**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility self report, State of Iowa Administrative Hearings Findings, and staff interviews, the facility failed to perform behavioral health assessments for Resident #1 after he was served a 30 day involuntary discharge notice following an alleged assault on another resident. Resident #1 had a documented history of major depressive disorder and suicidal ideation and was placed on one to one (1:1) supervision after the alleged assault. On [DATE] the 1:1 supervision was discontinued to address a staffing shortage without Resident #1 being assessed. During the early morning hours of [DATE], with no 1:1 supervision, Resident #1 used items within reach and committed suicide hours before his scheduled discharge from the facility. The facility reported a census of 124 residents. On [DATE] at 5:00 pm, the State Survey Agency informed the facility of the failure to perform behavioral health assessments following notification of an involuntary discharge created an Immediate Jeopardy situation, which resulted in the suicide of a resident. The Immediate Jeopardy began on [DATE]. The facility removed the immediacy on [DATE] at 12:00 pm when the facility staff implemented the following Corrective Actions: Audits of all residents for Psychosocial History compliance Audits of all residents for a history of suicidal ideation or attemptsCreation and Implementation of a Suicide Prevention PolicyCreation and Implementation of a Phone Answering PolicyEducation to all employees of Suicide in Older AdultsEducation to all employees of Recognizing Behavioral Symptoms in Residents at Risk for Self HarmEducation to all employees for Clinical Procedure for Care of Residents with Depression and Assessing and Screening for Suicide RiskEducation to all employees of Resident RightsAudits of all residents behavior documentation for suicidal ideationsDiagnosis report for impulsivenessEducation to managerial staff of Behavior Interventions may only be changed/modified/discontinued by the Executive Director or the Director of NursingThe scope and severity lowered from a J to a G (harm that is not immediate) at the time of the survey after ensuring the facility implemented their policy andprocedures, audits, and staff education.Findings include:The Minimum Data Set (MDS) of Resident #1 dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15 which indicated cognition intact. The MDS recorded the resident experienced mood symptoms of feeling down, depressed, or hopeless on one day of the lookback period. The MDS recorded the resident dependent upon staff assistance for chair/bed-to-chair transfers. The MDS documented diagnoses that included: paraplegia, anxiety, depression, and alcohol abuse with alcohol-induced mood disorder. The Care Plan of Resident #1 identified a Focus Area of Mood Behavior, stating Resident #1 had a diagnosis of Major Depressive Disorder. It directed staff to perform BIMS and PHQ-9 (an assessment used to screen for and measure the severity of depression) upon admission, quarterly, annually and as needed and to notify the physician as needed with concerns. The Care Plan additionally directed staff to keep the resident's routine the same as much as able and to offer opportunities for the resident to express feelings. The Care Plan additionally directed for social services to intervene as needed. The Care Plan identified an additional Focus Area of Abuse Vulnerability, history of suicide attempts. The Care Plan directed Staff to observe and provide a safe environment, staff to receive annual training and for Notifications to be made to Immediate Supervisor. The Facility Reported Incident (FRI) dated [DATE] documented that, on [DATE], Resident #3 reported to the facility chaplain that she had been physically assaulted by Resident #1 on [DATE]. According to the FRI, Resident #1 had grabbed and squeezed the upper leg of Resident #3 while he was passing by her in his electric wheelchair. The facility immediately ensured separation of the two residents, assigning a 1:1 Certified Nursing Assistant (CNA) to supervise Resident #1 to maintain that separation. A skin assessment of Resident #3 revealed black and blue bruises consistent with her account of the incident. The Sheriff's Office was contacted and a police report was filed. In a discussion between Resident #1 and the Administrator, Resident #1 displayed an unprompted awareness of the identity of Resident #1. The facility initiated an emergency discharge of Resident #1, and an Emergency Notice of Involuntary Discharge was hand delivered to Resident #1 on [DATE]. With the assistance of the facility's Social Services Director, Resident #1 filed an appeal to the discharge and a hearing took place on [DATE]. On [DATE], the Director of Nursing (DON) stated that she and the Administrator together notified Resident #1 on [DATE] that the discharge had been upheld in the hearing and offered him assistance to file a second appeal. She stated Resident #1 declined her assistance, stating he was resigned to it that he was discharging, and asked for some boxes to pack his belongings. She stated he also requested the facility continue to work on finding alternate placement as another facility that had accepted him was not his first choice of places to transfer to. The DON clarified the resident had received this notice earlier but had failed to open the envelope which contained the findings of the hearing. The Facility Reported Incident (FRI) dated [DATE] documented that at approximately 5:30 am on [DATE], facility staff discovered Resident #1 deceased in his room following a successful suicide attempt. The FRI detailed Staff B, Registered Nurse (RN) was the night shift supervisor on duty. Staff A, Licensed Practical Nurse (LPN), MDS Coordinator, was on call for any staffing issues. On [DATE], two CNAs failed to report for their scheduled shift. Staff A notified Staff B per protocol. The FRI further stated that the two staff members developed a coverage plan to ensure sufficient staffing, which included removing the 1:1 supervision of Resident #1 so the assigned CNA could perform general floor duties. Resident #1 was checked on at least every two hours with no noted concerns during these checks until approximately 5:30 am. On this check, Resident #1 was found on the floor of his room, surrounded by blood. The attending nurse assessed and determined Resident #1 had used a piece of glass from a broken picture frame and a set of scissors to cut himself, severing an artery of his left arm, resulting in death. Staff immediately called 911 and required persons were notified of the incident. During a chart review on [DATE], the Care Plan of Resident #1 failed to reflect any status updates regarding the assault, the involuntary discharge, or the 1:1 supervision. The Progress Notes portion of the resident's Electronic Health Record (EHR) failed to reflect any progress notes that had been entered by either of the facility social services representatives. The EHR additionally failed to document any psychosocial assessments having been completed following the notice of involuntary discharge on [DATE]. On [DATE] at 12:29 pm, Staff A, LPN, MDS Coordinator, stated she was on call the night of [DATE]. She reported she was asleep when Staff B, RN, texted to inform her that two CNAs had not reported for work. Staff A stated she instructed Staff B to call both absent staff members, providing her with phone numbers, and advised her to ask 2pm-10pm shift staff if anyone could stay late to assist. Staff A stated Staff B asked if the 1:1 supervision of Resident #1 could be removed, and she responded that it was acceptable as long as the resident was asleep. She added that a second CNA from the Memory Care Unit (MCU) were also reassigned so that each unit had a CNA on duty. Staff A further stated that there were two additional nurses on duty that night, both in orientation, and therefore she believed there was adequate staffing in the building. Staff A verbalized she felt Staff B would move the available staff around to accommodate the staffing needs. She also added the 1:1 supervision was intended to keep Resident #1 separated from other residents, and noted that on the night shift the 1:1 often sat outside the door while he slept rather than remaining in his room. She added that if the supervision had been for suicide watch, the approach would have been different. On [DATE] at 5:15 pm, Staff B, RN stated her shift began at 6:00 pm on [DATE]. She reported that, although her position was the night shift supervisor, she initially did not perform supervisory duties because she was covering for a nurse at 6:00 pm. Around 8:00 pm, a staffing agency nurse arrived, and from that time until approximately 10:00 pm, she resumed supervisory duties. At 10:00 pm, two CNAs failed to report for their shifts. After unsuccessfully attempting to contact them and asking on-duty staff to stay, she had contacted Staff A, the manager on call, and after informing her of the situation, requested the removal of the 1:1 supervision of Resident #1 as well as moving a second CNA from the MCU. Staff B stated she was aware Resident #1 was paralyzed, unable to get out of bed, and typically asleep by that time of night, which was why she requested the removal of the 1:1. She stated she returned to working the floor at 10:00 pm, and described the shift as busy. Staff B said that at approximately 5:30 am, she heard screaming from another area of the building. Following the sound, she heard staff calling her name regarding Resident #1. Upon entering his room, she observed the resident lying on the floor in a pool of blood. She directed another staff member to call 911, and she assessed the resident for a pulse and breathing, neither being present. Paramedics arrived quickly, and it was confirmed that Resident #1 had a do not resuscitate order; no CPR was performed. On [DATE] at 4:30 pm, the Social Services Director (SSD) stated she had helped Resident #1 file his appeal of the involuntary discharge. She stated she did not participate in the hearing regarding the discharge. The SSD stated she was on vacation from the 19th until the 23rd of July, returning to work on the 24th of July. Upon her return to work, she was informed the discharge was upheld and Resident #1 chose not to file a second appeal. She stated she went to his room to speak with him and told him she was sorry to hear about him losing his appeal and mentioned he would be transferring to another facility. She described Resident #1 would not make eye contact with her, although they normally had a good relationship. She stated she joked with him that at least at the other facility, he would be able to smoke and not get in trouble for it. When Resident #1 did not respond, she turned to leave, and Resident #1 stopped her and told her he did not want her to feel guilty about anything that happened, and that she had done all she could to help him. The SSD voiced that in hindsight, she felt this was a suicidal statement, but at the time he said it, she did not take it that way. The SSD also reported she had experience working a suicide hotline. The SSD stated the hearing regarding the involuntary discharge had taken place on [DATE] and when she had asked facility management if she was to participate in the hearing, she was told no. She explained after assisting him in filing the appeal, she had no further contact with Resident #1 until [DATE]. She stated she works more with the skilled residents in the facility while the other social service representative worked more with the long term care residents. She added his PHQ-9 scores were always zero, indicating no depression, saying he never gave any inclination he was thinking of suicide. She added that while nobody anticipated suicide, more follow up probably should have been provided. She stated there were no protocols in place of daily check ins but reiterated Resident #1 was offered psychiatric services but he declined them. She explained these services were offered after the appeal hearing had taken place, after the ruling was given. She explained the services offered were virtual and the Assistant Director of Nursing (ADON) for his hallway had acomputer, and attempted to get him to participate in the therapy session but the ADON was unaware of why therapy sessions had been set up. Another ADON in the facility explained to the resident the reason for the services and the resident then declined the services. In a second interview on [DATE] at 10:59 am, Staff A clarified she did not give Staff B specific direction for staffing needs in regards to the two nurses who were orientating on the night shift of [DATE]. She stated once she ok'd the removal of the 1:1 and the second CNA from the memory care unit, she assumed Staff B was taking care of the situation. She added she had worked the day shift on Wednesday [DATE] and then had to work the overnight shift as well. She got home around 7:00 am on [DATE]. She stated she received copies of the schedule for [DATE] via