted her to just ask basic general questions and nothing pertaining to the incident. The interview consisted of just general questions: Do you feel safe? She reported that she had not had a conversation about what happened that night. She avoided asking the East Hall residents if they had heard disturbances from the night before. She reported that none of the residents voiced any concerns about the active shooter incident or firearms. She was not made aware of residents being present in the lobby or on the smoke area patio (off the lobby) during the active shooter incident. She reported that if she was made aware of other residents, her interview would have included those residents. She confirmed that no referrals for follow-up psychiatric services were made for the residents.An undetermined number of residents were present in the lobby and the smoke area when CNA BB entered the facility (passing both areas) with a concealed firearm on 7/1/2025, confirmed by Receptionist HH.A psychiatric referral was processed on 7/17/2025 for R1, R2, R3, R4, and R5.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews and record review, the facility failed to provide sufficient qualified licensed nursing staff to achieve the highest practicable level of well-being for all residents. Specifically, the facility did not have a licensed nurse (Registered Nurse RN or Licensed Practical Nurse LPN) on duty for at least 30 minutes on [DATE] between 7:00 pm through 7:30 pm. The census was 83 residents. 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 Director of Clinical Operations, and Director of Operations were informed of the Immediate Jeopardy (IJ) on [DATE], at 3:48 pm. The noncompliance related to the IJ was identified to have existed on [DATE]. An acceptable Immediate Jeopardy Plan of Removal was provided on [DATE], and included additional staffing agency support, daily staffing schedules, shift rounding, emergency staffing plan, education on emergency procedures, state minimum daily PPD requirements, and maintaining a licensed nurse every shift. The survey team validated the implementation of the removal plan, and the Immediate Jeopardy was removed on [DATE]. After the removal of the Immediate Jeopardy, the deficiency remained at a scope and severity of an L, no actual harm, with potential for more than minimal harm widespread. Findings include:A review of the facility document titled Punches Report dated [DATE] to [DATE] revealed that there was no RN or LPN on duty at the facility on [DATE] except for LPN LLL. In an interview with LPN LLL, she revealed that she worked remotely on the morning of [DATE] and clocked out at 5:00 pm the same day, filling out a manual clock form. She stated that she did not work on [DATE] from 7:00 pm to 7:00 am. On [DATE] at 2:06 am, LPN AA documented that Code Blue was called by the receptionist at 8:00 pm. Once on the scene, he observed R6 in the chair, unresponsive. His skin was cold, and he did not have a pulse. LPN AA documented that he then asked the receptionist to call 911 while he initiated CPR [Cardiopulmonary Resuscitation] with nursing staff (Certified Medication Assistant (CMA) and Certified Nursing Assistant (CNA)). He documented that they performed CPR until the Emergency Medical Services (EMS) arrived. R6 was still unresponsive with no pulse upon the EMS arrival. The resident was pronounced dead by EMS at 8:30 pm. Interview with Business Office Manager (BOM) PP on [DATE] at 12:27 pm revealed the BOM stated that there was hardly ever a nurse in the facility on the night shift. She stated that sometimes there were only CMAs in the building. The BOM stated that LPN QQQ left the faciity on [DATE] at 7:00 pm, knowing that there was not a nurse in the facility, and LPN QQQ left the East wing knowing that there was not a nurse or CMA to relieve her. She stated that LPN QQQ gave the keys to one of the CMAs on the [NAME] wing, left, and went home. The BOM further revealed that she called the administrator 17 times on the night that R6 expired, and the Administrator did not respond to her phone calls or texts.Interview with LPN LLL on [DATE] at 3:56 pm revealed that she worked on [DATE] during the day shift and clocked out around 5:00 pm the same day. She stated that when she comes in and helps them, she uses a missed punch form, and that Human Resources (HR) keys her time in the system. She stated that the HR person entered the information incorrectly. LPN LLL stated that she did not work the 7:00 pm to 7:00 am shift on [DATE]. Further interview with LPN LLL revealed that she was not physically in the facility on [DATE], and she worked remotely and did a missed punch form. LPN LLL stated that she normally works the [NAME] wing on Saturday and Sunday, 7:00 pm to 7:00 am. She stated that when she works, there are always two Licensed nurses on the [NAME] wing and one nurse on the East wing. Interview with LPN ZZ on [DATE] at 11:33 am revealed that she was working on [DATE]. She stated that she left at 4:45 pm, and she was relieved by CMA YY. She stated that CMA RRR was working on the top hall of the [NAME] wing.Interview with LPN AA on [DATE] at 11:22 am revealed that he was initially scheduled to work across the street at the sister facility, but ended up at the current facility due to no nurses being in the building. He stated that he took report at the sister facility and came to the current facility around 7:30 pm. LPN AA reported that upon arrival at the facility at 7:30 pm, no nurse was present in the facility. He stated that there were two Certified Medication Assistants (CMAs) on the [NAME] wing. He stated that he got the keys to the