**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, review of facility policy, and review of a facility investigation, the facility failed to have an effective system in place to ensure resident safety for one (Resident (R) 140) of two sampled residents reviewed for elopements. On 09/04/2022, R140 eloped from the facility unescorted and unsupervised, and required police intervention to locate the resident and return him to the facility. On 06/28/2024, the Administrator and Director of Nursing (DON) were provided a copy of the CMS IJ Template and notified that the failure to ensure residents were provided supervision and protected from further elopement, constituted immediate jeopardy at F 689. The Immediate Jeopardy (IJ) at F 689 also constituted Substandard Quality of Care at 42 CFR 483.25. The IJ was determined to exist on 09/04/2022 when the facility discovered R140 had eloped from the building. The facility completed the following: 1. Resident 140 no longer resides in the facility. Resident was returned to facility by police at 22:29 on 09/04/2022. A head-to-toe assessment was completed by a licensed nurse on 09/04/2022, the nurse practitioner was notified by a licensed nurse on 09/04/2022, and SBAR [Situation, Background, Assessment Record] was completed on 09/04/2022 by a licensed nurse. (A) An elopement assessment was completed by a licensed nurse on 09/04/2022. (B) Ad Hoc QAPI [Quality Assurance Performance Improvement] meeting was held with the Administrator, Medical Director, Director of Nursing, Admissions Coordinator, Social Services Director, Dietary Manager, Human Resources Director, Housekeeping Director, Activities Director, and Therapy Director on 09/04/2022. (C) One-on-one supervision was initiated, and the care plan was updated by the Interdisciplinary Team (IDT) Director of Nursing, Social Services Director, Therapy Director, and clinical managers on 09/04/2022. (D) The resident Representative was notified in person of the incident by a licensed nurse on 09/05/2022. (E) Every shift behavior monitoring for exit-seeking behavior was continued per MAR and TAR [Medication Administration Record and Treatment Administration Record] on 09/04/2022 until discharge. The resident had a wanderguard placement prior to the incident on 09/04/2022 and was added to the care plan at the time by a licensed nurse. (F) Resident 140 was seen by NP [Nurse Practitioner] and/or physician on 09/06/2022. (G) One-on-one monitoring was placed on orders on 09/08/2022. (H) Resident was monitored by Social Services from 09/06-09/08/2022. (I) Resident 140 was reviewed by IDT for changes in behavior on 09/06/2022. 1. How other residents having the potential to be affected by the same deficient practice will be identified, and what corrective action will be taken: An elopement assessment was completed for 81 residents on 09/04/2022 to 09/06/2022 by licensed nurses. There were 3 residents at risk for elopement at the time the assessment was completed with elopement care plans in place. There were zero new residents identified at risk for elopement at the time the assessments were initiated and completed. Training What measures will be put into place and what systemic changes will be made to ensure that the deficient practice does not re-occur? Clinical and agency clinical staff were educated regarding elopement policy and elopement drill beginning 09/04/2022 and completed on 09/12/2022. Education was completed by the Director of Nursing, ADON [Assistant Director of Nursing], MDS [Minimum Data Set] nurse, other nurse managers, and the Dietary Manager. Any staff who fails to comply with the points of the in-servicing would be further educated and /or progressively disciplined as indicated up to termination. As an ongoing practice, an elopement assessment was completed upon admission, quarterly and as needed related to changes in the resident's exit-seeking behaviors. Discussion at clinical meetings of changes in behaviors with review of orders, review of MARs/TARs, care plan review, nurse' notes review, and reports by staff. Care plans will be updated as needed based on these reviews by the clinical leadership and IDT. Individual resident's care plans will be reviewed at least quarterly for needed updates as part of the resident's quarterly care plan conference. 1. How the corrective actions will be monitored to ensure the deficient practice does not reoccur, (i.e., what Quality Assurance Program will be put into place and by what date the systemic changes for each deficiency will be completed). Resident 140 was reviewed by IDT for changes in behavior on 09/13/2022, 09/21/2022, 09/27/2022, 10/04/2022, 10/25/2022, 11/01/2022, 11/04/2022, 11/08/2022, 11/15/2022, 11/29/2022, 12/05/2022, and 12/16/2022. One on Two monitoring on 09/23/2022 and changed to every 15-minute checks on 11/04/2022 with care plan revisions by licensed nurse, which remained until discharge. Ad Hoc QAPI meeting was held with the Administrator, Medical Director, and Interdisciplinary Team (IDT) on 09/04/2022. (C) Elopement Drills conducted daily for 14 days by the Administrator, Director of Nursing, Housekeeping Supervisor, and /or the Maintenance Director. The QAPI Committee included but not limited to the Administrator, Director of Nursing, Assistant Director of Nursing, Unit Managers, MDS Nurse and Medical Director will review the results. An extended survey was initiated on 07/02/2024, and the State Survey Agency (SSA) validated the facility's IJ Removal Plan on 07/03/2024. Based on the findings of this survey, it was determined the immediate jeopardy was removed and the deficient practice was corrected as alleged on 09/13/2022, prior to initiation of the investigation. Therefore, the IJ was determined to constitute Past Jeopardy. The findings include: A review of the facility policy titled Elopement Guideline, dated 04/05/2023, revealed it was to provide a safe and secure environment for all residents. In the event of resident elopement, the facility would implement its policies and procedures immediately to locate the resident in a timely manner. Elopement was defined as a situation in which a resident leaves the premises or a safe area without staff knowledge and necessary supervision. A review of the facility's undated policy titled, Regarding Missing Residents and Elopement revealed all residents were provided adequate supervision to meet each resident's nursing and personal care needs. All residents would be assessed for behaviors or conditions that put them at risk of elopement. All residents assessed to be at risk of elopement would have this issue addressed in their plan of care. A review of the electronic medical record (EMR) revealed that R140 was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy and alcohol dependence. A review of the EMR elopement risk assessment dated [DATE] revealed R140 had a low risk score of zero for elopement. A review of an EMR wandering risk assessment dated [DATE] revealed that R140 was at low risk for wandering. A review of the admission MDS, with an Assessment Reference Date (ARD) of 08/02/2022, revealed the resident had a Brief Interview for Mental Status (BIMS) score of seven out of 15, which indicated the resident was severely cognitively impaired. Per the MDS, the resident used a walker or a wheelchair, and needed physical assistance of one person for ambulation and locomotion. The MDS showed no wandering behaviors as of the date of this assessment. A review of the EMR progress noted dated 08/07/2022 revealed R140 had been wandering during the night. Per the note, at 5:59 AM, Resident also noted to wander as reported to me by his CNA [Certified Nurse Aide] tonight. Although there was no information in the progress note to indicate exit seeking behavior, a review of the EMR care plan revealed the care plan was updated that same date (08/07/2022) to show that the resident was now actively wandering and may be in other beds or close to exits. In response, interventions were added to place the resident on 15-minute location checks until a physician-ordered wander guard device arrived and placed on the left ankle. A review of the EMR physician's orders dated 08/10/2022 revealed the wander guard device was placed to the left ankle. Placement and function of the wander guard per physician orders was verified per documentation on the MAR. A review of Progress Notes revealed that on 08/18/2022, the resident reported that he was not feeling well. He went out to the emergency room (ER) on 08/19/2022 and returned on 08/20/2022 with no medical diagnosis identified; however, upon return R140 continued to state he did not feel well. On 08/25/2022, R140 was diagnosed as COVID-19 positive and was moved to the COVID Unit on the Southeast Hall. A wandering risk assessment dated [DATE] revealed the resident was now at high risk for wandering, due to a history of wandering and the placement of the wander guard device. This assessment showed the resident was now independent with locomotion in his wheelchair. Further review of the EMR revealed that on 08/31/2022, R140 was moved to a room on the Southwest Hall that was approximately 60 feet from an emergency exit door. A review of the EMR progress note (SBAR), dated 09/04/2022, revealed that at approximately 10:15 PM, Licensed Practical Nurse (LPN) 15, heard the alarm on the Southwest exit door, (which was equipped with a wander guard alarm) sounding. R140 was not in his room and the wheelchair was next to the bed. Staff were alerted and an elopement protocol was enacted. Police were notified and they found the resident, who was returned to the facility at approximately 10:29 PM. R140 was dressed appropriately for the weather and sustained no injuries in response to the elopement. Per the SBAR, the resident stated he was going home, and was placed on one-to-one supervision. Review of the facility investigation revealed that on 09/04/2022, sometime between 10:00 PM to 10:15 PM, R140 exited the facility through the Southwest emergency door, setting off the alarm. Per the investigation, the resident was found at a convenience store which was .6 tenth of a mile from the facility, downhill on a two-lane road. The facility stated the root cause was the resident's desire to go home. Review of the investigation revealed that the facility did not identify how long the alarm had been sounding before staff responded to it. A review of the facility form titled Confidential Witness Statement dated 09/04/2022, revealed LPN15 was in another resident's room to provide care and exited that room sometime between 10:10 PM to 10:15 PM. At that time, she heard the Southwest Door alarming. When she heard the alarm, she asked why the door was alarming and an unnamed resident stated that a tall male went out the door. Per the witness statement, LPN15 started searching the residents' rooms and did not find R140, whose wheelchair was still in his room. She alerted the other staff to search and notified the DON by 10:21 PM. Another nurse called 911 to notify the police of the elopement. At 10:28 PM the administrator was notified and at approximately 10:29 PM, the police returned R140 to the facility. Review of facility records revealed LPN15 was no longer employed at the facility and was unavailable for interview. Review of the witness statements for the other three staff who were assigned to the Southwest Unit that night revealed that all staff were either in resident rooms or on break and had not heard the alarm on the Southwest Door sound. The witness statements indicated that they were unaware that R140 had eloped from the facility until LPN15 identified the issue. Review of witness statements from staff working on the other units revealed that they, also, failed to hear the alarm sound when R140 eloped through the Southwest Hall door. A review of former Social Services progress notes found in the electronic medical record dated 09/06/2022, 09/07/2022, and 09/08/2022, revealed R140 did not remember leaving the facility. Per the resident's closed record, R140 was discharged from the facility on 12/16/2022 and was not available for an interview. Interview with R61 on 07/02/2024 at 9:30 AM revealed he was the resident who saw R140 go out the door and the alarm sounded. He stated he told staff he saw R140 go out the door. R61 could not remember how long the alarm had been sounding prior to staff responding. In an interview with LPN2 on 06/28/2024 at 1:15 PM, he stated he did not remember R140. LPN2 stated the emergency door alarmed if a resident tried to go out the door wearing the wander guard device. In an interview with CNA14 on 06/28/2024 at 2:27 PM, she stated she was one of the staff working on the Southwest Unit on the night that R140 eloped. She stated that she did not recall specifically where she was at the time, and did not hear the alarm sounding, CNA14 stated she was unaware that R140 had eloped. CNA14 stated R140's room was located near the south nurses' station to observe him for wandering the unit and she checked on R140 hourly. Attempts to interview the additional staff who were present on the night of 09/04/2022 were made; however, calls to these staff were not returned. In an interview with the DON on 06/28/2024 at 3:50 PM, she stated she was not the DON when R140 eloped; however, since 2022, the facility had assessments and interventions for elopement in place to ensure residents were safe and elopement does not reoccur. In an interview with the Administrator on 06/28/2024 at 11:05 AM, she stated she was not the Administrator at the time of R140's elopement and the Quality Assurance plan has ensured there have been no other elopements since 2022.