text from the facility, looked at the schedule and felt they were fully staffed. She stated in her mind, due to the extra two nurses, they had enough staff. She verified no assessment was completed on Resident #1 prior to removing the 1:1. She stated the reason for this was he was in bed, and she knew staff often sat outside of the room. She felt if he was sleeping, there was no reason for a staff member to be sitting there. She clarified she is the MDS Coordinator, and not an ADON. She was aware the facility required that any staffing changes could only be made at the direction of the DON or an ADON. She stated she normally would call the DON but did not call her that night due to having extra nurses in orientation on duty. She reiterated if they had not been there, she would have come in. On [DATE] at 3:05 pm, Staff D, Social Services designee, stated she had only worked at the facility for a few months. She stated she and Resident #1 had gotten off on the wrong foot when she started due to her needing to speak to him about him driving his electric wheelchair too fast through the halls. She stated once during the appeal process, she checked in with Resident #1 but he had been speaking with someone from Medicaid. She described him as being very closed off when she checked in on him and state that was the only time she had any contact with him after the involuntary discharge notice was given other than briefly saying hello in passing. On [DATE] at 9:04 am, Staff E, LPN stated she was the nurse assigned to Resident #1's hallway on [DATE] for the overnight shift. She stated she had been a nurse for over 20 years but had worked at the facility for a short time. She explained she was assigned to that hallway, as well as the MCU, and additionally needed to help in the Assisted Living part of the facility to administer insulin and cover meal breaks. She was also orienting Staff F, LPN who was a new nurse. She explained it was a very busy shift, and a new resident in the MCU unit was upset and exit seeking and setting off alarms much of the shift. She stated she did not see Resident #1 that shift until the morning. She stated she works throughout the building and did not know Resident #1 well. She added with the staffing pattern of most employees working in multiple areas of the building, she is unable to get to know the residents well or build rapport with them. She felt if she had known Resident #1 better, perhaps he would have confided in her as she had worked with other suicidal patients in the past and had been able to assist. She stated staff F, LPN administered insulin for Resident #1 that shift, and the Medication Aide administered his oral medications. She was aware that Resident #1 was under 1:1 supervision and the reason for the supervision. She stated no staff had informed her the 1:1 person had been removed from his room. She said that to her knowledge, Resident #1 had no prior suicidal ideations. When Staff E was told prior suicide attempt was included on the Resident Care Plan, she stated she is not familiar with the software program the facility uses for the resident's Electronic Health Records and did not know how to retrieve or read a resident care plan. On [DATE] at 10:18 am. Staff F, LPN stated she worked at the facility earlier in the summer as a CNA. She had recently passed the State Boards and obtained her LPN license, and was then training as an LPN. She stated she trained with Staff E on her shift on [DATE]. She stated the only interaction she had with Resident #1 during that shift was approximately 9:30 or 9:45 pm when she administered his night time insulin. She stated the Medication Aide had administered his oral medication. She had been told Resident #1 often refused his nightly scheduled catheter flush, and he did refuse it that night. She stated she attempted to make some small talk with the resident when she was in the room with him, but he only responded with one word answers. She stated she was aware that there had been a CNA removed from the MCU to cover staffing needs but was not aware the 1:1 supervision had been removed from Resident #1. She said some staff sat in his room with him at night and others sat in the hallway. She verified after 10:00 pm, she had not been back in Resident #1's room. The Fire Department Patient Care record dated [DATE] recording the following: Squad 3** responded. Crew was met at the front door by nursing home staff. Staff reported patient was on the *** hallway. Staff reported the patient was a Do Not Resuscitate but this was an unusual instance so they called 911. On arrival to the room, the patient was found on the floor in a large pool of blood. It was noted blood was found all over the room also. Night shift lead nurse was in the room crying. She reported they came into the room and found the patient like this. Staff was not able to provide a last known well time for the crew. It was noted that there was obvious death. The patient was not breathing and had no pulse. Noted that there was a small pair of scissors (with blood on them) on a table and broken glass on the bed. The patient was not disturbed by the EMS crew, no EMS interventions were taken. Crew was able to see multiple cuts to the left wrist from the doorway with a large pool of blood coming from cut site. Nursing home staff reported that the notes taped on the window and refrigerator door appear to be new. They state Thank you Railroad (female name). Crew removed all staff from the room at this time. The Medical Examiner and sheriff's office were called to the scene. While getting information from the staff, it was reported the patient was leaving the facility that day. Staff was able to provide a current DNR status and a face sheet. On arrival of the Sheriff's Office, crew explained the circumstances they walked into. No further actions were taken. The scene was turned over to the Sheriff's Office.On [DATE], the DON stated no staff called her the night of [DATE]. She stated that Staff F, LPN had been a CNA prior to becoming an LPN and she could have been pulled to sit with Resident #1 that night. She stated if staff had called her, that would have been her directive, to not remove the 1:1 but to have Staff F act as the 1:1. In an email dated [DATE] at 1:24 PM, the Administrator indicated the facility follows the nursing standards of practice related to assessments.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility self report, State of Iowa Administrative Hearings Findings, staff and family interviews, and facility policy review, the facility failed to recognize and address potential statements and behaviors that indicated Resident #1's self harm risk after he was served a 30 day involuntary discharge notice following an alleged assault on another resident. Resident #1 had a documented history of major depressive disorder and suicidal ideation and was placed on one to one (1:1) supervision after the alleged assault. In the days leading up to his discharge, multiple staff members stated they observed Resident #1's potential signs of worsening depression or heard him verbalize comments of potential self-harm but did not report these concerns to facility management. During the early morning hours of [DATE], without 1:1 supervision in place, Resident #1 used items within reach and committed suicide hours before his scheduled discharge from the facility. The facility reported a census of 124 residents. On [DATE] at 5:00 pm, the State Survey Agency informed the facility the staff failure to recognize, address and report potential statements and behaviors of self-harm following the notification of an involuntary discharge created an Immediate Jeopardy situation, which resulted in the suicide of a resident. The Immediate Jeopardy began on [DATE] The facility removed the immediacy on [DATE] at 12:00 pm when the facility staff implemented the following Corrective Actions: Audits of all residents for Psychosocial History compliance Audits of all residents for a history of suicidal ideation or attemptsCreation and Implementation of a Suicide Prevention PolicyCreation and Implementation of a Phone Answering PolicyEducation to all employees of Suicide in Older AdultsEducation to all employees of Recognizing Behavioral Symptoms in Residents at Risk for Self HarmEducation to all employees for Clinical Procedure for Care of Residents with Depression and Assessing and Screening for Suicide RiskEducation to all employees of Resident RightsAudits of all residents behavior documentation for suicidal ideationsDiagnosis report for impulsivenessEducation to managerial staff of Behavior Interventions may only be changed/modified/discontinued by the Executive Director or the Director of NursingThe scope and severity lowered from a J to a G (harm that is not immediate) at the time of the survey after ensuring the facility implemented their policy and procedures, audits, and staff education.Findings include:The Minimum Data Set (MDS) of Resident #1 dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15 which indicated cognition intact. The MDS recorded the resident experienced mood symptoms of feeling down, depressed, or hopeless on one day of the lookback period. The MDS recorded the resident dependent upon staff assistance for chair/bed-to-chair transfers. The MDS documented diagnoses that included: paraplegia, anxiety, depression, and alcohol abuse with alcohol-induced mood disorder. The Care Plan of Resident #1 identified a Focus Area of Mood Behavior, stating Resident #1 had a diagnosis of Major Depressive Disorder. It directed staff to perform BIMS and PHQ-9 (an assessment used to screen for and measure the severity of depression) upon admission, quarterly, annually and as needed and to notify the physician as needed with concerns. The Care Plan additionally directed staff to keep the resident's routine the same as much as able and to offer opportunities for the resident to express feelings. The Care Plan additionally directed for social services to intervene as needed. The Care Plan identified an additional Focus Area of Abuse Vulnerability, history of suicide attempts. The Care Plan directed Staff to observe and provide a safe environment, staff to receive annual training and for Notifications to be made to Immediate Supervisor. The Facility Reported Incident (FRI) dated [DATE] documented that, on [DATE], Resident #3 reported to the facility chaplain that she had been physically assaulted by Resident #1 on [DATE]. According to the FRI, Resident #1 had grabbed and squeezed the upper leg of Resident #3 while he was passing by her in his electric wheelchair. The facility immediately ensured separation of the two residents, assigning a 1:1 Certified Nursing Assistant (CNA) to supervise Resident #1 to maintain that separation. A skin assessment of Resident #3 revealed black and blue bruises consistent with her account of the incident. The Sheriff's Office was contacted and a police report was filed. In a discussion between Resident #1 and the Administrator, Resident #1 displayed an unprompted awareness of the identity of Resident #1. The facility initiated an emergency discharge of Resident #1, and an Emergency Notice of Involuntary Discharge was hand delivered to Resident #1 on [DATE]. With the assistance of the facility's Social Services Director, Resident #1 filed an appeal to the discharge and a hearing took place on [DATE]. On [DATE], the Director of Nursing (DON) stated that she and the Administrator together notified Resident #1 on [DATE] that the discharge had been upheld in the hearing and offered him assistance to file a second appeal. She stated Resident #1 declined her assistance, stating he was resigned to it that he was discharging, and asked for some boxes to pack his belongings. She stated he also requested the facility continue to work on finding alternate placement as another facility that had accepted him was not his first choice of places to transfer to. The DON clarified the resident had received this notice earlier but had failed to open the envelope which contained the findings of the hearing. The Facility Reported Incident (FRI) dated [DATE] documented that at approximately 5:30 am on [DATE], facility staff discovered Resident #1 deceased in his room following a successful suicide attempt. The FRI detailed Staff B, Registered Nurse (RN) was the night shift supervisor on duty. Staff A, Licensed Practical Nurse (LPN), MDS Coordinator, was on call for any staffing issues. On [DATE], two CNAs failed to report for their scheduled shift. Staff A notified Staff B per protocol. The FRI further stated that the two staff members developed a coverage plan to ensure sufficient staffing, which included removing the 1:1 supervision of Resident #1 so the assigned CNA could perform general floor duties. Resident #1 was checked on at least every two hours with no noted concerns during these checks until approximately 5:30 am. On this check, Resident #1 was found on the floor of his room, surrounded by blood. The attending nurse assessed and determined Resident #1 had used a piece of glass from a broken picture frame and a set of scissors to cut himself, severing an artery of his left arm, resulting in death. Staff immediately called 911 and required persons were notified of the incident. In the follow up investigation of the incident, the facility stated during the investigation, it was discovered a voicemail had been left on an unattended facility phone. To ensure emergency response protocols, the facility implemented a new policy to address that issue. The follow up further stated the decision to reassign the 1:1 CNA was made by Staff A and Staff B without reporting to or obtaining permission from the DON, as required by facility policy. Using the facility's Just Culture Algorithm, it was determined that this constituted a change due to failure to report and request approval from their supervisor for the staffing change. Both staff members received a suspension. On [DATE] at 12:29 pm, Staff A, LPN, MDS Coordinator stated she was on call the night of [DATE]. She reported she was asleep when Staff B, RN, texted to inform her that two CNAs had not reported for work. Staff A stated she instructed Staff B to call both absent staff members, providing her with phone numbers, and advised her to ask 2pm-10pm shift staff if anyone could stay late to assist. Staff A stated Staff B asked if the 1:1 supervision of Resident #1 could be removed, and she responded that it was acceptable as long as the resident was asleep. She added that a second CNA from the Memory Care Unit (MCU) were also reassigned so that each unit had a CNA on duty. Staff A further stated that there were two additional nurses on duty that night, both in orientation, and therefore she believed there was adequate staffing in the building. Staff A verbalized she felt Staff B would move the available staff around to accommodate the staffing needs. She also added the 1:1 supervision was intended to keep Resident #1 separated from other residents, and noted that on the night shift the 1:1 often sat outside the door while he slept rather than remaining in his room. She added that if the supervision had been for suicide watch, the approach would have been different.On [DATE] at 1:10 pm, Staff G, Certified Nurse Aide (CNA) stated she acted as the 1:1 on the 2:00 pm to 10:00 pm shift on [DATE]. She stated Resident #1 was making a lot of phone calls. She stated she was in the room with him for part of the shift and sitting in the hallway for part of the shift. She stated she thought one of the phone calls he had made had been to a bank. She overheard him stating he wanted money to go to his nephew if anything were to happen to him. She stated otherwise he was acting normal and she did not think anything of the statement. She said she had only been employed at the facility for a month or so and this was her first job as a CNA and she did not know Resident #1 well. She stated after she was sitting in the hallway, she overheard him talking and initially thought he was speaking to her. She stepped into the room and heard him on the phone so she stepped back into the hallway and was relieved by another staff member at 10:00 pm. On [DATE] at 1:55 pm, Staff H, CNA stated she worked with Resident #1 for a short time on [DATE] on the 2-10 shift, when Staff G was on break. She stated Resident #1 asked her to take him outside to smoke, so they went to the far end of the building outdoors and he smoked and then she assisted him back to his room. She stated Resident #1 had been acting depressed for several days. She said once the judgement came back that he had to move out, she knew there was nothing anyone could do about it. She stated she did not bring any concerns of his depression forward to any management or the social worker. She stated everyone knew how depressed he was, all the nurses on the floor, etc. She stated anybody who worked that hallway knew he was depressed. Staff H said she had worked at the facility for several years and knew Resident #1 pretty well. She stated he was very quiet and seemed down, but she had no idea he was contemplating suicide. She stated if she had any idea, she would have reported it and felt any other staff member would have as well. On [DATE] at 5:15 pm, Staff B, RN stated her shift began at 6:00 pm on [DATE]. She reported that, although her position was the night shift supervisor, she initially did not perform supervisory duties because she was covering for a nurse at 6:00 pm. Around 8:00 pm, a staffing agency nurse arrived, and from that time until approximately 10:00 pm, she resumed supervisory duties. At 10:00 pm, two CNAs failed to report for their shifts. After unsuccessfully attempting to contact them and asking on-duty staff to stay, she had contacted Staff A, the manager on call, and after informing her of the situation, requested the removal of the 1:1 supervision of Resident #1 as well as moving a second CNA from the MCU. Staff B stated she was aware Resident #1 was paralyzed, unable to get out of bed, and typically asleep by that time of night, which was why she requested the removal of the 1:1. She stated she returned to working the floor at 10:00 pm, and described the shift as busy. Staff B said that at approximately 5:30 am, she heard screaming from another area of the building. Following the sound, she heard staff calling her name regarding Resident #1. Upon entering his room, she observed the resident lying on the floor in a pool of blood. She directed another staff member to call 911, and she assessed the resident for a pulse and breathing, neither being present. Paramedics arrived quickly, and it was confirmed that Resident #1 had a do not resuscitate order; no CPR was performed. On [DATE] at 11:28 am, Staff I, CNA stated she was working the overnight shift on Resident #1's hallway on [DATE]. She stated she was the one who found him deceased . She stated that around 10:30 or maybe 11:00 pm, the 1:1 was pulled from Resident #1. She stated she was working the floor, following her normal routine. She thought it was around 1:00 am when she checked on him and asked him how he was doing. She stated she completed some charting and then around 2:00 am began her rounding again. She stated she checked on him again during that set of rounds and he was watching TV at that time. She stated at approximately 4:00 am, there was another resident on the same hall who needed to be woken up and gotten ready to go to dialysis. She made a light breakfast for that resident and made sure she ate. She said that around 4:15 she got the resident dressed and then about 4:30 she transported that resident to the front of the building to be picked up for dialysis and then went to do rounds again. She stated she checked on Resident #1 again during these rounds. Following the completion of her rounds, she stated she then needed to empty catheters for the applicable residents. Resident #1 had a catheter. She stated it was around 5:15 or 5:30 when she entered his room to empty his catheter and found him on the floor in a pool of blood and called for help. Staff I stated she knew Resident #1 pretty well. She added that when they found out he had to move out, many staff were upset about it. She said she didn't think he had done it (the assault). She explained that night, when she asked him how he was doing, he replied he was saying his good-byes. She expressed she should have known, when he said that, that something was wrong. She said she just keeps thinking about it. But he was moving to another facility. She stated she was not aware that anyone had reported any concerns to management of his depression. On [DATE] at 4:30 pm, the Social Services Director (SSD) stated she had helped Resident #1 file his appeal of the involuntary discharge. She stated she did not participate in the hearing regarding the discharge. The SSD stated she was on vacation from the 19th until the 23rd of July, returning to work on the 24th of July. Upon her return to work, she was informed the discharge was upheld and Resident #1 chose not to file a second appeal. She stated she went to his room to speak with him and told him she was sorry to hear about him losing his appeal and mentioned he would be transferring to another facility. She described Resident #1 would not make eye contact with her, although they normally had a good relationship. She stated she joked with him that at least at the other facility, he would be able to smoke and not get in trouble for it. When Resident #1 did not respond, she turned to leave, and Resident #1 stopped her and told her he did not want her to feel guilty about anything that happened, and that she had done all she could to help him. The SSD voiced that in hindsight, she felt this was a suicidal statement, but at the time he said it, she did not take it that way. The SSD also reported she had experience working a suicide hotline. The SSD stated the hearing regarding the involuntary discharge had taken place on [DATE] and when she had asked facility management if she was to participate in the hearing, she was told no. She explained after assisting him in filing the appeal, she had no further contact with Resident #1 until [DATE]. She stated she works more with the skilled residents in the facility while the other social service representative worked more with the long term care residents. She added his PHQ-9 scores were always zero, indicating no depression, saying he never gave any inclination he was thinking of suicide. She added that while nobody anticipated suicide, more follow up probably should have been provided. She stated there were no protocols in place of daily check ins but reiterated Resident #1 was offered psychiatric services but he declined them. She explained these services were offered after the appeal hearing had taken place, after the ruling was given. She explained the services offered were virtual and the Assistant Director of Nursing (ADON) for his hallway with a computer, attempting to get him to participate in the therapy session but was unaware of why therapy sessions had been set up. Another ADON in the facility explained to the resident the reason for the services and the resident then declined the services. On [DATE] at 4:47 pm, the DON stated that Staff F, LPN, who was in orientation that night, could have been pulled to be the 1:1 as she had worked as a CNA prior to becoming a nurse. She stated she didn't receive a phone call that night and that would have been her directive if anyone had called her. In regards to the referenced voicemail, she stated each hall of the facility has it's own cell phone that connects to the land lines. She stated after hours, there are prompts to be connected to the hall a person is trying to reach. She said on the night shift, the nurses generally only carry one phone, although they are covering more than one hall as a nurse. She said for instance, on night shift, there is one nurse who covers both the 300 hall and the 500 hall, but may only carry one of those two phones. She stated they found the voicemail on the phone of the hall where Resident #1 resided. She said the family member who left the voicemail also had her own personal cell phone number but she didn't call her, or the police or anyone else that she was aware of. She said when she called the family member the following morning to inform her of Resident #1's death, the family member stated she had left a voicemail the night before. In a second interview on [DATE] at 10:59 am, Staff A, LPN, MDS Coordinator clarified she did not give Staff B specific direction for staffing needs in regards to the two nurses who were orientating on the night shift of [DATE]. She stated once she ok'd the removal of the 1:1 and the second CNA from the memory care unit, she assumed Staff B was taking care of the situation. She added she had worked the day shift on Wednesday [DATE] and then had to work the overnight shift as well. She got home around 7:00 am on [DATE]. She stated she received copies of the schedule for [DATE] via text from the facility, looked at the schedule and felt they were fully staffed. She stated in her mind, due to the extra two nurses, they had enough staff. She verified no assessment was completed on Resident #1 prior to removing the 1:1. She stated the reason for this was he was in bed, and she knew staff often sat outside of the room. She felt if he was sleeping, there was no reason for a staff member to be sitting there. She clarified she is the MDS Coordinator, and not an ADON. She was aware the facility required staffing changes could only be made at the direction of the DON or an ADON. She stated she normally would call the DON but did not call her that night due to having extra nurses in orientation on duty. She reiterated if they had not been there, she would have come in. On [DATE] at 11:17 am, Staff J, RN stated she had worked at the facility for several months. She stated she did not notice a big mood change in Resident #1, but noted he was more quiet. She said right after the allegations of the assault were made against