medication cart from one of the CMAs from the [NAME] wing. Interview with LPN QQQ on [DATE] at 12:15 pm revealed that on [DATE], she was working on the East wing on the 7:00 am to 7:00 pm shift. She stated that she left the facility at 7:00 pm and gave the keys to the medication cart and the keys to the narcotics to a CMA on the [NAME] wing. She stated that the Director of Nursing (DON) PPP told her she could leave if she gave the keys to someone. LPN QQQ stated that DON PPP was not in the building at the time.Interview with RN JJJ on [DATE] at 12:46 pm revealed that she was working on the medication cart during the day on [DATE] at the sister facility, and did not know that there was no nurse on the East wing at the current facility. RN JJJ stated that she instructed LPN AA to go to the East wing to see if they needed him; if not, he was to return to the sister facility. RN JJJ stated that a CNA from the current facility called her and told her that they need her. When she came to the scene, EMS and cops were there, and R6 was lying on the ground with a white sheet over him. RN JJJ stated that she attempted to call the Administrator but did not get an answer and sent a text message.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, record review, and a review of the Administrator and Director of Nursing (DON) Job Description, the Administration failed to provide oversight related to workplace violence, failed to provide sufficient qualified licensed nursing staff to achieve the highest practicable level of well-being for all residents, and failed to protect residents from alleged emotional and potential physical abuse during an active shooter incident. The census was 83.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 Nurse Consultant, and Operations Consultant were informed of the Immediate Jeopardy (IJ) on [DATE], at 3:48 pm. The noncompliance related to the IJ was identified to have existed on [DATE]. An acceptable Immediate Jeopardy Plan of Removal was provided on [DATE] and included education on emergency plan, workplace violence and an active shooter situation, policy review, job description review, additional education related to managing daily operations, coordinate and oversee department heads, providing education and compliance training, ensure licensure staff have appropriate education, competency checks are maintained. The survey team validated the implementation of the removal plan, and the Immediate Jeopardy was removed on [DATE]. After the removal of the Immediate Jeopardy, the deficiency remained at a scope and severity of an L, no actual harm, with potential for more than minimal harm widespread. Findings include:The facility had a Job Description for the job title of Administrator. The description documented the purpose of this position is leads, guides, and directs the operations of the healthcare facility in accordance with local, state, and federal regulations, standards, and established facility policies and procedures to provide appropriate care and services to residents. Identifies, in conjunction with the Director of Nursing and selected department heads, the facility's key performance indicators. Establishes an ongoing system to monitor these key indicators such as the Quality Assurance and Performance Improvement process throughout the facility. Promotes and encourages an environment of trust among all employees related to the overarching goal of resident safety and abuse prevention. The facility had a Job Description for the job title of Director of Nursing. The description included that the Director of Nursing position purpose is to planning, organizing, developing, and directing the overall operation of the Nursing Service Department in accordance with local, state, and federal standards and regulations, established facility policies and procedures and as may be directed by the Administrator and the Medical Director, to provide appropriate care and services to the residents. Interprets and communicates policies and procedures to nursing staff, and monitors staff practices and implementation. Oversees nursing schedules to ensure resident needs, regulatory and budget standards are met. Ensures delivery of compassionate quality care and nursing supervision as evidenced by adequate staff coverage on the units, general cleanliness, and maintaining optimal resident functions. Monitors for allegations of potential abuse or neglect, or misappropriation of resident property and participates in the investigative process. Facility Administration, specifically the Administrator and DON, failed to protect residents and effectively oversee areas of the facility that were included in their job descriptions. 1. The facility's Administration failed to implement and enforce policies and procedures that ensure the safety and security of residents when two staff members, Certified Nursing Assistant (CNA) BB and CNA CC, accessed the facility on [DATE] with concealed firearms and engaged in threatening behavior in the presence of residents. Additionally, the facility failed to ensure that a licensed nurse (Registered Nurse (RN) or Licensed Practical Nurse (LPN)) was present in the building on [DATE] from 7:00 pm to 7:30 pm and available to respond to medical emergencies. Cross-reference to F600, F725.2. The Administration failed to protect residents from alleged emotional and potential physical abuse during an active shooter incident. Cross-reference to F600.3. The Administration failed to provide sufficient qualified licensed nursing staff to achieve the highest practicable level of well-being for all residents. The facility did not have a licensed nurse on duty for at least 30 minutes on [DATE] between 7:00 pm to 7:30 pm. Cross-reference to F725. 