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility implemented the following actions to remove Immediate Jeopardy: 1. On 03/26/19 at approximately 9:45 PM, a law enforcement officer escorted Certified Nursing Assistant (CNA) #13 out of the building and off the property. 2. On 03/26/19, the Administrator informed staff to immediately contact the police if CNA #13 attempted to reenter again, after CNA #13 had re-entered the facility to retrieve alleged belongings and left. 3. On 03/26/19, Administrator suspended CNA #13, pending investigation, and then subsequently terminated her position on 04/02/19. 4. On 03/27/19, the Regional Director of Operations (RDO) interviewed Resident #52 related to possible safety concerns when CNA #13 returned to the facility and entered the resident's room to retrieve personal belongings, after local law enforcement had escorted her out of the facility on 03/26/19. 5. On 03/28/19, the Administrator, at the time of the incident that occurred on 03/26/19, ended their employment with the facility. 6. On 03/27/19 to 03/28/19, the Assistant Director of Nursing (ADON) and Interim Director of Nursing (IDON) conducted an in-service on the facility's Abuse Policy to the staff. Staff signed an Abuse Program Acknowledgment form verifying eighty-eight (88) staff members received training on abuse. The facility assured all newly hired staff would be educated on their Abuse Policy before they were permitted to work in the facility. 7. On 04/15/19, via email, the RDO educated the Administrator on the Abuse Prevention Policy including reporting of abuse, types of abuse, abuse prevention, investigation, and immediate intervention to ensure resident(s) safety upon hire. 8. On 05/10/19, the RDO interviewed Resident #11, to determine his/her mindset (related to fear, intimidation, or abuse) after the abuse incident that occurred on 03/26/19. 9. On 05/11/19, the RDO was educated by the Regional Nurse Consultant on the Abuse Prevention policy; including receiving background and pre-employment reference checks prior to staff starting their employment, conducting a thorough investigation, keeping resident(s) safe during the investigation, and timely reporting. 10. On 05/11/19, the Maintenance Director and Environmental Services Director changed the code on the entry/exit doors to decrease the risk of CNA #13 from entering the building during after hours in the future. 11. On 05/13/19, the Regional Director of Human Resources educated the Payroll Coordinator, per job description, related to facility's policy on pre-employment screenings. 12. From 05/13/19 to 05/14/19, the Payroll Coordinator with the assistance of the RDHR conducted a one hundred percent (100%) audit of Employee files. The audits included checking criminal backgrounds, references, abuse registry, and licensure and/or certification validations. 13. On 05/16/19, the RDO educated the Administrator on the timely reporting of abuse, investigation of abuse allegations, receiving background checks and conducting re-employment reference checks prior to employing staff. 14. From 05/28/19 to 06/06/19, the Social Service Director (SSD) conducted interviews with ten (10) residents regarding their overall satisfaction with facility services and whether they had any issues or concerns that needed addressing. 15. On 06/22/19, the Administrator educated the Maintenance Director on how to change the entry/exit door codes for three (3) door locks. The entry/exit codes would be changed when the Administrator notified the Maintenance Director that an employee was suspended related to abuse and/or neglect. According to the new procedure implemented by the facility on 06/22/19, the Administrator notified the Maintenance Director that the facility suspended an employee to decrease the risk of the suspended employee returning to the facility. The facility would notify the Maintenance Director ASAP, assign a staff person to the hallway to monitor exit doors until the codes were changed, and the Maintenance Director would change all entry/exit codes within two (2) hours of notification, which would ensure the overall safety and security of residents. 16. On 05/01/19, at the Quarterly scheduled meeting, the [NAME] President of Clinical Services, Chief Operating Officer, facilitated Abuse Training along with the Corporate Director of Education. The Chief Operating Officer scheduled Quarterly Meetings with all Administrators, Directors of Nursing, Regional Director of Operations and other Regional team members. In addition, Abuse Training would be conducted at each Quarterly Regional Meeting, on an on-going basis. 17. The Administrator and/or Designee would monitor staff understanding of the education by conducting staff interviews three (3) times a week for four (4) weeks regarding Abuse Prevention Program and monthly for three (3) months. The Administrator would add to the monthly in-service the Abuse Prevention education with questions and answer session to validate understanding; then on an on-going basis a segment of the Abuse Program would remain on the monthly in-service calendar. 18. The RDO would monitor the Administrator's understanding of the education by reviewing with the Administrator the initial report of an allegation of abuse to ensure a thorough investigation was conducted. Then would stay in contact with the Administrator throughout the investigation. The RDO would review the final report to ensure the investigation was complete and all aspects of the Abuse policy was followed; to include timely reporting, resident safety was ensured during the investigation, all interviews conducted, interventions were taken, and any other issues of abuse and/or neglect identified to ensure appropriate actions were taken and a thorough investigation completed. 19. The RDO and/or the Regional Nurse Consultant (RNC), on an ongoing basis would review all initial and final self-reported abuse incidents to ensure all were reported timely, resident safety was established immediately, the investigation was started immediately and conducted thoroughly. In addition, newly reported allegations discovered during the investigation was reported. 20. The [NAME] President of Clinical Services (VPCS) would review the investigative files and the recommended outcome made by the new Administrator and the RDO related to the self-reported incidences for three (3) months to ensure the Abuse policies and procedures were followed. 21. On 06/21/19, the Administrator reviewed with the Medical Director the change in scope and severity as it related to the immediate jeopardy tags. In addition, discussed actions to correct identified concerns. The Medical Director identified and directed the Maintenance Director and Administrator to fix surveillance cameras outside the facility's building and place monitors at each nursing station. 22. The outcome of the monitoring of the education would be reported to the Quality Assurance Process Improvement Committee (QAPI). If any patterns were identified an action plan would be written by the committee; this action plan would be monitored weekly by the Administrator until resolved. The QAPI Committee consisted of the Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), Social Services Director (SSD), Activity Director, Dietary Manager (DM), Maintenance Director, Environmental Services Director (ESD), Business Office Manager (BOM), admission Director and Medical Director. The State Agency Validated the removal immediate jeopardy prior to exit on 06/24/19 as follows: 1. Review of the Law Enforcement Incident/Investigation Report, with a print date of 06/21/19, revealed on 03/26/19 at approximately 9:42 PM, a law enforcement officer came to the facility to investigate the incident of possible charges of Theft by Unlawful Taking Over $500 of Resident #11's missing monies. Record review of the facility Self Reportable Investigation Summary, not dated, revealed Licensed Practical Nurse (LPN) #8 immediately went to Resident #11's room upon hearing yelling, and removed CNA #13 from the room, the police entered the building and escorted the CNA off the property. Review of CNA #13's written statement, dated 03/27/19, revealed the police transported him/her to a gas station and left him/her there around 11:00 PM on 03/26/19. Interview on 6/23/19 at 10:45 AM, with the current Administrator, revealed staff informed her and per her review of the facility investigation a police officer with the badge number 6163 escorted CNA #13 out of the building on 03/26/19 around 9:45 PM. 2. Attempted telephone interview with the previous Administrator, on 06/20/19 at 4:00 PM, 06/23/19 at 11:00 AM, and 06/24/19 at 4:30 PM, revealed surveyor left a voice mail message to return call; however, the previous Administrator did not returned the surveyor's call. Interview with Licensed Practical Nurse (LPN) #7, on 06/23/19 at 1:45 PM, revealed after CNA #13 returned and entered the building, on 03/26/19, staff were instructed not to let her back in the building to ensure resident safety. 3. Review of the facility's Personnel Change Form, dated 03/28/19, revealed CNA #13 was terminated on 04/02/19. Interview with Resident #11, on 06/22/19 at 4:30 PM, revealed he/she had not seen CNA #13 since the day of the incident. 4. Review of Resident #52's clinical record revealed the facility assessed the resident with a score of fifteen (15) on the Brief Interview of Mental Status (BIMS), on 02/09/19, indicating the resident was cognitively intact. Interview with the RDO, on 06/23/19 at 3:35 PM, revealed she interviewed Resident #52 on 03/26/19, and the resident voiced no safety concerns with facility staff. 5. Review of the facility's Personnel Change Form for the Administrator at the time of the incident, dated effective 03/28/19, revealed Administrator voluntarily surrender the Administrator position on 03/28/19. Attempted telephone interview with the previous Administrator, on 06/20/19 at 4:00 PM, 06/23/19 at 11:00 AM, and 06/24/19 at 4:30 PM, revealed surveyor left a voice mail message to return call; however, the previous Administrator did not return the surveyor's call. Interview with the current Administrator of the facility, on 06/23/19 at 10:30 AM, revealed the former Administrator ended their employment on 03/28/19. 