him, she specifically asked him if he had thoughts of suicide. She stated she asked him this because he seemed especially down that day. She said he denied it and laughed and said he would never do that. She said she did not work with him the week of [DATE]. On [DATE] at 11:37 am, Staff K, CNA stated she had been currently working at the facility for about one and a half years, but had also worked her prior and left. She stated she knew Resident #1 well and used to take care of him when he previously lived on another hall of the facility. She said she worked with him nearly every day she was scheduled to work. She described him as being down in the dumps over the last few weeks. She said he was very quiet. She said she occasionally acted as the 1:1 CNA and escorted him on a shopping trip on the local bus. She said recently, he was using his tablet more, and was not as talkative. She said prior to this, he would come to eat in the dining room and roam all over the facility. She said some mornings, she noticed the night shift 1:1 were sitting outside in the hallway with his door shut when she came on shift. She said in her opinion, they needed to be in the room with him but understood he also liked his privacy. She said she often assisted a second staff member to use the full body mechanical lift to transfer from his bed to his chair in the mornings, and he just seemed down. He used to visit with other male residents at meals before he was notified of needing to move out. She said she had noticed recently when it was time for his insulin, he would just park his chair near the medication cart, and sit with his head down and wait for the insulin then go back to his room. She said the nurses were aware of his behaviors, everybody could see it. On [DATE] at 11:45 am, Staff L, Certified Medication Aide (CMA) stated Resident #1 seemed a bit depressed. She said she didn't work his area of the building too often, and in his last week, she maybe only saw him once. She said he just seemed different. He used to be more bubbly, talking to everyone. Then he started staying in his room, not talking as much. She said it was out of the ordinary but she hadn't felt it was alarming. On [DATE] at 11:47 am, Staff M, CNA stated she had sat with him 1:1 a couple of days earlier in the week before the incident. She said he was very quiet. After he was dressed and out of bed, he asked her to just sit in the room and watch TV. She said they left the room once, he wanted to speak with the DON about his leaving. He was telling her he didn't want to go to the facility that had accepted him. There was another facility he wanted to go to instead. She said she asked him if he was nervous and he stated no, he just wanted to go to an alternate facility. She stated he was back in his room at the end of her shift, and just seemed quieter than usual.On [DATE] at 1:57 pm, Staff N, CNA stated she was scheduled to be the 1:1 on the 10:00 pm to 6:00 am shift on 724/25. She stated she was with him for approximately 45 minutes to an hour when she was pulled to work the floor in another area of the facility. She stated she looked in on him and he was watching TV and she sat in the hallway and had no interaction with him. She was not aware of any changes in him. On [DATE] at 3:05 pm, Staff D, Social Services designee, stated she had only worked at the facility for a few months. She stated she and Resident #1 had gotten off on the wrong foot when she started due to her needing to speak to him about him driving his electric wheelchair too fast through the halls. She stated once during the appeal process, she checked in with Resident #1 but he had been speaking with someone from Medicaid. She described him as being very closed off when she checked in and that was the only time she made contact with him other than saying hello in the hallways. On [DATE] at 9:04 am, Staff E, LPN stated she was the nurse assigned to Resident #1's hallway on [DATE] for the overnight shift. She stated she had been a nurse for over 20 years but had worked at the facility for a short time. She explained she was assigned to that hallway, as well as the MCU, and additionally needed to help in the Assisted Living part of the facility to administer insulin and cover meal breaks. She was also orienting Staff F, LPN who was a new nurse. She explained it was a very busy shift, and a new resident in the MCU was upset and exit seeking and setting off alarms much of the shift. She stated she did not see Resident #1 that shift until the morning. She stated she works throughout the building and did not know Resident #1 well. She added with the staffing pattern of most employees working in multiple areas of the building, she is unable to get to know the residents well or build rapport with them. She felt if she had known Resident #1 better, perhaps he would have confided in her as she had worked with other suicidal patients in the past and had been able to assist. She stated staff F, LPN administered insulin for Resident #1 that shift, and the Medication Aide administered his oral medications. She was aware that Resident #1 was under 1:1 supervision and the reason for the supervision. She stated no staff had informed her the 1:1 person had been removed from his room. She said that to her knowledge, Resident #1 had no prior suicidal ideations. When Staff E was told prior suicide attempt was included on the Resident Care Plan, she stated she is not familiar with the software program the facility uses for the resident's Electronic Health Records and did not know how to retrieve or read a resident care plan. Staff E Stated that Staff I, CMA had the phones prior to 10:00 pm as she was passing medications. She said at 10:00 pm, she thought that Staff F had the phones but she did not remember for sure. She said she had difficulty with the phones on prior shifts, she would find a Missed Call notification without the phone ever ringing. She said she would find the ringer volume was turned off but felt it could have been accidental that it got turned off based on the style of the phone and where the ringer switch is. She also stated she was not aware of how to listen to voicemails on the phones as the phones require a code to get into them and she doesn't know the codes. She said one phone in the facility has the code written on the back of the phone but the other ones do not. She said the normal routine for her was to carry both phones, but she did not have them that night as she was orienting another nurse.On [DATE] at 10:18 am, Staff F, LPN stated she worked at the facility earlier in the summer as a CNA. She had recently passed the State Boards and obtained her LPN license, and was then training as an LPN. She stated she trained with Staff E on her shift on [DATE]. She stated the only interaction she had with Resident #1 during that shift was approximately 9:30 or 9:45 pm when she administered his night time insulin. She stated the Medication Aide had administered his oral medication. She had been told Resident #1 often refused his nightly scheduled catheter flush, and he did refuse it that night. She stated she attempted to make some small talk with the resident when she was in the room with him, but he only responded with one word answers. She stated she was aware that there had been a CNA removed from the MCU unit to cover staffing needs but was not aware the 1:1 supervision had been removed from Resident #1. She said some staff sat in his room with him at night and others sat in the hallway. She verified after 10:00 pm, she had not been back in Resident #1's room. Staff F stated after 10:00 pm, she had both sets of keys (to the medication carts) and was given the phone to the MCU. She stated she did not have the phone for the hallway Resident #1 was on. She voiced she did know how to listen to voicemails on the facility phones but she didn't have that phone. On [DATE] at 1:18 pm, a family member of Resident #1 stated their family members all had apps on their phones they used to communicate with each other. She stated on the night of [DATE], Resident #1 had sent a message on the app It's check out time. She stated she did not think anything of it but another family member contacted her and stated she felt that meant he was thinking of suicide. She stated she called the facility but the phone rang to voicemail. She left a voicemail asking staff to keep an eye on him. She stated she had not had direct contact with Resident #1 for some time as he had asked her to sign some paperwork for him regarding something to do with his wheelchair. She had refused to sign the paperwork and he had been angry with her. She said after she called the facility and left the voicemail, she went to sleep. She received a phone call the next morning telling her he had committed suicide. She said he was supposed to be under 24 hour surveillance. She said from what she had heard, the facility was short staffed and they had nobody to watch him. She said she didn't know if Resident #1 knew they were short staffed when he killed himself. She stated maybe if he had surveillance, they could have saved his life. She added if they had just listened to his voicemail, that could have saved his life. On [DATE] at 1:42 pm, Staff O, CNA stated she had worked at the facility for a couple of years. She stated she most often worked on the skilled unit, but Resident #1 came down to visit that part of the building almost daily. She said she last saw him the day before the incident and told him that he looked nice. She said he replied to her that looking nice was only on the outside, not the inside. She stated she asked him if he was ok and he replied he was fine but the whole situation was off. She said she asked him again if he was ok and told him she would talk to him more the next day and he replied ok. She told him she would see him tomorrow and he replied the same. On [DATE] at 2:10 pm, Staff D, Social Services designee, stated her normal routine is to complete the PHQ-9 on residents and the BIMS assessment. She stated there is also a trauma assessment available that is specific to residents who have a history of trauma, but she had never used that assessment. She said the normal routine is only to do these assessments during the MDS period. On [DATE] at 2:55 pm, Staff P, ADON for the hall Resident #1 resided on, stated she had been the ADON for a few months. Prior to that, she worked at the facility for several years but didn't know Resident #1 well. She said she would see him around as he was very mobile through the facility. She said she had not had any conversations with him regarding his discharge and that no staff had brought any concerns to her regarding him. She said if staff had any concerns they should report it to the charge nurse and the charge nurse should report it to her. She said she had attempted to assist him in the virtual therapy sessions but he refused to participate. The Fire Department Patient Care record dated [DATE] recording the following: Squad 3** responded. Crew was met at the front door by nursing home staff. Staff reported patient was on the *** hallway. Staff reported the patient was a Do Not Resuscitate but this was an unusual instance so they called 911. On arrival to the room, the patient was found on the floor in a large pool of blood. It was noted blood was found all over the room also. Night shift lead nurse was in the room crying. She reported they came into the room and found the patient like this. Staff was not able to provide a last known well time for the crew. It was noted that there was obvious death. The patient was not breathing and had no pulse. Noted that there was a small pair of scissors (with blood on them) on a table and broken glass on the bed. The patient was not disturbed by the EMS crew, no EMS interventions were taken. Crew was able to see multiple cuts to the left wrist from the doorway with a large pool of blood coming from cut site. Nursing home staff reported that the notes taped on the window and refrigerator door appear to be new. They state Thank you Railroad (female name). Crew removed all staff from the room at this time. The Medical Examiner and sheriff's office were called to the scene. While getting information from the staff, it was reported the patient was leaving the facility that day. Staff was able to provide a current DNR status and a face sheet. On arrival of the Sheriff's Office, crew explained the circumstances they walked into. No further actions were taken. The scene was turned over to the Sheriff's [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observations, facility video and staff interviews, the facility failed to ensure a resident with exit seeking behavior did not exit the facility without staff knowledge. (Resident #4) The facility reported census was 125. The State Agency informed the facility of the Immediate Jeopardy (IJ) on 9/17/24 at 3:30 pm. The IJ began on August 4, 2024. Facility staff removed the Immediate Jeopardy on 9/24/24 through the following actions: - Resident placed on 1:1 observation on 8/4/24 