4. The Administration failed to utilize Quality Assurance Performance Improvement (QAPI) for adverse events related to workplace violence and staffing. Cross- reference to F600, F725, F867 On [DATE] at 2:06 am, LPN AA documented that Code Blue was called by the receptionist at 8:00 pm. Once on the scene, he observed R6 in the chair, unresponsive. His skin was cold, and he did not have a pulse. LPN AA documented that he then asked the receptionist to call 911 while he initiated CPR [Cardiopulmonary Resuscitation] with nursing staff (Certified Medication Assistant (CMA) and CNA). He documented that they performed CPR until the Emergency Medical Services (EMS) arrived. R6 was still unresponsive with no pulse upon the EMS arrival. The resident was pronounced dead by EMS at 8:30 pm. Interview with LPN AA on [DATE] at 11:22 am revealed that he was initially scheduled to work across the street at the sister facility, but ended up at the current facility due to no nurses being in the building. He stated that he took report at the sister facility and came to the current facility around 7:30 pm. LPN AA reported that upon arrival at the facility at 7:30 pm, no nurse was present in the facility. He stated that there were two CMAs on the [NAME] wing. He stated that he got the keys to the medication cart from one of the CMAs from the [NAME] wing. Interview on [DATE] at 2:31 pm with CNA EE confirmed being in the East wing hall during the time of the altercation between CNA DD and CNA BB. She reported that R1 was sitting in a geriatric chair in front of the nurse station, and R2 (room [ROOM NUMBER]) was standing in the doorway of her room, which is directly across from the nurse station. She reported that CNA BB was using profanity and speaking in a loud, angry voice. She reported witnessing CNA BB leaving the hall and later returning to the nurse station with a purse. She reported that CNA BB removed a firearm from her purse and waved the firearm in the air at the nurse station. She stated that R1 was still in front of the nurse station in a geriatric chair and witnessed the firearm. She stated that CNA BB placed the firearm back into her purse and began pacing the hall using profanity and continuing to speak in a loud, angry voice tone with the purse in her hand. CNA EE reported that several residents' room doors were open in the hall. CNA EE reported observing CNA CC sitting at the nurse station and opening her bookbag, revealing a firearm. She further revealed that she contacted the Administrator to inform her of the incident and did not contact 911. CNA EE stated that the Administrator contacted 911. CNA EE reported that she was not aware she needed to contact 911 immediately. Interview on [DATE] at 3:31 pm with the Administrator revealed that the two Certified Nursing Assistants (CNAs) had never worked in her building until [DATE]. The Administrator confirmed that both CNAs were contract agency staff. She was not familiar with the two agency CNAs (CNA BB and CNA CC), work ethics, or background checks. The Administrator revealed that she serves as the Human Resources (HR) personnel and is solely responsible for the training and hiring of new staff in her building. The Administrator stated that contract and/or agency staff do not receive training/orientation on the facility handbook, nor are they provided a copy of the facility handbook (the handbook contains information for prohibiting firearms in the facility). The Administrator revealed that the day after the incident, she placed a sign up No Firearms Prohibited in the front entrance of the facility to ensure all staff and visitors are aware not to bring firearms in the building.Interview with the Director of Nursing (DON) on [DATE] at 3:00 pm revealed that she was made aware of an active shooter incident at 4:00 am on [DATE] by another staff member. She reported that staff only completed assessments for cognitive residents, not all residents in East Hall. The DON stated that she did not interview or follow up with any of the CNAs to determine if any residents witnessed the events or were awake in the East hall, as this information was not made known to her. She reported that she received information from the Administrator that no residents were up or awake. She was only informed of rumors of staff threatening to use a firearm. The DON stated that if she had been made aware of or heard anything indicating a loud argument, residents witnessing a firearm, or a resident feeling uncomfortable or threatened, her interventions and response as the DON would have been different.Interview on [DATE] at 12:03 pm with the Administrator revealed that the committee tracks and trends concerns based on identified problems. When asked if the Quality Assurance (QA) program had identified a concern or developed an action plan regarding the firearm incident or staff training, she reported no. She stated that she was unsure of why the facility did not provide training to all employees, including contract workers, regarding workplace violence. She confirmed that training on workplace violence and the prohibition on firearms will be provided this week for all employees. The Administrator revealed that the staffing of licensed nurses was not a part of her Quality Assurance (QA) meetings, because staffing was not a concern. The QA team never placed emphasis on licensed nurses' coverage, only on CNA coverage. An undetermined number of residents were present in the lobby and the smoke area when CNA BB entered the facility (passing both areas) with a concealed firearm on [DATE], confirmed by Receptionist HH.A psychiatric referral was processed on [DATE] for R1, R2, R3, R4, and R5.