6. Review of the facility's in-service training on Teaching Moment Regarding Abuse and Misappropriation, dated 03/27/19 and 03/28/19, revealed eighty-eight (88) staff members received training and signed an Abuse Program Acknowledgment form. Review of the facility's in-service training on Teaching Moment Regarding Abuse and Misappropriation, dated 04/01/19 through 06/20/19, revealed twenty-two (22) newly hired staff members received training and signed an Abuse Program Acknowledgment form. Interview with Certified Nursing Assistant (CNA) #14, on 06/23/19 at 12:00 PM, revealed she was educated on abuse types, when and to whom to report an abuse allegation. CNA #14 stated after staff were suspended they were not allowed back in the building and the codes to the doors were changed. Interview with CNA #15, on 06/23/19 at 12:15 PM, revealed the facility had recently re-educated her on the types of abuse and her responsibility to report immediately if witnessed. She stated if an employee was suspended, staff should not allow them back into the building and the door codes would be changed by Maintenance. Interview with CNA #16, on 06/23/19 at 12:30 PM, revealed she was knowledgeable of the types of abuse She stated if witnessed she would report to her supervisor immediately. CNA #16 stated the facility recently re-educated her on the abuse policy and if an abuse allegation was made against a staff member, they were suspended pending investigation and were not allowed back into the building. In addition, the management team would obtain statements from staff and then Maintenance would change the door codes to ensure resident safety. Interview with Housekeeper #1 and #2, on 06/23/19 at 12:45 PM, revealed the facility recently re-educated them on the abuse policy. They stated they would report abuse if witnessed or if an allegation of abuse was reported to them. Each stated if an allegation of abuse was made the employee would be suspended and not allowed back into the building until the investigation was completed. Also that the door codes would be changed to ensure resident safety. Interview with Dietary Staff #1, on 06/23/19 at 12:50 PM, revealed the facility recently trained her on abuse, required her to take a test and sign an acknowledgment form that she understood the abuse policy and facility expectations. She also stated if an employee was suspended, they were not allowed back in the building and the door codes were changed. Interview with CNA #12, on 06/23/19 at 12:55 PM, revealed the facility recently provided training on the abuse policy, that she had to take a test and sign an acknowledgement statement saying she understood the policy. She stated the facility had a strict abuse policy and, if suspended, staff were not allowed back in the building, while the investigation was on going. CNA #12 stated the Administrator would have the Maintenance Director change the door lock codes to ensure resident safety and prevent the suspended employee from gaining entry into the facility by using the code. Interview with CNA # 17, on 06/23/19 at 1:10 PM, revealed if a staff member threatened a resident, staff would protect the resident and report the incident immediately. In addition, a suspended staff member was not allowed back in the building. CNA #17 stated the facility trained her recently on the abuse policy. She stated she had to sign an acknowledgement sheet and take a test to ensure she understood the policy. Interview with LPN #1, on 06/23/19 at 1:38 PM, revealed the facility required he re-read the abuse policy, take a test and sign an acknowledgement statement that he understood his responsibility. He stated if he received a report of abuse, he would immediately protect the resident by removing the employee from the building. LPN #1 stated he would then report the incident to the Administrator and other appropriate authorities if needed. In addition, the staff would monitor doors until the Maintenance Director could change the code on the locks to ensure resident safety. Interview with Licensed Practical Nurse (LPN) #7, on 06/23/19 at 1:45 PM, revealed she had recent training on the abuse policy. She stated she was responsible for reporting allegations of abuse, keeping the resident safe, removing the alleged perpetrator form the building and not allowing them back in. LPN #7 stated after suspending the alleged perpetrator the doors would be monitored by assigned staff, until the Maintenance Director could change the door codes to ensure resident safety. Interview with LPN #4, on 06/23/19 at 1:50 PM, revealed it was her responsibility to report and protect residents from all types of abuse. She stated all staff recently were required to attend abuse training after the incident with Resident #11. LPN #4 stated she would call the Administrator immediately after an allegation of any type of abuse. She would remove the employee and not allow them back in the building. She stated until the door codes were changed she would assign staff to monitor all exit doors. Interview with the Environmental Services Director, on 06/24/19 at 4:48 PM, revealed the previous DON trained her on abuse, reporting abuse, and residents' safety after the annual survey. Attempted telephone interview the Interim Director of Nursing (IDON), on 06/24/19 at 5:00 PM, revealed surveyor left a voice mail message to return call, however, no one answered and a voice mail message was left to return call. However, the surveyor did not receive a returned call. Attempted telephone interview with the Assistant Director of Nursing (ADON), on 06/24/19 at 6:53 PM, revealed surveyor left a voice mail message to return call; however, the surveyor did not receive a returned call. 7. Interview with the RDO, on 06/23/19 at 3:35 PM, revealed she trained the Administrator on Abuse, via email, by emailing her the abuse policy to read. The RDO stated she later sent the Administrator a questionnaire related to the abuse policy that the Administrator completed and returned to her. Interview with the Administrator, on 06/24/19 at 7:17 PM, revealed the RDO trained her on the facility's abuse policy. The Administrator stated she also received abuse training from the Director of Education at Regional Office Quarterly Meeting conduct on 05/11/19. Review of the RDO's email correspondence to all administrators in the region, dated sent on 06/14/19 at 9:25 PM, revealed she sent an email telling the administrators that surveyors were verifying facility investigations began immediately and that they were thorough. She attached the Abuse Policy, Incident Report Form, and an Example of Investigation Summary for them to refer to when completing abuse investigations. 8. Review of the facility's Social Services Behavior Assessment forms for Resident #11, dated 03/26/19, 03/27/19, and 03/28/19, revealed the previous ADON assessed the resident's behavior on 03/26/19, as angry about money stolen; on 03/27/19, as tearful and stated found out his/her aunt was ill; and on 03/28/19 with no negative behaviors. Interview with the RDO, on 06/23/19 at 3:35 PM, revealed she interviewed Resident #11 on 05/10/19, and he/she displayed and voiced no concerns of fear or intimidation related to the incident that occurred on 03/26/19. Observation of Resident #11, on 06/22/19 at 4:30 PM, revealed the resident was in bed playing a video game. During interview, the resident smiled continuously even when questioned about the alleged incident of abuse. The resident did not appear intimidated, nor were there any visible bruises or injuries. Interview with Resident #11, on 06/22/19 at 4:30 PM, revealed he/she was originally upset regarding the incident, before the facility reimbursed the money. The resident stated the previous Administrator came and questioned him/her about the incident and how he/she felt about it, but since it was usually early in the morning when he/she did not talk much. 9. Interview with the RDO, on 06/23/19 at 3:35 PM, revealed she received abuse training from the Regional Director of Education/Nurse Consultant at Regional Office Quarterly Meeting conduct on 05/11/19. She said the training included receiving background and pre-employment reference checks, prior to staff starting their employment; conducting a thorough investigation; keeping resident(s) safe during the investigation; and reporting abuse investigations timely. Telephone interview with the Director of Education/Corporate Nurse Consultant Trainer, on 06/24/19 at 5:09 PM, revealed she explained the Abuse Policy to the attendees at the Regional Quarterly Meeting held on 05/11/19, and they completed competency questions on abuse to ensure they retained the information she taught. 10. Attempted telephone interview with the previous Maintenance Director, on 06/22/19 at 10:00 AM, revealed surveyor left a voice mail message for him to return call; however, he never returned surveyor's call. Interview with the Environmental Services Director, on 06/24/19 at 4:48 PM, revealed she assisted the previous Maintenance Director with changing the door entry/exit codes shortly after the annual survey. She said she assisted him by reading the on-line directions while he physically changed the codes. She stated the previous Director of Nursing trained her on abuse on 05/11/19. 11. Attempted telephone interview, on 06/24/19 at 6:27 PM, with the previous Payroll Employee was made, however, no one answered and a voice mail message was left to return call. Attempted telephone interview, on 06/24/19 at 6:37 PM, with the Regional Director of Human Resources was made, however, no one answered and a voice mail message was left to return call. 12. Attempted telephone interview, on 06/24/19 at 6:27 PM, with the previous Payroll Employee was made; however, no one answered and a voice mail message was left to return call. Attempted telephone interview, on 06/24/19 at 6:37 PM, with the Regional Director of Human Resources was made; however, no one answered and a voice mail message was left to return call. Review of the facility's Employee Tracking Audit Tool, not dated, revealed the facility-tracked employees' certification/license, criminal history, references, TB assessments, and abuse registry checks upon hire and annually thereafter. Review of seven (7) sampled employee files, on 06/21/19 at 10:00 AM, revealed the facility employee files contained certification/license, criminal history, references, TB assessments, and abuse registry checks. Interview with the Business Office Manager, on 06/24/19 at 6:00 PM, revealed she began employment with the facility on 11/28/18, and started completing pre-employment checks. She stated she was trained by the RDO to complete reference, criminal background, licensee/certification, abuse registry, and Office of Inspector General checks on all potential employees before allowing them to work in the facility. Interview with the Administrator, on 06/24/19 at 7:17 PM, revealed she audited all new hire employee files to ensure reference, abuse registry, licensure/certification and other mandated pre-employment requirements were met. In addition, she directed the DON to verify all employee TB assessments were completed. 13. Interview with the Administrator, on 06/24/19 at 7:17 PM, revealed she was trained by the RDO on abuse reporting and auditing all new hire employee files to ensure reference, abuse registry, licensure/certification and other mandated pre-employment requirements were met. 14. Review of the facility's Resident Interview forms, not dated, revealed the SSD conducted resident interview questionnaires 05/28/19 through 06/06/19, related to how they felt about their treatment, services, and safety at the facility. The forms noted the residents replied they felt safe in the facility. Interview with Social Services Director, on 06/23/19 at 11:40 PM, revealed she interviewed residents and documented the interviews on a Resident Interview form on 05/28/19 through 06/06/19. She stated the residents voiced no concerns related to staff treatment or their overall safety at the facility. Interviews with Resident #35 at 8:10 AM, Unsampled Resident A at 8:15 AM, and Unsampled Resident B at 8:22 AM, on 06/21/19, revealed they felt safe at the facility and had no concerns related to abuse. The residents stated if they felt someone treated them badly they would report it immediately to the nurse on duty or the Administrator. 15. Immediately after the door codes were changed, the Administrator and the Maintenance Director would round to confirm changes of codes were effective. The Maintenance Director documented door code changes on a Door Code Tracking Tool to ensure no prior codes were duplicated. Review of an In-Service Record, dated 06/22/19, revealed the Administrator trained the Maintenance Director on how to re-code door key locks. The training included information from Secure Care Advantage 1000, [NAME] Simplex 1000 Series, and Door Guard IEI. Interview with the Maintenance Director, on 06/24/19 at 3:54 PM, revealed the Administrator/DON/ADON would notify him if they terminated and/or suspended an employee and he would change the door entry/exit codes within two hours of notification. He said they developed a log to track all door code changes and the logs would be housed at each nursing station and in his office. According to the Maintenance Director, the log would be reviewed at QAPI. The Maintenance Director further stated on 06/22/19, he changed all door entry/exit codes and logged them in on the tracking sheet, per the Administrator. The Maintenance Director stated the Administrator trained him on how to change the entry/exit door codes for three (3) door locks and he read the facility's security manual, which also gave direction on entry/exit door codes. Interview with the Admissions Director, Business Office Manager, Dietary Services Director, and Activities Director, on 06/24/19 at 6:00 PM, revealed the Administrator trained them to immediately remove the alleged perpetrator from the facility premises. They stated if the alleged perpetrator threatened to harm anyone, they were supposed to notify local law enforcement to keep them from returning to the facility. They said they were also trained to notify the Maintenance Director immediately and place a staff member in the hall to monitor the doors until the MD changed the door entry/exit codes. Interview with the Administrator, on 06/24/19 at 7:17 PM, revealed when the facility terminated an employee the Maintenance Director would change all the facility's entry/exit codes within two (2) hours and track the code changes on a log. Per the Administrator, after the codes were changed, she and the Maintenance Director would round on all doors to ensure codes were working, as a second validation with their signatures after completed. They would keep a copy of all code changes in their Emergency Management Procedure book housed at each nursing station accessible to staff at all times. Record Review of the facility's Door Code Change Tracking Log, not dated, revealed it contained Door Locations, Date and Time code changes were made, Prior Code and New Code, the Initials of the Individuals verifying code changes were made, and Reason codes were change. 