**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility investigation review, staff and resident interviews, and facility policy review the facility staff failed to report an allegation of abuse to a supervisor and the alleged prepetrator continued to work unattended behind closed doors with other residents. On June 27, 2024, the Director of Nursing Services (DNS) learned of a Certified Nurse Aide (CNA) slapping Resident #12 on his upper arm which occurred on June 19, 2024. This failure resulted in residents living at the facility to be exposed to the potential of abuse therefore causing an Immediate Jeopardy to the health, safety, and security of the resident. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of June 19, 2024 on August 27, 2024 at 2:01 p.m The facility staff removed the IJ on June 27, 2024 through the following actions: a. The local police, residents physician and family/responsible party were notified of the allegation on 6/27/24. An initial report was made to DIAL on 6/27/24 within the expected two hour time frame. b. Staff members who failed to report immediately on 6/19/24 received immediate education and re-did the Iowa required Dependent Adult Abuse course online on 6/27/24. Corrective action was completed as well with both staff members. c. The social services manager interviewed all residents to determine if there were any concerns by residents of care and treatment by staff members this began on 6/27/24. None were identified. d. Education on abuse and neglect began 6/27/24 to all staff regarding the treatment of residents and the importance of immediately notifying leadership and/or supervisor of any allegation so steps can be immediately taken to remove/separate suspected staff from residents. A quiz for comprehension was completed by staff. Education was completed with all staff prior to any staff working another shift. e. To ensure deficient practice will not recur, Administrator or designee will implement the following measures: i. Administrator or designee will audit through abuse and neglect questionnaires 5 team members randomly to include all shifts daily X10 days to ensure staff education on abuse and neglect investigation and reporting. ii. Audits will be taken to QAPI for further review and recommendations. f. Center leadership has continued to provide daily reminders to staff on the need to report immediately any suspected abuse and/or neglect. g. Center leadership to include the Director of Nursing, Administrator and Social Services have ensured that their phone numbers have been made available for all staff to place in their phones to ensure ability to call them at all times. h. A Skills Fair was completed on August 6 and 7 where continuing reminders and education was again provided. After ensuring the facility implemented education and their policy and procedures prior to surveyors entrance on August 26, 2024, the deficiency at F610 at a J level will be considered past non-compliance. The facility identified a census of 27 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #12 documented diagnoses of stroke, hypertension and depression. The MDS showed the Brief Interview for Mental Status (BIMS) score of 4, indicating severe cognitive impairment. Review of the facility provided Incident report dated 6/27/24 at 5:00 p.m., completed by the Director of Nursing Services (DNS) revealed Certified Nursing Assistant (CNA) staff presented to my office to report that on 6/19/24 while providing bedtime cares one of the other CNA staff was frustrated with Resident #12 when he yelled out as his pericare was being provided and she swatted his upper arm as he yelled out. Review of Resident #12's Progress Notes revealed on 6/27/24 at 10:20 p.m., staff notified DNS that an event had been witnessed on 6/19/24 during bedtime cares that another staff had swatted resident on his arm when he had called out during bedtime cares. Review of written statement by Staff D, CNA dated 6/27/24 revealed last week a CNA confided in me that she witnessed Staff C smack Resident 12's arm after getting frustrated with him. She said they were getting Resident #12 read for bed at 10:00 p.m. and changing his brief. He was turned on his side, facing the wall and holding the other CNA's hand. Staff C got upset that he was holding the CNA's hand and smacked his arm. The CNA told her she had no reason to be upset since he wasn't touching her. Review of facility intake information the facility submitted a self report on 6/27/24 at 9:34 p.m Interview on 8/28/24 at 11:19 a.m., with Staff B revealed she was assisting Staff C, CNA with changing Resident #12. Staff B rolled Resident #12 toward her as he had been touching Staff C and she was getting angry. Resident #12 starting touching Staff B and Staff C slapped him on his upper shoulder area. Resident #12 stated ouch you dumb broad. Staff C responded to Resident #12 by saying he needed to stop touching us. When Staff C left the room Staff B looked at Resident #12's upper shoulder area and did not see any red marks. Staff B revealed she now knows that she should have reported the incident right away but did not trust the charge nurse that was working that night as they worked with Staff C on overnight shift. Interview on 8/26/24 at 11:31 a.m. with Staff D revealed she was working with Staff B on an evening shift. Staff B told Staff D that Staff B witnessed Staff C hit Resident #12. Staff D revealed she told Staff B she needed to report that to the DNS. Staff D revealed she thought Staff B had told the DNS until she worked with Staff B again a couple days later and learned she had not reported it yet. Staff B had asked Staff D to go with her to report it. Staff D revealed she now knows she should have reported the incident as soon as she learned about it. Review of Staff C, CNA's time cards revealed the following information: a. 6/19/24 punch in at 5:49 p.m., and punched