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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 Director of Clinical Operations, and Director of Operations were informed of the Immediate Jeopardy (IJ) on [DATE], at 3:48 pm. The noncompliance related to the IJ was identified to have existed on [DATE]. An acceptable Immediate Jeopardy Plan of Removal was provided on [DATE], and included review of policies and procedures for emergency staffing, review of job descriptions, education on additional staffing agency support, daily staffing schedules, shift rounding, emergency staffing plan, education on how to respond to active shooter events and emergency preparedness, and an ad hoc QAPI meeting. The survey team validated the implementation of the removal plan, and the Immediate Jeopardy was removed on [DATE]. After the removal of the Immediate Jeopardy, the deficiency remained at a scope and severity of an L, no actual harm, with potential for more than minimal harm widespread. Based on staff interviews, record review, and a review of the facility's policy titled Quality Assurance-Performance Improvement Management (QAPI) Change Process- Work Instruction, the facility failed to identify concerns and effectively implement Quality Assurance Process Improvement (QAPI) plans related ensure all staff received active shooter/workplace violence training to ensure residents (including R1, R2, R3, R4, and R5) were free from abuse from an active shooter/workplace violence incident. In addition, the facility to ensure availability of sufficient licensed nurse staffing was present and available in the building to respond to medical emergencies for a code blue for R6, who was later pronounced deceased by Emergency Medical Services (EMS). The census was 83.Findings Include: The QAPI policy titled Quality Assurance Performance Improvement Management dated [DATE] stated It is the policy of this facility to develop, implement, and maintain an effective comprehensive data driven program that focuses on indicators of the outcomes of care and quality of life and addresses all the care and unique services the facility provides. Adverse Event is an untoward, undesirable and unsafe unanticipated event that causes death or serious injury, or the risk thereof. 2. Governing and Leadership: (iv) Ensure the program is adequately resourced, including ensuring staff time, equipment, and technique training as needed (vii) Setting clear expectations around safety, quality rights, choices, and respect.1. Record review of the police report and the no trespass ban form, both documents dated [DATE], revealed that two Certified Nursing Assistants (CNAs), CNA BB and CNA CC brought firearms into the building threatening coworkers in the proximity of residents (R5 and an undetermined number of residents were present in the lobby and the smoke area). CNA BB removed the weapon from her purse, waved the weapon in the air, and proceeded to walk down the hallway, making threatening comments with the firearm concealed in her purse. CNA CC was sitting at the East wing nurse station, opening her bookbag, which revealed her firearm, with a resident (R1) at the nurses' station and residents (R2 and R3) present on the East wing.2. Record review revealed on [DATE] between the hours of 7:00 pm through 7:30 pm, R6 was observed by staff to be nonresponsive, sitting on the facility patio. Continued record review revealed that there were no licensed nurses (Licensed Practical Nurse (LPN) or Registered Nurse (RN)) available in the building (7:00 pm through 7:30 pm) to respond to medical emergencies. A blue code was not called until 8:00 pm, and the resident was pronounced deceased by Emergency Medical Services (EMS) at 8:30 pm outside on the patio at the facility.The Administrator was unable to provide evidence that the facility had or was currently addressing workplace violence and active shooter incidents, nor was there a systematic review of the issue to develop an action plan meeting the residents' needs, prior to the incident on [DATE]. Record review revealed that the facility did not post a No Weapons or Firearms poster on the exterior entrance doors until [DATE].R1, R2, R3, R4, and R5 did not receive psychological evaluations until [DATE].Interview on [DATE] at 12:03 pm with the Administrator revealed that the QAPI committee tracks and trends based on identified problems. When asked if the Quality Assurance (QA) program had identified a concern or developed an action plan regarding the firearm incident or staff training, she reported no. She stated that she was unsure of why the facility did not provide training to all employees, including contract workers, regarding workplace violence. She confirmed that training on workplace violence and the prohibition on firearms will be provided this week for all employees. The Administrator revealed that the staffing of licensed nurses was not a part of her QA meetings, because staffing of licensed nurses was not a concern. The QA team never placed emphasis on licensed nurses' coverage, only on CNA coverage.Interview on [DATE] at 1:26 pm with the Regional Director of Operations (RDOP) revealed that the facility has recommendations for agency staff training requirements prior to hire. However, they are required and are unsure why training is not followed up to ensure these requirements are met. The RDOP stated they recommend that the facility put agency staff through the facility orientation; however, that is just a recommendation.Cross-reference F600, F725, and F835