16. Telephone interview with the Chief Operating Officer (COO), on 06/24/19 at 4:15 PM, revealed he scheduled quarterly meetings with all Administrators, DONs, RDOs, and other Regional team members and at the last meeting held on 05/01/19, they were in-serviced on Abuse by the [NAME] President of Clinical Services. The COO stated Abuse training would be an on-going topic at their quarterly meetings. Their next meeting was scheduled on 07/23/19. Telephone interview with the Corporate Director of Education/VP of Clinical Services, on 06/24/19 at 4:22 PM, revealed she attended the Regional Quarterly Meeting held on 05/11/19 and in-serviced Administrators, DONs, RDOs, and other Regional team members on Abuse. She stated they covered all protocols of abuse and they took abuse allegations extremely serious. She also stated they completed a role-play on abuse and mock surveys to ensure the different types of abuse were covered. According to the Corporate Director of Education/VP of Clinical Services, she audited the facility's abuse investigation files to ensure abuse policies and procedures, which included ensuring the alleged perpetrator was immediately removed from the building. Telephone interview with the Director of Education/Corporate Trainer, on 06/24/19 at 5:09 PM, revealed she explained the Abuse Policy to the attendees at the Regional Quarterly Meeting held on 05/11/19, and they completed competency questions on abuse to ensure they retained the information she taught. In addition, she stated they reviewed all state survey results at the meetings for quality assurance purposes and gave direction as needed. 17. Interviews with several CNAs, LPNs, Housekeeping staff, Environmental staff, and Dietary Staff during the survey, on 06/20/19 through 06/24/19, revealed the Administrator and DON re-educated them to the facility's Abuse Policy, since their annual survey was completed. Staff stated they signed the Abuse Program Acknowledgement form and completed post-tests ensuring they comprehended the policy. Interviews with Staff hired after 05/01/19, confirmed they were educated on the facility's Abuse Policy. Interview with the Administrator, on 06/24/19 at 7:17 PM, revealed she rounded the facility and questioned staff on the abuse policy ensuring they comprehended the Abuse Policy by knowing the types of abuse and abuse reporting requirements that included knowing their chain of command. 18. Interview with the RDO, on 06/23/19 at 3:35 PM, revealed she continued to monitor the Administrator's understanding of the abuse investigation process. The RDO stated she gave the Administrator scenarios of abuse reporting and the Administrator demonstrated what actions she would take throughout her investigation of the abuse allegations. She also stated the Administrator comprehended the trainings she received on including pre-employment checks. Interview with the Administrator, on 06/24/19 at 7:17 PM, revealed the RDO monthly audited the facility's abuse investigative files to ensure she conducted a complete and thorough investigation, placed appropriate interventions, and took appropriate actions throughout the investigative process. 19. Interview with the RDO, on 06/23/19 at 3:35 PM, revealed she continued to audit and monitor all initial and final self-reported abuse incidents to ensure all were reported timely, resident safety was established immediately, the investigation was started immediately and thorough. 20. Telephone interview with the Corporate Director of Education/VP of Clinical Services, on 06/24/19 at 4:22 PM, revealed she reviewed and would continue review for three months, all the Administrator's investigative files to ensure the Administrator followed the Abuse policies and procedures when concluding the investigation. The Corporate Director of Education/VP of Clinical Services stated on 05/11/19, they received abuse training at the Regional Meeting. 21. Interview with the Medical Director, on 06/24/19 at 5:25 PM, revealed the Administrator had called him to discuss the notification of immediate jeopardy on 06/21/19. He stated they discussed corrective actions and how to ensure residents were protected from abuse. Interview with the Administrator, on 06/24/19 at 7:17 PM, revealed she informed the Medical Director that all abuse deficiencies were elevated to immediate jeopardy on 06/21/19. During the meeting the Medical Director suggested the cameras outside the facility be fixed and to place monitors at each nursing station. She stated she contacted a company to come give the facility an estimate. 22. Review of the facility's QAPI Committee Meeting Minutes' Agenda and Sign-In Signature Sheet, dated 05/21/19, revealed QAPI Committee met to discuss their annual survey results. Review of the facility's AdHoc Quality Assurance Meeting's Agenda and Sign-In Signature Sheet, dated 06/22/19, revealed QAPI Committee met to discuss the identified concern regarding door codes were changed back to previous code changes. Interview with the Administrator, on 06/24/19 at 7:17 PM, revealed the QAPI Committee consisted of the Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), Social Services Director (SSD), Activity Director, Dietary Manager (DM), Maintenance Director, Environmental Services Director (ESD), Business Office Manager (BOM), admission Director and Medical Director. She stated the audit and monitoring results would be taken to the QAPI committee for review and if any patterns were identified an action plan would be developed and implemented to ensure issues were resolved. Interview with the Maintenance Director, on 06/24/19 at 3:54 PM, revealed he would attend the QAPI committee to discuss his door code changing log and other audits as required. Interview with the Admissions Director, Business Office Manager, Dietary Services Director, and Activities Director, on 06/24/19 at 6:00 PM, revealed they attended facility QAPI meetings and would review audits and monitoring to determine patterns in need of corrective action plans. Review of the Facility's policy titled Abuse Prevention Program, not dated, revealed the policy address the following components of abuse: Pre-employment Screening of Potential Employees, Orientation and Training of Employees, Identifying Abuse, Rep[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility implemented the following actions to remove Immediate Jeopardy: 1. On 03/26/19 at approximately 9:45 PM, a law enforcement officer escorted Certified Nursing Assistant (CNA) #13 out of the building and off the property. 2. On 03/26/19, the Administrator informed staff to immediately contact the police if CNA #13 attempted to re-enter again, after CNA #13 had re-entered the facility to retrieve alleged belongings and left. 3. On 03/26/19, Administrator suspended CNA #13, pending investigation, and then subsequently terminated her position on 04/02/19. 4. On 03/27/19, the Regional Director of Operations (RDO) interviewed Resident #52 related to possible safety concerns when CNA #13 returned to the facility and entered the resident's room to retrieve personal belongings, after local law enforcement had escorted her out of the facility on 03/26/19. 5. On 03/28/19, the Administrator, at the time of the incident that occurred on 03/26/19, ended their employment with the facility. 6. On 03/27/19 to 03/28/19, the Assistant Director of Nursing (ADON) and Interim Director of Nursing (IDON) conducted an in-service on the facility's Abuse Policy to the staff. Staff signed an Abuse Program Acknowledgment form verifying eighty-eight (88) staff members received training on abuse. The facility assured all newly hired staff would be educated on their Abuse Policy before they were permitted to work in the facility. 7. On 04/15/19, via email, the RDO educated the Administrator on the Abuse Prevention Policy including reporting of abuse, types of abuse, abuse prevention, investigation, and immediate intervention to ensure resident(s) safety upon hire. 8. On 05/10/19, the RDO interviewed Resident #11, to determine his/her mindset (related to fear, intimidation, or abuse) after the abuse incident that occurred on 03/26/19. 9. On 05/11/19, the RDO was educated by the Regional Nurse Consultant on the Abuse Prevention policy; including receiving background and pre-employment reference checks prior to staff starting their employment, conducting a thorough investigation, keeping resident(s) safe during the investigation, and timely reporting. 10. On 05/11/19, the Maintenance Director and Environmental Services Director changed the code on the entry/exit doors to decrease the risk of CNA #13 from entering the building during after hours in the future. 11. On 05/13/19, the Regional Director of Human Resources educated the Payroll Coordinator, per job description, related to facility's policy on pre-employment screenings. 12. From 05/13/19 to 05/14/19, the Payroll Coordinator with the assistance of the RDHR conducted a one hundred percent (100%) audit of Employee files. The audits included checking criminal backgrounds, references, abuse registry, and licensure and/or certification validations. 13. On 05/16/19, the RDO educated the Administrator on the timely reporting of abuse, investigation of abuse allegations, receiving background checks and conducting re-employment reference checks prior to employing staff. 14. From 05/28/19 to 06/06/19, the Social Service Director (SSD) conducted interviews with ten (10) residents regarding their overall satisfaction with facility services and whether they had any issues or concerns that needed addressing. 15. On 06/22/19, the Administrator educated the Maintenance Director on how to change the entry/exit door codes for three (3) door locks. The entry/exit codes would be changed when the Administrator notified the Maintenance Director that an employee was suspended related to abuse and/or neglect. According to the new procedure implemented by the facility on 06/22/19, the Administrator notified the Maintenance Director that the facility suspended an employee to decrease the risk of the suspended employee returning to the facility. The facility would notify the Maintenance Director ASAP, assign a staff person to the hallway to monitor exit doors until the codes were changed, and the Maintenance Director would change all entry/exit codes within two (2) hours of notification, which would ensure the overall safety and security of residents. 16. On 05/01/19, at the Quarterly scheduled meeting, the [NAME] President of Clinical Services, Chief Operating Officer, facilitated Abuse Training along with the Corporate Director of Education. The Chief Operating Officer scheduled Quarterly Meetings with all Administrators, Directors of Nursing, Regional Director of Operations and other Regional team members. In addition, Abuse Training would be conducted at each Quarterly Regional Meeting, on an on-going basis. 17. The Administrator and/or Designee would monitor staff understanding of the education by conducting staff interviews three (3) times a week for four (4) weeks regarding Abuse Prevention Program and monthly for three (3) months. The Administrator would add to the monthly in-service the Abuse Prevention education with questions and answer session to validate understanding; then on an on-going basis a segment of the Abuse Program would remain on the monthly in-service calendar. 