until he was moved to the locked Memory Care Unit on 8/5/24. - Neuro checks initiated, witness statement obtained, and notifications made on 8/4/24. - Elopement assessment and care plan updated 8/5/24. - Staff education on elopement and documentation began 8/4/24. - Residents wander guard immediately checked for functionality on 8/4/24. - Staffing was reviewed for time of incident and determined not to be a contributing factor. How will you identify other residents who are at risk for being affected by this alleged deficient practice: All residents at risk for elopement have potential to be affected by this alleged deficient practice. What measures will you put into place or what system changes will you make to ensure that the deficient practice does not recur. - Staff education for elopement began 8/4/24. - All residents with wander guards were reviewed, tested and ensured orders were put in place for monitoring on 8/4/24 and 9/19/24. - Elopement drills were conducted 7/31/24 and 8/5/24. - Elopement Risk Assessments were reviewed on all residents and revised, if necessary, on 8/4/24. - All elopement care plans were reviewed and revised as necessary on 8/4/24. - Elopement Book at front desk was reviewed and updated as necessary on 8/4/24. - All Maintenance logs were reviewed and found in compliance with alarm monitoring on 8/4/24. - TARS reviewed and physician orders updated to include what functionality of the alarm looks like on 9/19/24. - Ideacom, our wander guard service vendor, sent a technician to Lutheran Living on 9/19/24 at approximately 7:30 PM and recalibrated the Wanderguard after the system passed all tests. The technician was unable to duplicate the issue and felt it was a technology glitch. Technician increased the sensitivity of the wander guard zones for optimal coverage. - Main entrance was monitored by staff, until Ideacom technician arrived to evaluate system and increase sensitivity. - Implementation of a Weekend Manager on Duty to ensure we have coverage at the front entrance every day of the week. - Wanderguard alarm on doors will continue to be monitored ongoing. - Wanderguard bracelets on residents will continue to be monitored ongoing. How the corrective action will be monitored to ensure that the deficient practice does not recur. - Negative findings will be corrected immediately and reported at Quality Assurance and Performance Improvement Meeting and conduct education training as needed. - Ongoing random reviews of this system will be incorporated into the monthly - Quality Assurance Performance Improvement Program. The scope lowered from J to D at the time of the survey after ensuring the facility implemented the education, audits and their policy and procedures. Findings include: According to the Minimum Data Set (MDS) dated [DATE], Resident #4 had a Brief Interview for Mental Status (BIMS) score of 5, indicating a severely impaired cognitive status. Resident #4 required maximal to dependent assistance with transfers, mobility, dressing, toilet use and personal hygiene needs and he was frequently incontinent of bladder and bowel. Resident #4's diagnosis included cerebrovascular accident (stroke) with hemiplegia, Non-Alzheimer ' s dementia and atrial fibrillation. According to the facilities Elopement Risk Screen Tool dated 7/8/24, Resident #4 scored 30 and was determined at high risk for elopement. Resident #4's Care Plan indicated he was at risk for elopement with goal to keep resident safe and secure during his stay and interventions to: 1. Complete quarterly and as needed Elopement Assessments. 2. Observe, monitor, document behaviors, and mood exit seeking concerns and notify supervisor, social worker and physician as needed. 3. Notify supervisor if wanderguard (Accutech LC1200) is missing or not functioning properly. 4. Wanderguard bracelet placement-wanderguard is placed on wheelchair. Monitor per facility protocol. According to the August Treatment Administration Record (TAR), staff are to ensure Wanderguards are checked for proper placement and functioning each shift. August TAR indicates Resident #4's wanderguard was recorded as functioning and placed properly on his wheelchair throughout August. In an interview on 9/22/24 at 6:12 p.m. a visitor/witness (MB) stated on the morning of 8/4/24 she was visiting a friend and another resident outside the front entrance. She saw Resident #4 outside in his wheelchair talking on the phone. Resident #4 then began propelling himself down the sidewalk. The visitor (MB) stood and started towards Resident #4 as he began to gain speed down the slope, then tipped over onto his right side, onto the grass. The visitor (MB) turned back to the facility and ran inside to get help. The visitor (MB) stated the staff responded immediately. The visitor (MB) stated there was no alarm sounding or staff present outside during the time Resident #4 was outside. The visitor (MB) stated the alarm sounded when Resident #4 was propelled by staff back into the facility. In an interview on 9/22/24 at 5:56 p.m. Staff G, Certified Nurse Aide, stated she was working the day shift on 600 hall 8/4/24. Staff G stated she was on 300 hall that morning, talking to a resident when a family member ran in stating Resident #4 had tipped his wheelchair over, outside. Staff G stated she hollered for Staff H on 300 hall as they ran to the front entrance to help Resident #4. Staff G stated several staff arrived and took care of Resident #4 and got him back inside. Staff G stated there was no alarm sounding when she got to the front entrance. According to a statement written by Staff H on 8/5/24, Staff H, Certified Nurse Aide, stated she was working on 300 hall on 8/4/24 when she was asked by another staff (Staff G) for help. Staff H stated she ran behind Staff G with her nurse (Staff B) behind her. Staff H stated they all went outside where they found Resident #4 on the ground. They made sure he was okay and helped him back into his wheelchair. Once back inside the nurse took his vital signs and she went back to her hall. In an interview on 9/18/24 at 6:05 p.m. Staff B, Certified Medication Aide, stated after returning to 300 hall following her lunch break, she was informed by Staff H, that Resident #4 was outside on the ground near the tree. Staff B stated she started out, then was directed back in to get the nurse, before returning outside to assist. Staff B stated Resident #4 had tipped his wheelchair onto his right side onto the grass, near a tree along the sidewalk. Staff B stated she helped get Resident #4 back into his wheelchair. Staff B stated there was no alarms sounding when she initially went outside, but upon returning the wanderguard alarm did sound. Staff B stated wander guard tags are checked each shift for functioning and placement and when a wanderguard door alarm sounds it must be coded to disarm. According to a statement written by Staff M, Licensed Practical Nurse, Staff M stated she was alerted by staff to go outside the building as Resident #4 was on the ground with his wheelchair tipped over. Family members explained that Resident #4 was outside sitting area using his phone and the next thing they noticed, he began propelling his wheelchair on the sidewalk and the wheelchair tipped over onto the grass. Staff M stated she immediately instructed one staff to call the assigned nurse (Staff F) to make sure she was aware of the fall incident. Staff M sated Resident #4 was assessed, alert with no facial grimacing or voicing of pain or discomfort. Resident #4 was turned onto his back and active and passive range of motion performed. Resident #4 was then placed in a sitting position with gait belt applied and assisted up with assistance of 4 staff and transferred into his wheelchair. Resident #4 had a wander guard tag attached to his wheelchair and upon entering back into the facility the alarm sounded. Further assessment was conducted in the facility and noted pulse was 49. Verbal report given to staff and the nurse and Resident #4 was propelled to the dining room for lunch. The Assistant Director of Nursing was notified of the incident by text. In an interview on 9/18/24 at 6:42 p.m. Staff J, Certified Nurse Aide, stated she recalls the day before (8/3/24) Resident #4 eloped, she questioned whether the wanderguard was working properly. That day Resident #4 was near the elevator near the memory care unit next to wanderguard door units and the alarm did not sound. Staff J stated normally the elevator wanderguard alarm would sound when residents with Wanderguards get too close. Staff J stated she reported her observation to the nurse. In an interview on 9/18/24 at 6:32 p.m. Staff L, Certified Nurse Aide, stated on the morning of 8/4/24 she was assigned on 400 hall and Resident #4 was already actively trying to exit and stating he was leaving. Staff L stated this behavior had intensified over the last week. Staff L stated she had redirected him several times that morning and propelled him back to 400 hall lounge around 9:30 a.m. Then, while caring for another resident, she was informed Resident #4 had gotten outside. Staff L stated she came up front and several staff were outside with Resident #4. Staff L stated there was no wanderguard alarm sounding. Staff L stated the wanderguard alarm is loud and can easily be heard in the 400 hall. In an interview on 9/19/24 at 9:15 a.m. Staff E, Certified Medication Aide, stated she was working day shift on 400 hall 8/4/24. That morning Resident #4 was adamant about leaving and was exit seeking all morning, requiring redirection and propelling him back to 400 hall several times. During staff break times, the nurse (Staff F) stated she was going to give the resident some medication and that she would keep an eye on him. Staff E stated she went on break and returned 30 minutes later and began helping another aide, when a 300 hall aide came and stated Resident #4 had gotten outside. Staff E stated she got to the front door and by then several staff were already outdoors. Staff E stated there was no wanderguard alarm sounding, however it did sound as Resident #4 was brought back inside. Staff E stated the wanderguard alarm can be heard throughout the facility and requires a code to disarm it. In an interview on 9/19/24 at 11:14 a.m. Staff K, Certified Nurse Aide, stated she was working 400 hall on Saturday, 8/3/24 and noted Resident #4 was insistent on leaving and exit seeking all day. Staff K stated she shared this with the Sunday, 8/4/24 staff. Staff K stated she was working on the 500 hall on Sunday, 8/4/24 and had redirected Resident #4 more than once that morning. Staff K stated on the morning Resident #4 eloped, the alarm sounded briefly, then turned off. Staff K explained that the wander guard will alarm on the phones and display a code. In Resident #4's case, the phone alerted and displayed WG Hall 400, indicating it was a wander guard from someone on 400 hall. Staff K states she remembers that code at the time Resident #4 exited the building and it only lasted a few seconds. Staff K stated she was at the front entrance when Resident #4 was brought back in. Observation of facility video of the front entrance on 8/4/24, noted at 10:51:51 a.m. Resident #4 is observed exiting the front entrance in his wheelchair behind a visitor who had just coded the door open. At 10:57:30 a.m. a visitor is observed coding the front door and exiting. The video shows Resident #4 outside and visitors looking towards Resident #4. One visitor (MB) stands and starts towards Resident #4, then turns and runs into the facility at 11:02:50 to alert staff. At 11:03 a.m., nearly 11 minutes after Resident #4 exited the facility unsupervised and undetected, staff exit to assist Resident #4. Through testing the alarms, interviewing staff and watching the video, it was confirmed the wanderguard alarm never activated when Resident #4 exited the facility. During an observation on 9/19/24 at 10:57 a.m. Staff P, maintenance, was asked to test the wanderguard alarm system at the facilities front entrance. Staff P brought the wanderguard tag in close proximity to the wanderguard monitors and the alarm failed to sound. Minutes later a second attempt activated the wanderguard alarm requiring a code at the front door to disarm the alarm.