out on 6/20/24 at 6:09 a.m b. 6/20/24 punch in at 5:52 p.m., and punched out on 6/21/24 at 6:05 a.m c. 6/25/24 punch in at 5:57 p.m., and punched out on 6/26/24 at 6:05 a.m Review of facility provided policy titled Abuse and Neglect with a reviewed date of 7/22/24 revealed the following information: a. Alleged or suspected violations involving any mistreatment, neglect, exploitation or abuse including injuries of unknown origin will be reported immediately to the administrator. b. If an employee receives an allegation of abuse, neglect, exploitation or misappropriation of resident property or witnesses suspected abuse, neglect or misappropriation of resident property, the employee will take measures to protect the resident, provided the safety of the employee is not jeopardized. The employee will then report the allegation to a supervisor. b. The charge nurse or licensed nurse will be notified immediately, assess the situation to determine whether any emergency treatment or action is required and complete an initial investigation. If this is an injury of unknown origin, he or she also will attempt to determine the cause of the injury. The charge nurse also will ensure that any potential for further abuse is eliminated by taking one of the following actions: If this is an allegation of employee to resident abuse, the employee will be removed from providing direct care to all residents. Additionally, the employee will be placed on suspension pending the results of the internal investigation. Another employee will be assigned to complete the care of the resident. Interview on 8/28/24 at 3:23 p.m., with the Administrator revealed the incident should have been reported right away to the charge nurse or management to be able to separate the staff member from the residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, facility record review and facility policy review, the facility failed to ensure residents at risk for elopement were unable to exit the facility unattended for 1 of 1 residents reviewed for elopement (Resident #31). The facility failure resulted in an Immediate Jeopardy to the health, safety, and security of the residents. The facility reported a total census of 33 residents. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of May 3, 2023 on September 20, 2023 at 2:30 p.m., The Facility Staff removed the Immediate Jeopardy on May 3, 2023 through the following actions: a. Resident #31 ' s wander guard was checked and working. All other residents who wear a wander guard were checked immediately and all were working. b. Maintenance checked that all doors and alarms were functioning. c. Elopement drill was performed that shift on 5/3/2023, Day shift on 5/4/2023 and continued to be performed until all staff are present for at least one drill. d. Resident #31 was placed on 30 min checks for the wake time hours and hourly checks at night while sleeping. e. Social services has called all resident ' s first contact, told them about making sure not to hold the door open for anyone when entering or exiting the building and asked them to please pass this on to anyone who visits the residents in our nursing home. f. Bright colored signs have been placed on all exits reminding visitors to not open the doors or hold the doors for anyone else as it may be unclear if the other person is a staff member or a resident. g. All staff at the facility have been required to review the elopement policy prior to working the next shift. The scope lowered from a J to D at the time of the survey after ensuring the facility implemented education and their policy and procedures. The facility identified a census of 33 residents. Findings Include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident # 31 documented diagnoses of Alzheimer ' s disease, non- Alzheimer ' s dementia and non-traumatic brain dysfunction. The MDS showed the Brief Interview for Mental Status (BIMS) score or 4 indicating severe cognitive impairment. Review of Resident #31 ' s Care Plan with a revision date of 4/6/23 revealed the following information: a. The resident has potential for elopement related to the new environment and diagnosis of dementia. With a goal listed as resident will not leave the facility unattended. b. Interventions in place were to use a wander guard to alert staff to resident's movements and check wander guard functionality every shift to ensure wander guard is in working order. Review of the document titled Elopement Risk dated 3/14/23 revealed Resident #31 is at risk for elopement. Review of May Medication Administration Record revealed a nursing order check wander guard to make sure it is on and working everyday with a start date of 3/19/23. Review of Resident #31 ' s Progress Notes revealed the following: a. On 3/14/2023 at 5:43 p.m., fax sent to the primary care physician informing her that the resident is an elopement risk, and asked for an order for a wander guard. b. On 3/18/2023 at 12:59 p.m., Resident has been exit seeking. Stating she is going to go home and check on her kids. She has told multiple staff members this and has her coat laid out. Nurse has attempted re-orientation, called the daughter and the resident spoke with her. Nurse gave the resident multiple different jobs to distract her. Wander guard in place. Staff have communicated with each other resident is exit seeking and are all monitoring resident. c. On 5/3/2023 at 3:45 p.m., Late Entry entered on 5/4/23 at 2:04 p.m., Resident was noted ambulating outside of the building by a staff member with no alarm having been sounded. Resident does wear a wander guard and was noted to be in the front living room [ROOM NUMBER] minutes prior. Resident was by apartments stated that she was going to the motel to see if her husband was awake yet. Resident came back to the building willingly. Vital signs obtained and assessment completed, was in no apparent