18. The RDO would monitor the Administrator's understanding of the education by reviewing with the Administrator the initial report of an allegation of abuse to ensure a thorough investigation was conducted. Then would stay in contact with the Administrator throughout the investigation. The RDO would review the final report to ensure the investigation was complete and all aspects of the Abuse policy was followed; to include timely reporting, resident safety was ensured during the investigation, all interviews conducted, interventions were taken, and any other issues of abuse and/or neglect identified to ensure appropriate actions were taken and a thorough investigation completed. 19. The RDO and/or the Regional Nurse Consultant (RNC), on an ongoing basis would review all initial and final self-reported abuse incidents to ensure all were reported timely, resident safety was established immediately, the investigation was started immediately and conducted thoroughly. In addition, newly reported allegations discovered during the investigation was reported. 20. The [NAME] President of Clinical Services (VPCS) would review the investigative files and the recommended outcome made by the new Administrator and the RDO related to the self-reported incidences for three (3) months to ensure the Abuse policies and procedures were followed. 21. On 06/21/19, the Administrator reviewed with the Medical Director the change in scope and severity as it related to the immediate jeopardy tags. In addition, discussed actions to correct identified concerns. The Medical Director identified and directed the Maintenance Director and Administrator to fix surveillance cameras outside the facility's building and place monitors at each nursing station. 22. The outcome of the monitoring of the education would be reported to the Quality Assurance Process Improvement Committee (QAPI). If any patterns were identified an action plan would be written by the committee; this action plan would be monitored weekly by the Administrator until resolved. The QAPI Committee consisted of the Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), Social Services Director (SSD), Activity Director, Dietary Manager (DM), Maintenance Director, Environmental Services Director (ESD), Business Office Manager (BOM), admission Director and Medical Director. The State Agency Validated the removal immediate jeopardy prior to exit on 06/24/19 as follows: 1. Review of the Law Enforcement Incident/Investigation Report, with a print date of 06/21/19, revealed on 03/26/19 at approximately 9:42 PM, a law enforcement officer came to the facility to investigate the incident of possible charges of Theft by Unlawful Taking Over $500 of Resident #11's missing monies. Record review of the facility Self Reportable Investigation Summary, not dated, revealed Licensed Practical Nurse (LPN) #8 immediately went to Resident #11's room upon hearing yelling, and removed CNA #13 from the room, the police entered the building and escorted the CNA off the property. Review of CNA #13's written statement, dated 03/27/19, revealed the police transported him/her to a gas station and left him/her there around 11:00 PM on 03/26/19. Interview on 6/23/19 at 10:45 AM, with the current Administrator, revealed staff informed her and per her review of the facility investigation a police officer with the badge number 6163 escorted CNA #13 out of the building on 03/26/19 around 9:45 PM. 2. Attempted telephone interview with the previous Administrator, on 06/20/19 at 4:00 PM, 06/23/19 at 11:00 AM, and 06/24/19 at 4:30 PM, revealed surveyor left a voice mail message to return call; however, the previous Administrator did not returned the surveyor's call. Interview with Licensed Practical Nurse (LPN) #7, on 06/23/19 at 1:45 PM, revealed after CNA #13 returned and entered the building, on 03/26/19, staff were instructed not to let her back in the building to ensure resident safety. 3. Review of the facility's Personnel Change Form, dated 03/28/19, revealed CNA #13 was terminated on 04/02/19. Interview with Resident #11, on 06/22/19 at 4:30 PM, revealed he/she had not seen CNA #13 since the day of the incident. 4. Review of Resident #52's clinical record revealed the facility assessed the resident with a score of fifteen (15) on the Brief Interview of Mental Status (BIMS), on 02/09/19, indicating the resident was cognitively intact. Interview with the RDO, on 06/23/19 at 3:35 PM, revealed she interviewed Resident #52 on 03/26/19, and the resident voiced no safety concerns with facility staff. 5. Review of the facility's Personnel Change Form for the Administrator at the time of the incident, dated effective 03/28/19, revealed Administrator voluntarily surrender the Administrator position on 03/28/19. Attempted telephone interview with the previous Administrator, on 06/20/19 at 4:00 PM, 06/23/19 at 11:00 AM, and 06/24/19 at 4:30 PM, revealed surveyor left a voice mail message to return call; however, the previous Administrator did not return the surveyor's call. Interview with the current Administrator of the facility, on 06/23/19 at 10:30 AM, revealed the former Administrator ended their employment on 03/28/19. 6. Review of the facility's in-service training on Teaching Moment Regarding Abuse and Misappropriation, dated 03/27/19 and 03/28/19, revealed eighty-eight (88) staff members received training and signed an Abuse Program Acknowledgment form. Review of the facility's in-service training on Teaching Moment Regarding Abuse and Misappropriation, dated 04/01/19 through 06/20/19, revealed twenty-two (22) newly hired staff members received training and signed an Abuse Program Acknowledgment form. Interview with Certified Nursing Assistant (CNA) #14, on 06/23/19 at 12:00 PM, revealed she was educated on abuse types, when and to whom to report an abuse allegation. CNA #14 stated after staff were suspended they were not allowed back in the building and the codes to the doors were changed. Interview with CNA #15, on 06/23/19 at 12:15 PM, revealed the facility had recently re-educated her on the types of abuse and her responsibility to report immediately if witnessed. She stated if an employee was suspended, staff should not allow them back into the building and the door codes would be changed by Maintenance. Interview with CNA #16, on 06/23/19 at 12:30 PM, revealed she was knowledgeable of the types of abuse She stated if witnessed she would report to her supervisor immediately. CNA #16 stated the facility recently re-educated her on the abuse policy and if an abuse allegation was made against a staff member, they were suspended pending investigation and were not allowed back into the building. In addition, the management team would obtain statements from staff and then Maintenance would change the door codes to ensure resident safety. Interview with Housekeeper #1 and #2, on 06/23/19 at 12:45 PM, revealed the facility recently re-educated them on the abuse policy. They stated they would report abuse if witnessed or if an allegation of abuse was reported to them. Each stated if an allegation of abuse was made the employee would be suspended and not allowed back into the building until the investigation was completed. Also that the door codes would be changed to ensure resident safety. Interview with Dietary Staff #1, on 06/23/19 at 12:50 PM, revealed the facility recently trained her on abuse, required her to take a test and sign an acknowledgment form that she understood the abuse policy and facility expectations. She also stated if an employee was suspended, they were not allowed back in the building and the door codes were changed. Interview with CNA #12, on 06/23/19 at 12:55 PM, revealed the facility recently provided training on the abuse policy, that she had to take a test and sign an acknowledgement statement saying she understood the policy. She stated the facility had a strict abuse policy and, if suspended, staff were not allowed back in the building, while the investigation was on going. CNA #12 stated the Administrator would have the Maintenance Director change the door lock codes to ensure resident safety and prevent the suspended employee from gaining entry into the facility by using the code. Interview with CNA # 17, on 06/23/19 at 1:10 PM, revealed if a staff member threatened a resident, staff would protect the resident and report the incident immediately. In addition, a suspended staff member was not allowed back in the building. CNA #17 stated the facility trained her recently on the abuse policy. She stated she had to sign an acknowledgement sheet and take a test to ensure she understood the policy. Interview with LPN #1, on 06/23/19 at 1:38 PM, revealed the facility required he re-read the abuse policy, take a test and sign an acknowledgement statement that he understood his responsibility. He stated if he received a report of abuse, he would immediately protect the resident by removing the employee from the building. LPN #1 stated he would then report the incident to the Administrator and other appropriate authorities if needed. In addition, the staff would monitor doors until the Maintenance Director could change the code on the locks to ensure resident safety. Interview with Licensed Practical Nurse (LPN) #7, on 06/23/19 at 1:45 PM, revealed she had recent training on the abuse policy. She stated she was responsible for reporting allegations of abuse, keeping the resident safe, removing the alleged perpetrator form the building and not allowing them back in. LPN #7 stated after suspending the alleged perpetrator the doors would be monitored by assigned staff, until the Maintenance Director could change the door codes to ensure resident safety. Interview with LPN #4, on 06/23/19 at 1:50 PM, revealed it was her responsibility to report and protect residents from all types of abuse. She stated all staff recently were required to attend abuse training after the incident with Resident #11. LPN #4 stated she would call the Administrator immediately after an allegation of any type of abuse. She would remove the employee and not allow them back in the building. She stated until the door codes were changed she would assign staff to monitor all exit doors. Interview with the Environmental Services Director, on 06/24/19 at 4:48 PM, revealed the previous DON trained her on abuse, reporting abuse, and residents' safety after the annual survey. Attempted telephone interview the Interim Director of Nursing (IDON), on 06/24/19 at 5:00 PM, revealed surveyor left a voice mail message to return call, however, no one answered and a voice mail message was left to return call. However, the surveyor did not receive a returned call. Attempted telephone interview with the Assistant Director of Nursing (ADON), on 06/24/19 at 6:53 PM, revealed surveyor left a voice mail message to return call; however, the surveyor did not receive a returned call. 7. Interview with the RDO, on 06/23/19 at 3:35 PM, revealed she trained the Administrator on Abuse, via email, by emailing her the abuse policy to read. The RDO stated she later sent the Administrator a questionnaire related to the abuse policy that the Administrator completed and returned to her. Interview with the Administrator, on 06/24/19 at 7:17 PM, revealed the RDO trained her on the facility's abuse policy. The Administrator stated she also received abuse training from the Director of Education at Regional Office Quarterly Meeting conduct on 05/11/19. Review of the RDO's email correspondence to all administrators in the region, dated sent on 06/14/19 at 9:25 PM, revealed she sent an email telling the administrators that surveyors were verifying facility investigations began immediately and that they were thorough. She attached the Abuse Policy, Incident Report Form, and an Example of Investigation Summary for them to refer to when completing abuse investigations. 8. Review of the facility's Social Services Behavior Assessment forms for Resident #11, dated 03/26/19, 03/27/19, and 03/28/19, revealed the previous ADON assessed the resident's behavior on 03/26/19, as angry about money stolen; on 03/27/19, as tearful and stated found out his/her aunt was ill; and on 03/28/19 with no negative behaviors. Interview with the RDO, on 06/23/19 at 3:35 PM, revealed she interviewed Resident #11 on 05/10/19, and he/she displayed and voiced no concerns of fear or intimidation related to the incident that occurred on 03/26/19. Observation of Resident #11, on 06/22/19 at 4:30 PM, revealed the resident was in bed playing a video game. During interview, the resident smiled continuously even when questioned about the alleged incident of abuse. The resident did not appear intimidated, nor were there any visible bruises or injuries. Interview with Resident #11, on 06/22/19 at 4:30 PM, revealed he/she was originally upset regarding the incident, before the facility reimbursed the money. The resident stated the previous Administrator came and questioned him/her about the incident and how he/she felt about it, but since it was usually early in the morning when he/she did not talk much. 9. Interview with the RDO, on 06/23/19 at 3:35 PM, revealed she received abuse training from the Regional Director of Education/Nurse Consultant at Regional Office Quarterly Meeting conduct on 05/11/19. She said the training included receiving background and pre-employment reference checks, prior to staff starting their employment; conducting a thorough investigation; keeping resident(s) safe during the investigation; and reporting abuse investigations timely. Telephone interview with the Director of Education/Corporate Nurse Consultant Trainer, on 06/24/19 at 5:09 PM, revealed she explained the Abuse Policy to the attendees at the Regional Quarterly Meeting held on 05/11/19, and they completed competency questions on abuse to ensure they retained the information she taught. 