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, personnel records, medical examiner interview and staff interviews, the facility failed to provide adequate staff and supervision to assist a resident who called out for help in a timely manner for 1 of 5 residents (Resident #1) reviewed for safety. Per staff interview, Resident #1 called out for help on [DATE] at approximately 4:30 AM, and staff were unable to respond for up to 10 minutes. The resident subsequently found face down in bed, feet on the floor, unresponsive. The facility reported a census of 129 residents. The State Agency informed the facility of the Immediate Jeopardy (IJ) on [DATE] at 5:35 p.m. The IJ began on February 11, 2024, when Resident #1 found unresponsive. Facility staff removed the Immediate Jeopardy on [DATE] through the following actions: a. The Director of Nursing (DON) or designee will educate On-Call Clinical Staff on responsiveness to staffing calls. b. The DON or designee will educate direct care Licensed Nurses prior to working their next shift on escalation of unanswered attempts related to staffing to contact on call Nurse. c. Labor meeting daily Monday through Friday to review previous days staffing requirements and anticipate staffing needs with Executive Director, DON, Staffing Coordinator and other applicable staff. d. Resident interviews (10) regarding satisfaction with staffing ratios will be conducted by the Executive Director or designee weekly. e. Staff interviews (10) regarding satisfaction with staffing ratios will be conducted by the Executive Director or designee weekly. f. Nursing staff will be educated on responding to resident ' s needs prior to working next shift. (Calling out for assistance). The scope lowered from J to G at the time of the survey after ensuring the facility implemented education and their policy and procedure. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 diagnoses included: arthritis, osteoporosis, Alzheimer's disease, anxiety, and depression. A score of 3 out of 15 on the Brief Interview for Mental Status (BIMS) indicated a severe cognitive impairment. The assessment revealed Resident #1 required substantial/maximal assistance (meaning staff provided more than half of the effort to complete a task) for transfers to and from bed and chair, and to roll from lying on back to left and right side, and to return to lying on back on the bed. The MDS assesses Resident #1 as having clear speech with distinct intelligible words, and sometimes understood, and usually understood others. The Care Plan, created on [DATE], and initiated on [DATE], included a Focus Area for Safety and Falls R/T (related to) current medical and physical status. Poor safety awareness r/t dementia. Interventions included: 1. Body pillow to be placed when I am in bed, initiated [DATE]. 2. Med [NAME] (similar to a mattress) placed next to my bed, initiated on [DATE]. 3. Staff education to ensure placement of medmizer when in bed, initiated on [DATE]. 4. Bed in low position, no initiation date indicated. 5. Call light positioned for easy access, no initiation date indicated 6. Check for unmet needs: pain, toileting, hunger, thirst, temperature, no initiation date indicated A Care Plan Focus Area, initiated on [DATE], for ADL (Activities of Daily Living) Complications with Deficit's with ADL R/T current medical and physical status. Has meds and dx (diagnosis) that can affect ADL's. I have decreased mobility and depend on others to assist me with ADL's. Interventions included Bed Mobility x1 (one staff) extensive assist. I am not consistent with being able to turn side to side. I am dependent with laying to sitting. A Nursing Progress Note transcribed on [DATE] at 4:56 AM. by Staff K, Licensed Practical Nurse (LPN) stated: Resident was found by CNA (Certified Nursing Assistant) at 4:35 a.m. on the mat unresponsive. CNA notified Staff L, LPN about resident. No vitals noted. This nurse and Staff L verified resident's death at 4:35 a.m. This nurse called 911 to notify and speak with the Medical Examiner (ME) about resident. Waiting call back. During an interview on [DATE] at 7:41 AM, Staff H, Certified Nursing Assistant (CNA) stated she worked the night shift on [DATE], assigned to the 600 Hall. She stated she worked on a different hall then where Resident #1 resided. Staff H stated when Staff M, CNA left at 2:00 AM she also covered the 500 hall. She stated while on the 600 Hall, on her way to the 500 Hall around 4:30 AM heard the resident [Resident #1] yell out but didn't think it was anything serious. Staff H stated she headed into a different room a few doors down to provide care and answer the call light. While in this room, Staff I, CNA, came in the room and said Resident #1 was crying. Staff H stated it was about 5 to 10 minutes before they went to Resident #1's room and found her face down, the front part of her lower part of her body was on the fall mattress next to the bed, and the upper part of her body was on the upper part of the bed, chest down with her head face down, between the mattress and the side rail attached to the bed, the bed was in low position, and she was certain that was how the resident was positioned. Staff H stated she thought the resident must have reached for something and how she ended up on her stomach, and thought the resident yelled because her head was stuck there and she couldn't get up. The resident was pale, she didn't think she was breathing and sent Staff I to get the nurse. Staff L, LPN came to the room and directed them to turn the resident over, put her on the fall mattress and to get Staff K, LPN as that was the nurse assigned to the resident. When Staff K got to the room, the resident was on her back on the fall mattress. Staff H reported she had last seen the resident about an hour and a half prior, when provided incontinence care to the resident. At that time, the resident was in her bed, she thought positioned on her side and covered with a blanket. During an interview on [DATE] at 12:57 PM, Staff I, CNA, stated she worked the night shift on [DATE] on the 700 Hall. She stated another staff had left, and she was told by a nurse to cover both halls (assigned 700 Hall, and pick up 600 Hall). Staff I stated she told the nurse she couldn't cover both halls and they came to some sort of agreement to split one of the halls. She needed help for rounds, tried to find Staff H, CNA and as she looked for her saw the resident had slid partway out of the bed and onto a fall mat, her upper body was on the bed and her head was face down. The resident wasn't saying anything. Staff I stated she went to find Staff H, but found Staff L, LPN. Staff I stated Staff L told her it wasn't her hall and she needed to find Staff H. She found Staff H in another room and they went into Resident #1 room together, it didn't look like the resident was breathing so she went to get the nurse (Staff L). Staff L came, said to flip the resident over, they lifted the resident onto the fall mat on the floor and laid her on her back. Then she had to go to the locked unit so Staff K, the other nurse [LPN], could come over, Staff K was in the CCDI Unit because that CNA had also left in the middle of the shift that night. During an interview on [DATE] at 8:18 AM, Staff K, LPN, stated she worked the night shift on [DATE]. She stated she was in the CCDI unit when a CNA got her, told her the resident [Resident #1] had passed and Staff L needed help. When she got to the resident's room the resident was on the fall mattress positioned on her back, they had already moved her. Staff L said the resident was face down when they found her and turned her over, and they both confirmed the resident's death at that time. Staff K called 911 to notify the Medical Examiner (ME), and spoke to the ME when he came to the facility that morning. Staff K stated they were too short staffed that night, the aides that were there had to cover multiple halls so she called the manager on call, Staff S, Assistant Director of Nursing (ADON), to report they were very short staffed and needed help, Staff S refused to come to the facility and directed her to figure it out. During an interview on [DATE] at 4:29 PM, Staff L, LPN, stated she worked on the night shift on [DATE], and couldn't recall the details associated to the resident's death. She stated one of the CNA's came to her for help, the resident [Resident #1] was on the fall mattress and the bed, they had to turn her so she could assess her, but the other nurse, Staff K, had the resident that night, she came and took over, called the ME, notified family and charted it all, and really didn't remember much about it. During another interview on [DATE] at 9:24 AM, Staff L stated she remembered more about the night of [DATE]. She stated one of the aides came and told her the resident [Resident #1] was on a mat and a low bed, she [Staff L] told her it wasn't a fall because they were the same height and directed her to get the other aide to help her get the resident back in bed. Then both aides came and said she needed to come. Staff L stated when she got to the room the resident was face down on the bed, her lower body on the fall mat and her chest was sort of leaned onto the bed. Staff L turned her over onto her back, onto the mat, the resident wasn't breathing. Staff K arrived, and she told Staff K she was face down, and Staff K took over from there and why Staff K charted it. During an interview on [DATE] at 1:51 PM, Staff J, CNA, stated she worked at the facility through agency, a lot of double shifts and cared for the resident several times. On the night of [DATE] she was assigned to a different hall with the nurse, Staff L, and was there when Staff L came back from the resident's room, said the resident was found dead, face down. Staff J stated they were very short staffed that night. She stated she had taken care of the resident the day before and there were no concerns during the shift. During an interview on [DATE] at 9:11 AM, Staff M, CNA, stated she was scheduled to work the night shift on [DATE]. Staff M stated she told the Staff R, Scheduler that she couldn't work due to a family situation, but Staff R begged her to work until 2 a.m., and she agreed. Staff M thought there would be a someone scheduled to relieve her at 2:00 AM, but there was not. Staff M stated she reported off to one of the other aides from another hall before she left. Staff M reported she had last seen the resident [Resident #1] around 12:30 a.m. to check and change her, the resident was in her bed and okay at that time. She stated Staff K, LPN had just been in the room and administered medication to the resident. During an interview on [DATE] at 11:06 AM, Staff O, CNA, stated she had worked on all of the resident halls at the facility, usually on the night shift. When they are short staffed the CNA's have to take two halls, they can't hear call lights from the other Nurse's Station for the other hall they are also assigned to. On the night of [DATE] she was assigned to the CCDI Unit, by herself. She had a medical emergency that night and had to go to the Emergency Room, she thought it was around 3:30 AM. Staff K, LPN had to relieve her because they were so short staffed, the aides were already doubled up on halls that night. During an interview on [DATE] at 12:41 PM, the Investigator from the Medical Examiner office stated he went to the facility on the night of the residents death on [DATE]. He stated the resident was on her back, on a mattress on the floor, with a pillow under her head. The resident was dressed in a blue shirt and covered with a blanket. The Investigator stated staff reported to him the resident was found dead, and did not tell him she was found face down or had been moved. The payroll report and staff interview indicated night shift that started at 10 PM on [DATE] and ended at 6 a.m. on [DATE]. The Daily Night Shift Staffing Assignment Sheet for the 10 p.m. on [DATE] to 6 a.m. on [DATE] night shift revealed: Staff L, LPN, assigned to the 300, 600 and 700 Halls. Staff K, LPN, assigned to the 400 and 500 Halls, and the facility's locked CCDI Unit (Chronic Confusing or Dementing Illness). Staff J, CNA (Certified Nursing Assistant) assigned to the 300 Hall Staff P, CNA assigned to the 400 Hall. Staff M, CNA assigned to the 500 hall with notation went home at 2 a.m. Staff H, CNA assigned to the 600 Hall, with notation went to 500 at 2 a.m. Staff I, CNA, assigned to the 700 Hall, with notation covered 7 and 6 at 2 a.m. Staff O, CNA, assigned to the CCDI Unit. A payroll report for the staff that worked on the night shift on that night revealed Staff M clocked out at 1:57 AM, Staff O clocked out at 3:48 AM, with additional clock ins indicated for the shift. During an interview on [DATE] at 6:29 PM, with the DON and Staff S, ADON, and informed that Staff O clocked out at 3:48 a.m. on [DATE], the DON stated Staff O was a smoker, she probably clocked out for her break and forgot to clock in when she came back. When informed that Staff K reported she contacted Staff S on the [DATE] to [DATE] night shift with requests for assistance due to short staffing, the DON stated there was no proof that Staff K called for assistance, then Staff S stated they called her to notify her of the resident's death, but never asked for assistance. A Written Reprimand in Staff S's personnel file dated [DATE] stated on [DATE] - [DATE] the employee was called two times with concerns over lack of staff on the night shift. Staff S directed the CNA's to split hallways. The immediate supervisor had directed multiple times that the CNA's were not to split halls on the night shift. The employee failed to fulfill their on-call responsibilities and this potentially puts resident care at risk.