distress. Family, administration, Director of Nursing Services and Charge nurse are notified. Review of untitled document provided by the facility dated 5/3/23 at 3:15 p.m., revealed the following information: a. Resident was seen walking on the sidewalk outside of the building by our MDS nurse as she left work. Resident had her coat and shoes on. Just prior to this one of our nurses who is the case manager had set the code in the door for another resident to go outside for a walk. This resident was standing by the door so she waited to make sure the door latched and the wander guard system reset before she walked away. No staff between this time and when the resident was spotted on the sidewalk heard or disarmed the alarm for the wander guard after this. There were many visitors in the building at this time. Staff member reported just prior to this that she had toileted the resident in the resident room and the resident's roommate did have 2 female visitors and they were getting ready to leave as she finished toileting this resident. Resident followed this staff member to the common area and the staff member sat down to chart. b. Resident has repeatedly stated since arriving at the facility that she wants to go to where Her husband has been staying and points to the apartments on our campus that look like a motel. Repeatedly states, he lives in that place that they have for travelers when they get weary. When the staff got to the resident and when she came in she said I just wanted to knock on her husband's door and see if he was up. c. Resident was noted about 3:35 p.m., walking on the sidewalk outside of the building toward the apartments. Resident was in no distress, had on her coat and shoes. Stated that she was going to the motel to see if her husband was up yet. Temperature outside was 70 degrees and sunny, very light breeze. Resident has no soiled or torn parts on her clothing and shows no sign of falling. Walks in with staff who saw her on the sidewalk. Vital signs taken, assessed for injury. Brought to her room. Investigation started. Interview on 9/18/23 at 4:06 p.m., with Staff D, Certified Nursing Assistant (CNA) revealed she was assisting another resident when a staff member told her Resident #31 had left the building. Staff D revealed she had heard the alarm go off and Staff E, CNA reset the alarm without checking other doors. Staff D revealed the alarm system had been weird all day and the door alarms were going off for no reason. Staff D further revealed the staff had received education right away and then had drills until all the staff working in the facility had been through a drill. Interview on 9/19/23 at 2:23 p.m., with Staff F, Registered Nurse (RN) and Staff G, RN revealed they had been working the day Resident #31 left the building. They believe she exited the front door with visitors that day. Staff F, was leaving the facility for the day and when she was driving out of the parking lot she seen Resident #31 walking down the sidewalk to the apartments. Staff F exited her car to get to Resident #31. Staff G was in her office when the Hospice Chaplin told her one of the residents was walking down the sidewalk outside. Staff G immediately went out the front door and met up with Resident #31 and Staff F and assisted Resident #33 in returning to the facility. Staff F and Staff G revealed Resident #33 came back into the building with no problems and the charge nurse on duty assessed her. Interview on 9/19/23 at 2:42 p.m., with Staff E, CNA revealed she was working the day Resident #31 got out of the building. Staff E revealed they were busy and she heard the alarm and saw another resident going out to garden and reset the alarm for him to finish exiting the door. Staff E revealed she saw the wander guard alarm light blinking but thought it was for the other resident's wife standing too close to the door as he was going out to garden. She reset the alarm and did not check any other doors. Staff E revealed she did not know Resident #31 had exited the building until she was asked to come into the office and make a statement. Staff E revealed the facility did a lot of code purple which means missing resident drills until everyone had been through a drill. She revealed all the shifts had the education on code purple and they are still doing them. Interview on 9/19/23 at 3:15 p.m., with the Director of Nursing (DON) revealed the staff was very honest about the situation when she talked to them. The DON revealed during the investigation the facility learned another resident was going out to garden the same time as Resident #31 exited another door of the facility. Staff E reset the door alarms and did not check to see what door it was as she saw the other resident going outside. With the investigation the facility learned the staff was having alarm fatigue and the facility was able to assist with alarm announcements to help decrease the alarm fatigue. The DON revealed the staff did code purple drills until everyone of the staff had participated in one and the drills have continued since the incident. Review of the facility policy titled Elopement with a revision date of 7/11/23 revealed the following information: The purpose of this policy is: a. To assess and identify residents/clients at risk for elopement. b. To clearly define the mechanisms and procedures for monitoring residents/clients at risk for elopement. c. To provide a system of documentation for the prevention of, and in the event of, elopement. d. To minimize risk for elopement through individualized interventions. e. The definition of elopement is when a resident/client who needs supervision leaves the premises or a safe area without authorization. Interview on 9/20/23 at 3:48 p.m., with the DON revealed she has trained all her staff to be checking all doors when the alarms go off. This has helped and they have been continuing to code purple drills in the facility.