10. Attempted telephone interview with the previous Maintenance Director, on 06/22/19 at 10:00 AM, revealed surveyor left a voice mail message for him to return call; however, he never returned surveyor's call. Interview with the Environmental Services Director, on 06/24/19 at 4:48 PM, revealed she assisted the previous Maintenance Director with changing the door entry/exit codes shortly after the annual survey. She said she assisted him by reading the on-line directions while he physically changed the codes. She stated the previous Director of Nursing trained her on abuse on 05/11/19. 11. Attempted telephone interview, on 06/24/19 at 6:27 PM, with the previous Payroll Employee was made, however, no one answered and a voice mail message was left to return call. Attempted telephone interview, on 06/24/19 at 6:37 PM, with the Regional Director of Human Resources was made, however, no one answered and a voice mail message was left to return call. 12. Attempted telephone interview, on 06/24/19 at 6:27 PM, with the previous Payroll Employee was made; however, no one answered and a voice mail message was left to return call. Attempted telephone interview, on 06/24/19 at 6:37 PM, with the Regional Director of Human Resources was made; however, no one answered and a voice mail message was left to return call. Review of the facility's Employee Tracking Audit Tool, not dated, revealed the facility-tracked employees' certification/license, criminal history, references, TB assessments, and abuse registry checks upon hire and annually thereafter. Review of seven (7) sampled employee files, on 06/21/19 at 10:00 AM, revealed the facility employee files contained certification/license, criminal history, references, TB assessments, and abuse registry checks. Interview with the Business Office Manager, on 06/24/19 at 6:00 PM, revealed she began employment with the facility on 11/28/18, and started completing pre-employment checks. She stated she was trained by the RDO to complete reference, criminal background, licensee/certification, abuse registry, and Office of Inspector General checks on all potential employees before allowing them to work in the facility. Interview with the Administrator, on 06/24/19 at 7:17 PM, revealed she audited all new hire employee files to ensure reference, abuse registry, licensure/certification and other mandated pre-employment requirements were met. In addition, she directed the DON to verify all employee TB assessments were completed. 13. Interview with the Administrator, on 06/24/19 at 7:17 PM, revealed she was trained by the RDO on abuse reporting and auditing all new hire employee files to ensure reference, abuse registry, licensure/certification and other mandated pre-employment requirements were met. 14. Review of the facility's Resident Interview forms, not dated, revealed the SSD conducted resident interview questionnaires 05/28/19 through 06/06/19, related to how they felt about their treatment, services, and safety at the facility. The forms noted the residents replied they felt safe in the facility. Interview with Social Services Director, on 06/23/19 at 11:40 PM, revealed she interviewed residents and documented the interviews on a Resident Interview form on 05/28/19 through 06/06/19. She stated the residents voiced no concerns related to staff treatment or their overall safety at the facility. Interviews with Resident #35 at 8:10 AM, Unsampled Resident A at 8:15 AM, and Unsampled Resident B at 8:22 AM, on 06/21/19, revealed they felt safe at the facility and had no concerns related to abuse. The residents stated if they felt someone treated them badly they would report it immediately to the nurse on duty or the Administrator. 15. Immediately after the door codes were changed, the Administrator and the Maintenance Director would round to confirm changes of codes were effective. The Maintenance Director documented door code changes on a Door Code Tracking Tool to ensure no prior codes were duplicated. Review of an In-Service Record, dated 06/22/19, revealed the Administrator trained the Maintenance Director on how to re-code door key locks. The training included information from Secure Care Advantage 1000, [NAME] Simplex 1000 Series, and Door Guard IEI. Interview with the Maintenance Director, on 06/24/19 at 3:54 PM, revealed the Administrator/DON/ADON would notify him if they terminated and/or suspended an employee and he would change the door entry/exit codes within two hours of notification. He said they developed a log to track all door code changes and the logs would be housed at each nursing station and in his office. According to the Maintenance Director, the log would be reviewed at QAPI. The Maintenance Director further stated on 06/22/19, he changed all door entry/exit codes and logged them in on the tracking sheet, per the Administrator. The Maintenance Director stated the Administrator trained him on how to change the entry/exit door codes for three (3) door locks and he read the facility's security manual, which also gave direction on entry/exit door codes. Interview with the Admissions Director, Business Office Manager, Dietary Services Director, and Activities Director, on 06/24/19 at 6:00 PM, revealed the Administrator trained them to immediately remove the alleged perpetrator from the facility premises. They stated if the alleged perpetrator threatened to harm anyone, they were supposed to notify local law enforcement to keep them from returning to the facility. They said they were also trained to notify the Maintenance Director immediately and place a staff member in the hall to monitor the doors until the MD changed the door entry/exit codes. Interview with the Administrator, on 06/24/19 at 7:17 PM, revealed when the facility terminated an employee the Maintenance Director would change all the facility's entry/exit codes within two (2) hours and track the code changes on a log. Per the Administrator, after the codes were changed, she and the Maintenance Director would round on all doors to ensure codes were working, as a second validation with their signatures after completed. They would keep a copy of all code changes in their Emergency Management Procedure book housed at each nursing station accessible to staff at all times. Record Review of the facility's Door Code Change Tracking Log, not dated, revealed it contained Door Locations, Date and Time code changes were made, Prior Code and New Code, the Initials of the Individuals verifying code changes were made, and Reason codes were change. 16. Telephone interview with the Chief Operating Officer (COO), on 06/24/19 at 4:15 PM, revealed he scheduled quarterly meetings with all Administrators, DONs, RDOs, and other Regional team members and at the last meeting held on 05/01/19, they were in-serviced on Abuse by the [NAME] President of Clinical Services. The COO stated Abuse training would be an on-going topic at their quarterly meetings. Their next meeting was scheduled on 07/23/19. Telephone interview with the Corporate Director of Education/VP of Clinical Services, on 06/24/19 at 4:22 PM, revealed she attended the Regional Quarterly Meeting held on 05/11/19 and in-serviced Administrators, DONs, RDOs, and other Regional team members on Abuse. She stated they covered all protocols of abuse and they took abuse allegations extremely serious. She also stated they completed a role-play on abuse and mock surveys to ensure the different types of abuse were covered. According to the Corporate Director of Education/VP of Clinical Services, she audited the facility's abuse investigation files to ensure abuse policies and procedures, which included ensuring the alleged perpetrator was immediately removed from the building. Telephone interview with the Director of Education/Corporate Trainer, on 06/24/19 at 5:09 PM, revealed she explained the Abuse Policy to the attendees at the Regional Quarterly Meeting held on 05/11/19, and they completed competency questions on abuse to ensure they retained the information she taught. In addition, she stated they reviewed all state survey results at the meetings for quality assurance purposes and gave direction as needed. 17. Interviews with several CNAs, LPNs, Housekeeping staff, Environmental staff, and Dietary Staff during the survey, on 06/20/19 through 06/24/19, revealed the Administrator and DON re-educated them to the facility's Abuse Policy, since their annual survey was completed. Staff stated they signed the Abuse Program Acknowledgement form and completed post-tests ensuring they comprehended the policy. Interviews with Staff hired after 05/01/19, confirmed they were educated on the facility's Abuse Policy. Interview with the Administrator, on 06/24/19 at 7:17 PM, revealed she rounded the facility and questioned staff on the abuse policy ensuring they comprehended the Abuse Policy by knowing the types of abuse and abuse reporting requirements that included knowing their chain of command. 18. Interview with the RDO, on 06/23/19 at 3:35 PM, revealed she continued to monitor the Administrator's understanding of the abuse investigation process. The RDO stated she gave the Administrator scenarios of abuse reporting and the Administrator demonstrated what actions she would take throughout her investigation of the abuse allegations. She also stated the Administrator comprehended the trainings she received on including pre-employment checks. Interview with the Administrator, on 06/24/19 at 7:17 PM, revealed the RDO monthly audited the facility's abuse investigative files to ensure she conducted a complete and thorough investigation, placed appropriate interventions, and took appropriate actions throughout the investigative process. 19. Interview with the RDO, on 06/23/19 at 3:35 PM, revealed she continued to audit and monitor all initial and final self-reported abuse incidents to ensure all were reported timely, resident safety was established immediately, the investigation was started immediately and thorough. 20. Telephone interview with the Corporate Director of Education/VP of Clinical Services, on 06/24/19 at 4:22 PM, revealed she reviewed and would continue review for three months, all the Administrator's investigative files to ensure the Administrator followed the Abuse policies and procedures when concluding the investigation. The Corporate Director of Education/VP of Clinical Services stated on 05/11/19, they received abuse training at the Regional Meeting. 21. Interview with the Medical Director, on 06/24/19 at 5:25 PM, revealed the Administrator had called him to discuss the notification of immediate jeopardy on 06/21/19. He stated they discussed corrective actions and how to ensure residents were protected from abuse. Interview with the Administrator, on 06/24/19 at 7:17 PM, revealed she informed the Medical Director that all abuse deficiencies were elevated to immediate jeopardy on 06/21/19. During the meeting the Medical Director suggested the cameras outside the facility be fixed and to place monitors at each nursing station. She stated she contacted a company to come give the facility an estimate. 