Based on interviews, clinical record review, facility policy review and facility investigation review, the facility failed to ensure a resident was not subjected to involuntary seclusion when a staff member had used verbal threats to impose the understanding to a resident that she was not allowed to leave her room. This deficient practice resulted in Resident #385 displaying behaviors of anxiety, tearfulness, and fear of the staff member that imposed the involuntary seclusion to the residents room for one of four residents reviewed for abuse (Resident #385). This deficient practice resulted in an Immediate Jeopardy (IJ) to the health and safety of a resident who resided at the facility. The facility reported a census of 140 residents. Findings Include: On 10/4/23, the Iowa Department of Inspections and Appeals staff contacted the facility staff to notify them the Department staff determined an Immediate Jeopardy situation existed at the facility. The Immediate Jeopardy had a start date of 5/16/23. The facility staff removed the immediacy on 10/5/23 at 2:55 PM, and decreased the scope from a J to a D level after the facility staff completed the following; a. All staff have been trained on June 23, 2023, August 9, 2023 and September 6, 2023 about how to report abuse b. Building administrator has her personal cell phone number listed on PCC to alert any staff working in the building to call Administrator immediately with any concern of abuse c. Grievances are reviewed in a timely manner, and any resident concerns are immediately followed up on, to prevent any abuse from occurring d. Involuntary seclusion is identified in the abuse policy, and staff have been trained. If a resident is crying, or told they should stay in their room by a staff person, another staff member should immediately intervene, ensure the resident's safety and notify the Executive Director or designee immediately. The Quarterly Minimum Data Set (MDS) assessment for Resident #385 dated 07/05/2023 revealed the resident scored 15 out of 15 on a Brief Interview for Mental Status exam, which indicated the resident was cognitively intact. The Investigation Summary, undated, and unsigned, revealed the following allegation: [Resident #385] filed a grievance with Social Services stating Certified Nursing Assistant (CNA) [Staff V] was mean to her. Stated she put her in room and told her not to come out. Stated she pushed her into her room aggressively with no foot rest so her foot was caught and drug back under her chair hurting her knee. She stated the CNA was very mean and unfriendly. The Section of the Investigation Summary dated 5/17/23 documented as follows; Went to meet with Resident#385. She states that yesterday a CNA got on my case. She states she threw me in my room. She states she was not hurt and has no injures. She does not remember the name of the CNA. When asked if she feels safe here she says she does, but she just hopes it doesn't happen again Encouraged Resident (R) to let me know if there are any other concerns. She agreed. Grievance Form dated 5/16/23 documented a grievance reported to the Director of Social Services was voiced from Resident#385, therapy and activities as follows; Staff V, CNA, was very mean to resident. Put her in her room and told her not to come out. Pushed her into her room aggressively with no foot rest so her foot was caught and drug back under her chair hurting her knee. Resident stated the CNA was very mean and unfriendly. The action plan resolution and date of resolution were left blank. On 09/28/2023 at 7:35 AM, the Executive Director, (ED), stated the resident had talked with the Director of Social Services,(DSS), about her concerns with CNA Staff V. The ED reported the resident had approached the DSS and told her she was afraid of the CNA. Resident#385 reported she felt safe at the facility but not around that specific staff member. The Resident stated the CNA had abruptly pushed her wheelchair into her room and told her she couldn't come out of her room. On 10/02/2023 at 11:58 AM, the ED advised there is not a time specified on the grievance filed by the resident as the facility felt the incident rose to the level of an abuse allegation and was treated it as such. On 10/02/23 5:55 PM, the Director of Social Services (DSS), reported she was given the information for the grievance from another staff member. The DSS did not directly speak with or observe the Resident on the day of the incident. The DSS advised she wrote the information on a grievance form and put it in one of the ADON's mailbox. The ADON brought the grievance and concern up the following morning in their daily meeting. On 10/03/2023 8:45 AM, ED reported there were cameras near the lobby and the front door but she was not aware if there were any cameras in the area where the incident occurred. The ED would follow up with this and get back. The ED reported no cameras were reviewed during the facility investigation. The ED reviewed the resident's records and was unable to locate any documentation regarding any nursing assessment completed. The ED advised she talked to the resident the following day and asked the resident about the incident and she reported she was not in pain. The ED stated she did not believe she documented this anywhere. There was no documentation that the Power of Attorney, family, or medical staff were notified of the incident. During an interview on 10/03/2023 at 10:08 AM., Staff X, Activities Assistant stated she and a co-worker were gathering residents for an activity and went to the Resident #385's room where they found the resident in her wheelchair. The resident looked confused and almost teary eyed, like a kid who got in trouble. The resident advised she needed to use the restroom and the CNA just pushed her into her room and left. That day and the next day the resident seemed to be looking over her shoulder. Staff K interpreted this as she was watching for the CNA that had put her in her room. That same day the resident stated she is mean to me-she told me I needed to stay in my room. During an interview on 10/03/23 at 10:56 AM., Staff HH Director of People and Culture (previously the Activities Director ) reported, the resident told one of my staff, either Staff X or Staff II and one of them came to me and reported that the resident shared she was pushed into her room and told her she couldn't leave. The resident was not coming out her room. On 10/03/23, review of Email documentation received from The Director of People and Culture and formerly the Activities Director revealed the following: a. 5/17/2023 11:16 AM Email from the Director of Life and Community Enrichment sent to the Director of Social Services-Did you write a grievance up for Resident #385? Staff X mentioned she thought you did. She is still very upset about Staff V (CNA) being mean to her. The resident literally never complains or anything so it seem legit. b. 5/17/2023 1:21 PM Email from the Director of Social Services sent to the Director of Life and Community Enrichment-I have not. I will today though. Unfortunately this seems like a very common occurrence. c. 5/17/2023 1:22 PM Email from the Director of Life and Community Enrichment to the Director of Social Services-With the staff member or Resident #385? d. 5/17/2023 1:22 PM Email from the Director of Social Services sent to the Director of Life and Community Enrichment-Staff member e .5/17/2023 Email from the Director of Life and Community Enrichment to the Director of Social Services-That is a shame. When she was Agency working here she seemed great, but I have definitely seen a change. f. 5/17/2023 1:24 PM Email from the Director of Social Services sent to the Director of Life and Community Enrichment-Did the resident mention to you what Staff V did/said? I'm trying to recall what she told me yesterday. Something about she put her in her room and told her not to come out. Then something else. g. 5/17/2023 2:26 PM Director of Life and Community Enrichment sent to the Director of Social Services- Staff II and Staff X said she mentioned that she was bullying her and being mean to her and that this wasn't this first instance and that it happens every time she works. She mentioned she pushed her into her room and told her she couldn't come out. During an interview on 10/03/23 at 2:05 PM., Staff II the current Activities Director advised she was involved with this incident with the resident. It was right before an activity event so it was between one and 1:00 and 1:30 pm. She was getting the residents from their rooms before the activity and Resident #385 was in her room and she wasn't acting normal. She appeared to be upset and when asked the resident said she had to stay in her room. When Staff II inquired about this the resident said the staff member got mad at her and said she had to stay in her room. The resident was able to point out the staff member that reportedly told her she had to stay in her room. Staff II reported this information to her supervisor at the time. The Facility Policy titled Abuse, Neglect, and Exploitation dated April 2008 with the most current revised version dated January 2023 advised the following: It is policy of this community to take appropriate steps to prevent the occurrence of Abuse, Neglect and Misappropriation of resident property. It is also the policy of this community to take appropriate steps to ensure that all alleged violations of federal or state laws which involve mistreatment, neglect, abuse, injuries of unknown source, and misappropriation of resident property (alleged violations) are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in a serious bodily injuring, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides jurisdiction in long-term are facilities), in accordance with State law through established procedures. Further, The Community investigates each such alleged violation thoroughly and reports the results of all investigations to the administrator or his or her designated representative, and to other officials in accordance with State law, including to the State Survey Agency. The facility policy documented under the sub title Definitions as follows; Abuse: The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. During an interview on 10/4/23 at 2:46 PM, Staff DD, CNA (Certified Nurse Aide) queried if she knew Resident #385 and she stated yes. Staff DD asked if the resident self propelled or if she needed push in her wheelchair throughout the building and she stated they always pushed her everywhere. During an interview on 10/4/23 at 3:09 PM, Staff EE, CNA queried if she knew Resident #385 and she stated yes, the resident was really nice and didn't really talk much. Staff EE asked if they resident moved around herself and she stated the resident was heavy and really weak and she had trouble when she rolled her. Staff EE asked if the resident self propelled herself in the wheelchair and she stated she didn't recall the resident ever moving her feet by herself and never self propelled. Staff EE asked if the resident ever stated issues with other CNAs and how they treated her and she stated no, she didn't remember that, she stated the resident quiet and didn't talk much, and mainly smiled. During an interview on 10/4/23 3:43 PM, Staff FF, CNA queried if she knew Resident #385 and she stated yes. Staff FF asked if the resident ever self propelled in her wheelchair and she stated she couldn't remember but they always took her to supper in her wheelchair. Staff FF stated the resident used a stand lift and she assumed she didn't move herself around too much. During an interview on 10/04/23 at 07:30 PM, Staff E, CNA queried if she knew Resident #385 and she stated yes. Staff E asked if she propelled herself in the wheelchair and she stated Resident #385 used a stand lift and they always pushed her in the wheelchair. On 10/4/23 at 2:25 PM, when queried whether Resident #385 could self propel in her wheelchair, Staff BB, Certified Nursing Assistant (CNA) responded she did not think so, and further explained she had never seen the resident do it. Staff BB explained she would always push her back to her room when she came in.