22. Review of the facility's QAPI Committee Meeting Minutes' Agenda and Sign-In Signature Sheet, dated 05/21/19, revealed QAPI Committee met to discuss their annual survey results. Review of the facility's AdHoc Quality Assurance Meeting's Agenda and Sign-In Signature Sheet, dated 06/22/19, revealed QAPI Committee met to discuss the identified concern regarding door codes were changed back to previous code changes. Interview with the Administrator, on 06/24/19 at 7:17 PM, revealed the QAPI Committee consisted of the Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), Social Services Director (SSD), Activity Director, Dietary Manager (DM), Maintenance Director, Environmental Services Director (ESD), Business Office Manager (BOM), admission Director and Medical Director. She stated the audit and monitoring results would be taken to the QAPI committee for review and if any patterns were identified an action plan would be developed and implemented to ensure issues were resolved. Interview with the Maintenance Director, on 06/24/19 at 3:54 PM, revealed he would attend the QAPI committee to discuss his door code changing log and other audits as required. Interview with the Admissions Director, Business Office Manager, Dietary Services Director, and Activities Director, on 06/24/19 at 6:00 PM, revealed they attended facility QAPI meetings and would review audits and monitoring to determine patterns in need of corrective action plans. Review of the Facility's policy titled Abuse Prevention Program, not dated, revealed the policy address the following components of abuse: Pre-employment Screening of Potential Employees, Orientation and Training of Employees, Identifying Abuse, Reporting Suspect/Alleged Abuse, Protecting Residents by[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility implemented the following actions to remove Immediate Jeopardy: 1. On 03/26/19 at approximately 9:45 PM, a law enforcement officer escorted Certified Nursing Assistant (CNA) #13 out of the building and off the property. 2. On 03/26/19, the Administrator informed staff to immediately contact the police if CNA #13 attempted to re-enter again, after CNA #13 had re-entered the facility to retrieve alleged belongings and left. 3. On 03/26/19, Administrator suspended CNA #13, pending investigation, and then subsequently terminated her position on 04/02/19. 4. On 03/27/19, the Regional Director of Operations (RDO) interviewed Resident #52 related to possible safety concerns when CNA #13 returned to the facility and entered the resident's room to retrieve personal belongings, after local law enforcement had escorted her out of the facility on 03/26/19. 5. On 03/28/19, the Administrator, at the time of the incident that occurred on 03/26/19, ended their employment with the facility. 6. On 03/27/19 to 03/28/19, the Assistant Director of Nursing (ADON) and Interim Director of Nursing (IDON) conducted an in-service on the facility's Abuse Policy to the staff. Staff signed an Abuse Program Acknowledgment form verifying eighty-eight (88) staff members received training on abuse. The facility assured all newly hired staff would be educated on their Abuse Policy before they were permitted to work in the facility. 7. On 04/15/19, via email, the RDO educated the Administrator on the Abuse Prevention Policy including reporting of abuse, types of abuse, abuse prevention, investigation, and immediate intervention to ensure resident(s) safety upon hire. 8. On 05/10/19, the RDO interviewed Resident #11, to determine his/her mindset (related to fear, intimidation, or abuse) after the abuse incident that occurred on 03/26/19. 9. On 05/11/19, the RDO was educated by the Regional Nurse Consultant on the Abuse Prevention policy; including receiving background and pre-employment reference checks prior to staff starting their employment, conducting a thorough investigation, keeping resident(s) safe during the investigation, and timely reporting. 10. On 05/11/19, the Maintenance Director and Environmental Services Director changed the code on the entry/exit doors to decrease the risk of CNA #13 from entering the building during after hours in the future. 11. On 05/13/19, the Regional Director of Human Resources educated the Payroll Coordinator, per job description, related to facility's policy on pre-employment screenings. 12. From 05/13/19 to 05/14/19, the Payroll Coordinator with the assistance of the RDHR conducted a one hundred percent (100%) audit of Employee files. The audits included checking criminal backgrounds, references, abuse registry, and licensure and/or certification validations. 13. On 05/16/19, the RDO educated the Administrator on the timely reporting of abuse, investigation of abuse allegations, receiving background checks and conducting re-employment reference checks prior to employing staff. 14. From 05/28/19 to 06/06/19, the Social Service Director (SSD) conducted interviews with ten (10) residents regarding their overall satisfaction with facility services and whether they had any issues or concerns that needed addressing. 15. On 06/22/19, the Administrator educated the Maintenance Director on how to change the entry/exit door codes for three (3) door locks. The entry/exit codes would be changed when the Administrator notified the Maintenance Director that an employee was suspended related to abuse and/or neglect. According to the new procedure implemented by the facility on 06/22/19, the Administrator notified the Maintenance Director that the facility suspended an employee to decrease the risk of the suspended employee returning to the facility. The facility would notify the Maintenance Director ASAP, assign a staff person to the hallway to monitor exit doors until the codes were changed, and the Maintenance Director would change all entry/exit codes within two (2) hours of notification, which would ensure the overall safety and security of residents. 16. On 05/01/19, at the Quarterly scheduled meeting, the [NAME] President of Clinical Services, Chief Operating Officer, facilitated Abuse Training along with the Corporate Director of Education. The Chief Operating Officer scheduled Quarterly Meetings with all Administrators, Directors of Nursing, Regional Director of Operations and other Regional team members. In addition, Abuse Training would be conducted at each Quarterly Regional Meeting, on an on-going basis. 17. The Administrator and/or Designee would monitor staff understanding of the education by conducting staff interviews three (3) times a week for four (4) weeks regarding Abuse Prevention Program and monthly for three (3) months. The Administrator would add to the monthly in-service the Abuse Prevention education with questions and answer session to validate understanding; then on an on-going basis a segment of the Abuse Program would remain on the monthly in-service calendar. 18. The RDO would monitor the Administrator's understanding of the education by reviewing with the Administrator the initial report of an allegation of abuse to ensure a thorough investigation was conducted. Then would stay in contact with the Administrator throughout the investigation. The RDO would review the final report to ensure the investigation was complete and all aspects of the Abuse policy was followed; to include timely reporting, resident safety was ensured during the investigation, all interviews conducted, interventions were taken, and any other issues of abuse and/or neglect identified to ensure appropriate actions were taken and a thorough investigation completed. 19. The RDO and/or the Regional Nurse Consultant (RNC), on an ongoing basis would review all initial and final self-reported abuse incidents to ensure all were reported timely, resident safety was established immediately, the investigation was started immediately and conducted thoroughly. In addition, newly reported allegations discovered during the investigation was reported. 20. The [NAME] President of Clinical Services (VPCS) would review the investigative files and the recommended outcome made by the new Administrator and the RDO related to the self-reported incidences for three (3) months to ensure the Abuse policies and procedures were followed. 21. On 06/21/19, the Administrator reviewed with the Medical Director the change in scope and severity as it related to the immediate jeopardy tags. In addition, discussed actions to correct identified concerns. The Medical Director identified and directed the Maintenance Director and Administrator to fix surveillance cameras outside the facility's building and place monitors at each nursing station. 22. The outcome of the monitoring of the education would be reported to the Quality Assurance Process Improvement Committee (QAPI). If any patterns were identified an action plan would be written by the committee; this action plan would be monitored weekly by the Administrator until resolved. The QAPI Committee consisted of the Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), Social Services Director (SSD), Activity Director, Dietary Manager (DM), Maintenance Director, Environmental Services Director (ESD), Business Office Manager (BOM), admission Director and Medical Director. The State Agency Validated the removal immediate jeopardy prior to exit on 06/24/19 as follows: 1. Review of the Law Enforcement Incident/Investigation Report, with a print date of 06/21/19, revealed on 03/26/19 at approximately 9:42 PM, a law enforcement officer came to the facility to investigate the incident of possible charges of Theft by Unlawful Taking Over $500 of Resident #11's missing monies. Record review of the facility Self Reportable Investigation Summary, not dated, revealed Licensed Practical Nurse (LPN) #8 immediately went to Resident #11's room upon hearing yelling, and removed CNA #13 from the room, the police entered the building and escorted the CNA off the property. Review of CNA #13's written statement, dated 03/27/19, revealed the police transported him/her to a gas station and left him/her there around 11:00 PM on 03/26/19. Interview on 6/23/19 at 10:45 AM, with the current Administrator, revealed staff informed her and per her review of the facility investigation a police officer with the badge number 6163 escorted CNA #13 out of the building on 03/26/19 around 9:45 PM. 2. Attempted telephone interview with the previous Administrator, on 06/20/19 at 4:00 PM, 06/23/19 at 11:00 AM, and 06/24/19 at 4:30 PM, revealed surveyor left a voice mail message to return call; however, the previous Administrator did not returned the surveyor's call. Interview with Licensed Practical Nurse (LPN) #7, on 06/23/19 at 1:45 PM, revealed after CNA #13 returned and entered the building, on 03/26/19, staff were instructed not to let her back in the building to ensure resident safety. 3. Review of the facility's Personnel Change Form, dated 03/28/19, revealed CNA #13 was terminated on 04/02/19. Interview with Resident #11, on 06/22/19 at 4:30 PM, revealed he/she had not seen CNA #13 since the day of the incident. 4. Review of Resident #52's clinical record revealed the facility assessed the resident with a score of fifteen (15) on the Brief Interview of Mental Status (BIMS), on 02/09/19, indicating the resident was cognitively intact. Interview with the RDO, on 06/23/19 at 3:35 PM, revealed she interviewed Resident #52 on 03/26/19, and the resident voiced no safety concerns with facility staff. 5. Review of the facility's Personnel Change Form for the Administrator at the time of the incident, dated effective 03/28/19, revealed Administrator voluntarily surrender the Administrator position on 03/28/19. Attempted telephone interview with the previous Administrator, on 06/20/19 at 4:00 PM, 06/23/19 at 11:00 AM, and 06/24/19 at 4:30 PM, revealed surveyor left a voice mail message to return call; however, the previous Administrator did not return the surveyor's call. Interview with the current Administrator of the facility, on 06/23/19 at 10:30 AM, revealed the former Administrator ended their employment on 03/28/19. 