Based on clinical record review, staff interview, Facility Investigation Review and facility policy review the facility failed to thoroughly and timely investigate a resident's allegations of mean/aggressive treatment and involuntary seclusion by a facility staff member, failed to separate residents from an alleged perpetrator after staff had become aware of allegations, and failed to maintain thorough documentation regarding investigation into the resident's allegations for one of four residents reviewed for abuse (Resident #385). This deficient practice resulted in an Immediate Jeopardy to the health and safety of a resident who resided at the facility. The Facility had a census of 140. Findings Include: On 10/4/23 at 3:55 PM, the Iowa Department of Inspections, Appeals, and Licensing staff contacted the facility staff to notify them the Department staff determined an Immediate Jeopardy situation existed at the facility. The Immediate Jeopardy had a start date of 5/16/23. The facility staff removed the immediacy on 10/5/23 at 2:55 PM, and decreased the scope J to D level after the facility staff completed the following: 1. Staff member was immediately suspended, and terminated after investigation 2. All staff have been in-serviced on the abuse policies on the following dates: June 23, 2023, August 9, 2023, September 6, 2023 3. I have attached sign in sheets 4. All new hires are required to complete Iowa Dependent Adult Abuse training prior to working on the floor 5. HR audits employee files to ensure all staff are compliant with renewing adult dependent abuse training. 6. All resident admitted prior to 5/16/23 will be interviewed to determine if they have any concerns about abuse, and any negative findings will be investigated thoroughly. 7. All staff the that worked with employee will be interviewed to determine if they ever witnessed any abuse towards a resident from this employee. 8. Staff will be re-inserviced on abuse, abuse reporting, identifying abuse, beginning 10/4/23. 9. Staff will be in-serviced on actions to take until administrator/designee arrives including ensuring resident ' s safety, separate staff/residents, collect any evidence, calling 9-1-1 if appropriate. 10. The nurse is responsible for ensuring safety until administrator/designee can arrive. 11. The executive Director/Administrator, or designee conducts a thorough investigation which includes interviewing the resident, alleged perpetrator, any witnesses, residents that may have also been affected or witnessed, and staff that may have witnessed. 12. The Executive Director/Administrator is on-call 24/7 for any allegations of abuse. If the Executive Director is unable to be available a designee is responsible for any allegations of abuse. 13. All reports will be submitted within the timeframes outlined in the regulations regardless of time of day. 14. Please see attached training, on September 6, 2023, all staff were trained on grievances and abuse. The Quarterly Minimum Data Set (MDS) assessment for Resident #385 dated 07/05/2023 revealed the resident scored 8 out of 15 on a Brief Interview for Mental Status exam, which indicated the resident was severally cognitively impaired. The Investigation Summary, undated, and unsigned, revealed the following allegation: [Resident #385] filed a grievance with Social Services stating CNA (Certified Nursing Assistant) [Staff V] was mean to her. Stated she put her in room and told her not to come out. Stated she pushed her into her room aggressively with no foot rest so her foot was caught and drug back under her chair hurting her knee. She stated the CNA was very mean and unfriendly. The Section of the Investigation Summary dated 5/17/23 documented, Went to meet with resident. She states that yesterday a CNA got on my case. She states she threw me in my room. She states she was not hurt and has no injures. She does not remember the name of the CNA. When asked if she feels safe here she says she does, but she just hopes it doesn't happen again Encouraged R (resident) to let me know if there are any other concerns. She agreed. On 09/28/2023 a document titled, [Facility Name Redacted] Grievance was reviewed. It provided the following information: Resident # 385 Today's date 5/16/2023 Grievance heard by the Director of Social Services. Voiced by individual resident, therapy and activities. The grievance advised: Staff V, CNA, was very mean to resident. Put her in her room and told her not to come out. Pushed her into her room aggressively with no foot rest so her foot was caught and drug back under her chair hurting her knee. Resident stated the CNA was very mean and unfriendly. Review of the investigation provided by the facility lacked the schedule of employees who worked the same date and or shift as the alleged event, interview with other residents regarding Staff V interview with the resident's roommate, and information regarding availability of cameras in the area. The Investigation file lacked time cards to verify when Staff V had worked, as staff interviews conducted by the State Agency revealed conflicting dates of incident and when further action was taken. Interviews conducted by the State Agency regarding the alleged incident revealed staff members were aware of the resident's allegations prior to the DSS becoming aware (Staff X, Activities Assistant, Staff II, Activities Assistant at time of incident, Staff HH, Director of People and Culture). The Investigation Summary provided by the facility lacked interviews with Staff X, Staff II, and Staff HH who had been aware of the allegations prior to the Director of Social Services. On 09/28/2023 7:35 AM, the Executive Director, (ED), was interviewed. The resident had talked with the Director of Social Services,(DSS), about her concerns with CNA Staff V. The ED advised the resident had approached the DSS and told her she was afraid of the CNA. Resident reported she felt safe at the facility but not around that specific staff member. The Resident reported the CNA had abruptly pushed her wheelchair into her room and told her she couldn't come out of her room. A Facility Investigation was completed by the Executive Director. On 09/28/2023 at 8:00 AM an undated facility report titled Investigation Summary provided and narrated by the Executive Director/Administrator (ED), was reviewed. On 5/17/2023 Social Services gave grievance to the Executive Director. The report summarized an alleged incident with Resident #385 and Staff member V Certified Nursing Assistant (CNA), pushed her into her room aggressively with no foot rest so her foot was caught and drug back under her chair hurting her knee. R states CNA is mean and unfriendly. Corrective Action by facility: Staff V CNA, date of hire is 12/29/2022. The alleged perpetrator is currently suspended pending investigation. The report also advised the ED met with the Resident. The Resident reported yesterday a CNA got on my case. The Resident advised she threw me in my room The Resident reported she was not hurt and she does not have any injuries. She does not remember the name of the staff person. She advised she feels safe here and says she hopes it doesn't happen again. Conclusion-Per recommendation of the Executive Director, employee will be terminated. On 10/02/2023 11:58 AM, the ED reported there is not a time specified on the grievance filed by the resident as the facility felt the incident rose to the level of an abuse allegation and was treated it as such. On 10/02/23 05:55 PM.,the Director of Social Services (DSS), stated she was given the information for the grievance from another staff member. The DSS did not directly speak with or observe the Resident on the day of the incident. The DSS advised she wrote the information on a grievance form and put it in one of the Assistant Director of Nursing's (ADON) mailbox. The ADON brought the grievance and concern up the following morning in their daily meeting. On 10/03/2023 8:45 AM, the ED reported there are cameras near the lobby and front door but she is not aware if there are any cameras in the area where the incident occurred. The ED will follow up with this and get back with this Surveyor. The ED reported no cameras were reviewed during the facility investigation. The ED reviewed the resident's records and was unable to locate any documentation regarding any nursing assessment completed. The ED advised she talked to the resident the following day and asked the resident about the incident and she reported she was not in pain. The ED advised she does not believe she documented this anywhere. The Facility investigation also lacked interviews with other residents and other staff members. The Facility Assessment also lacked nursing assessment or documentation regarding the incident. There was no documentation that the Power of Attorney, family, or medical staff were notified of the incident. On 10/03/2023 at 10:08 AM., Staff X Activities Assistant stated she and a co-worker were gathering residents for an activity and went to the resident's room where they found the resident in her wheelchair. The resident looked confused and almost teary eyed, like a kid who got in trouble. The resident advised she needed to use the restroom and the CNA just pushed her into her room and left. That day and the next day the resident seemed to be looking over her shoulder. Staff X interpreted this as she was watching for the CNA that had put her in her room. That same day the resident stated she is mean to me, she told me I needed to stay in my room. On 10/03/23 at 10:56 AM., Staff HH Director of People and Culture (previously the Activities Director ) reported, what she could remember was the resident told one of my staff, either Staff X or Staff II and one of them came to me and reported that the resident shared she was pushed into her room and told her she couldn't leave. The resident was not coming out her room. 10/03/23 11:20 AM Email documentation was received from The Director of People and Culture and formerly the Activities Director. That email correspondence reads as follows: a. 5/17/2023 11:16 AM Email from the Director of Life and Community Enrichment sent to the Director of Social Services-Did you write a grievance up for Resident #385? Staff X mentioned she thought you did. She is still very upset about Staff V (CNA) being mean to her. The resident literally never complains or anything so it seem legit. b. 5/17/2023 1:21 PM Email from the Director of Social Services sent to the Director of Life and Community Enrichment-I have not. I will today though. Unfortunately this seems like a very common occurrence. c. 5/17/2023 1:22 PM Email from the Director of Life and Community Enrichment to the Director of Social Services-With the staff member or Resident #385? d. 5/17/2023 1:22 PM Email from the Director of Social Services sent to the Director of Life and Community Enrichment-Staff member e. 5/17/2023 Email from the Director of Life and Community Enrichment to the Director of Social Services-That is a shame. When she was Agency working here she seemed great, but I have definitely seen a change. f. 5/17/2023 1:24 PM Email from the Director of Social Services sent to the Director of Life and Community Enrichment-Did the resident mention to you what Staff V did/said? I'm trying to recall what she told me yesterday. Something about she put her in her room and told her not to come out. Then something else. g. 5/17/2023 2:26 PM Director of Life and Community Enrichment sent to the Director of Social Services- Staff II and Staff X said she mentioned that she was bullying her and being mean to her and that this wasn't this first instance and that it happens every time she works. She mentioned she pushed her into her room and told her she couldn't come out. During an interview on 10/03/23 at 2:05 PM., with Staff II the current Activities Director reported she was involved with this incident with the resident. It was right before an activity event so it was between 1:00 and 1:30 pm. She was getting the residents from their rooms before the activity and Resident #385 was in her room and she wasn't acting normal. She appeared to be upset and when asked the resident said she had to stay in her room. When Staff II inquired about this the resident said the staff member got mad at her and said she had to stay in her room. The resident was able to point out the staff member the following day that reportedly told her she had to stay in her room. Staff II reported this information to her supervisor at the time. The Facility Policy titled Abuse, Neglect, and Exploitation dated April 2008 with the most current revised version dated January 2023 advised the following: It is policy of this community to take appropriate steps to prevent the occurrence of Abuse, Neglect and Misappropriation of resident property. It is also the policy of this community to take appropriate steps to ensure that all alleged violations of federal or state laws which involve mistreatment, neglect, abuse, injuries of unknown source, and misappropriation of resident property (alleged violations) are reported immediately. 5. Investigation: a. Any person who knows or has reasonable cause to suspect that a resident has been or is being abused, neglected, or exploited shall immediately report such knowledge or suspicion to the administrator. b. The administrator, director of nursing, or designee will notify the appropriate regulatory. investigative, or law enforcement agencies immediately, in accordance with state regulations. c. Allegations of abuse, neglect, or exploitation will be thoroughly investigated. The investigation will be initiated upon receipt of the allegation. The administrator, or designee, will complete the investigation process. d. The investigation can include, but is not limited to: i. The name(s) of the resident(s) involved ii. The date and time the incident occurred i. The circumstances surrounding the incident iv. Where the incident took place V The names of any witnesses vi. The name of the person(s) alleged with committing the act