6. Review of the facility's in-service training on Teaching Moment Regarding Abuse and Misappropriation, dated 03/27/19 and 03/28/19, revealed eighty-eight (88) staff members received training and signed an Abuse Program Acknowledgment form. Review of the facility's in-service training on Teaching Moment Regarding Abuse and Misappropriation, dated 04/01/19 through 06/20/19, revealed twenty-two (22) newly hired staff members received training and signed an Abuse Program Acknowledgment form. Interview with Certified Nursing Assistant (CNA) #14, on 06/23/19 at 12:00 PM, revealed she was educated on abuse types, when and to whom to report an abuse allegation. CNA #14 stated after staff were suspended they were not allowed back in the building and the codes to the doors were changed. Interview with CNA #15, on 06/23/19 at 12:15 PM, revealed the facility had recently re-educated her on the types of abuse and her responsibility to report immediately if witnessed. She stated if an employee was suspended, staff should not allow them back into the building and the door codes would be changed by Maintenance. Interview with CNA #16, on 06/23/19 at 12:30 PM, revealed she was knowledgeable of the types of abuse She stated if witnessed she would report to her supervisor immediately. CNA #16 stated the facility recently re-educated her on the abuse policy and if an abuse allegation was made against a staff member, they were suspended pending investigation and were not allowed back into the building. In addition, the management team would obtain statements from staff and then Maintenance would change the door codes to ensure resident safety. Interview with Housekeeper #1 and #2, on 06/23/19 at 12:45 PM, revealed the facility recently re-educated them on the abuse policy. They stated they would report abuse if witnessed or if an allegation of abuse was reported to them. Each stated if an allegation of abuse was made the employee would be suspended and not allowed back into the building until the investigation was completed. Also that the door codes would be changed to ensure resident safety. Interview with Dietary Staff #1, on 06/23/19 at 12:50 PM, revealed the facility recently trained her on abuse, required her to take a test and sign an acknowledgment form that she understood the abuse policy and facility expectations. She also stated if an employee was suspended, they were not allowed back in the building and the door codes were changed. Interview with CNA #12, on 06/23/19 at 12:55 PM, revealed the facility recently provided training on the abuse policy, that she had to take a test and sign an acknowledgement statement saying she understood the policy. She stated the facility had a strict abuse policy and, if suspended, staff were not allowed back in the building, while the investigation was on going. CNA #12 stated the Administrator would have the Maintenance Director change the door lock codes to ensure resident safety and prevent the suspended employee from gaining entry into the facility by using the code. Interview with CNA # 17, on 06/23/19 at 1:10 PM, revealed if a staff member threatened a resident, staff would protect the resident and report the incident immediately. In addition, a suspended staff member was not allowed back in the building. CNA #17 stated the facility trained her recently on the abuse policy. She stated she had to sign an acknowledgement sheet and take a test to ensure she understood the policy. Interview with LPN #1, on 06/23/19 at 1:38 PM, revealed the facility required he re-read the abuse policy, take a test and sign an acknowledgement statement that he understood his responsibility. He stated if he received a report of abuse, he would immediately protect the resident by removing the employee from the building. LPN #1 stated he would then report the incident to the Administrator and other appropriate authorities if needed. In addition, the staff would monitor doors until the Maintenance Director could change the code on the locks to ensure resident safety. Interview with Licensed Practical Nurse (LPN) #7, on 06/23/19 at 1:45 PM, revealed she had recent training on the abuse policy. She stated she was responsible for reporting allegations of abuse, keeping the resident safe, removing the alleged perpetrator form the building and not allowing them back in. LPN #7 stated after suspending the alleged perpetrator the doors would be monitored by assigned staff, until the Maintenance Director could change the door codes to ensure resident safety. Interview with LPN #4, on 06/23/19 at 1:50 PM, revealed it was her responsibility to report and protect residents from all types of abuse. She stated all staff recently were required to attend abuse training after the incident with Resident #11. LPN #4 stated she would call the Administrator immediately after an allegation of any type of abuse. She would remove the employee and not allow them back in the building. She stated until the door codes were changed she would assign staff to monitor all exit doors. Interview with the Environmental Services Director, on 06/24/19 at 4:48 PM, revealed the previous DON trained her on abuse, reporting abuse, and residents' safety after the annual survey. Attempted telephone interview the Interim Director of Nursing (IDON), on 06/24/19 at 5:00 PM, revealed surveyor left a voice mail message to return call, however, no one answered and a voice mail message was left to return call. However, the surveyor did not receive a returned call. Attempted telephone interview with the Assistant Director of Nursing (ADON), on 06/24/19 at 6:53 PM, revealed surveyor left a voice mail message to return call; however, the surveyor did not receive a returned call. 7. Interview with the RDO, on 06/23/19 at 3:35 PM, revealed she trained the Administrator on Abuse, via email, by emailing her the abuse policy to read. The RDO stated she later sent the Administrator a questionnaire related to the abuse policy that the Administrator completed and returned to her. Interview with the Administrator, on 06/24/19 at 7:17 PM, revealed the RDO trained her on the facility's abuse policy. The Administrator stated she also received abuse training from the Director of Education at Regional Office Quarterly Meeting conduct on 05/11/19. Review of the RDO's email correspondence to all administrators in the region, dated sent on 06/14/19 at 9:25 PM, revealed she sent an email telling the administrators that surveyors were verifying facility investigations began immediately and that they were thorough. She attached the Abuse Policy, Incident Report Form, and an Example of Investigation Summary for them to refer to when completing abuse investigations. 8. Review of the facility's Social Services Behavior Assessment forms for Resident #11, dated 03/26/19, 03/27/19, and 03/28/19, revealed the previous ADON assessed the resident's behavior on 03/26/19, as angry about money stolen; on 03/27/19, as tearful and stated found out his/her aunt was ill; and on 03/28/19 with no negative behaviors. Interview with the RDO, on 06/23/19 at 3:35 PM, revealed she interviewed Resident #11 on 05/10/19, and he/she displayed and voiced no concerns of fear or intimidation related to the incident that occurred on 03/26/19. Observation of Resident #11, on 06/22/19 at 4:30 PM, revealed the resident was in bed playing a video game. During interview, the resident smiled continuously even when questioned about the alleged incident of abuse. The resident did not appear intimidated, nor were there any visible bruises or injuries. Interview with Resident #11, on 06/22/19 at 4:30 PM, revealed he/she was originally upset regarding the incident, before the facility reimbursed the money. The resident stated the previous Administrator came and questioned him/her about the incident and how he/she felt about it, but since it was usually early in the morning when he/she did not talk much. 9. Interview with the RDO, on 06/23/19 at 3:35 PM, revealed she received abuse training from the Regional Director of Education/Nurse Consultant at Regional Office Quarterly Meeting conduct on 05/11/19. She said the training included receiving background and pre-employment reference checks, prior to staff starting their employment; conducting a thorough investigation; keeping resident(s) safe during the investigation; and reporting abuse investigations timely. Telephone interview with the Director of Education/Corporate Nurse Consultant Trainer, on 06/24/19 at 5:09 PM, revealed she explained the Abuse Policy to the attendees at the Regional Quarterly Meeting held on 05/11/19, and they completed competency questions on abuse to ensure they retained the information she taught. 10. Attempted telephone interview with the previous Maintenance Director, on 06/22/19 at 10:00 AM, revealed surveyor left a voice mail message for him to return call; however, he never returned surveyor's call. Interview with the Environmental Services Director, on 06/24/19 at 4:48 PM, revealed she assisted the previous Maintenance Director with changing the door entry/exit codes shortly after the annual survey. She said she assisted him by reading the on-line directions while he physically changed the codes. She stated the previous Director of Nursing trained her on abuse on 05/11/19. 11. Attempted telephone interview, on 06/24/19 at 6:27 PM, with the previous Payroll Employee was made, however, no one answered and a voice mail message was left to return call. Attempted telephone interview, on 06/24/19 at 6:37 PM, with the Regional Director of Human Resources was made, however, no one answered and a voice mail message was left to return call. 12. Attempted telephone interview, on 06/24/19 at 6:27 PM, with the previous Payroll Employee was made; however, no one answered and a voice mail message was left to return call. Attempted telephone interview, on 06/24/19 at 6:37 PM, with the Regional Director of Human Resources was made; however, no one answered and a voice mail message was left to return call. Review of the facility's Employee Tracking Audit Tool, not dated, revealed the facility-tracked employees' certification/license, criminal history, references, TB assessments, and abuse registry checks upon hire and annually thereafter. Review of seven (7) sampled employee files, on 06/21/19 at 10:00 AM, revealed the facility employee files contained certification/license, criminal history, references, TB assessments, and abuse registry checks. Interview with the Business Office Manager, on 06/24/19 at 6:00 PM, revealed she began employment with the facility on 11/28/18, and started completing pre-employment checks. She stated she was trained by the RDO to complete reference, criminal background, licensee/certification, abuse registry, and Office of Inspector General checks on all potential employees before allowing them to work in the facility. Interview with the Administrator, on 06/24/19 at 7:17 PM, revealed she audited all new hire employee files to ensure reference, abuse registry, licensure/certification and other mandated pre-employment requirements were met. In addition, she directed the DON to verify all employee TB assessments were completed. 13. Interview with the Administrator, on 06/24/19 at 7:17 PM, revealed she was trained by the RDO on abuse reporting and auditing all new hire employee files to ensure reference, abuse registry, licensure/certification and other mandated pre-employment requirements were met. 14. Review of the facility's Resident Interview forms, not dated, revealed the SSD conducted resident interview questionnaires 05/28/19 through 06/06/19, related to how they felt about their treatment, services, and safety at the facility. The forms noted the residents replied they felt safe in the facility. Interview with Social Services Director, on 06/23/19 at 11:40 PM, revealed she interviewed residents and documented the interviews on a Resident Interview form on 05/28/19 through 06/06/19. She stated the residents voiced no concerns related to staff treatment or their overall safety at the facility. Interviews with Resident #35 at 8:10 AM, Unsampled Resident A at 8:15 AM, and Unsampled Resident B at 8:22 AM, on 06/21/19, revealed they felt safe at the facility and had no concerns related to abuse. The residents stated if they felt someone treated them badly they would report it immediately to the nurse on duty or the Administrator. 15. Immediately after the door codes were changed, the Administrator and the Maintenance Director would round to confirm changes of codes were effective. The Maintenance Director documented door code changes on a Door Code Tracking Tool to ensure no prior codes were duplicated. Review of an In-Service Record, dated 06/22/19, revealed the Administrator trained the Maintenance Director on how to re-code door key locks. The training included information from Secure Care Advantage 1000, [NAME] Simplex 1000 Series, and Door Guard IEI. Interview with the Maintenance Director, on 06/24/19 at 3:54 PM, revealed the Administrator/DON/ADON would notify him if they terminated and/or suspended an employee and he would change the door entry/exit codes within two hours of notification. He said they developed a log to track all door code changes and the logs would be housed at each nursing station and in his office. According to the Maintenance Director, the log would be reviewed at QAPI. The Maintenance Director further stated on 06/22/19, he changed all door entry/exit codes and logged them in on the tracking sheet, per the Administrator. The Maintenance Director stated the Administrator trained him on how to change the entry/exit door codes for three (3) door locks and he read the facility's security manual, which also gave direction on entry/exit door codes. Interview with the Admissions Director, Business Office Manager, Dietary Services Director, and Activities Director, on 06/24/19 at 6:00 PM, revealed the Administrator trained them to immediately remove the alleged perpetrator from the facility premises. They stated if the alleged perpetrator threatened to harm anyone, they were supposed to notify local law enforcement to keep them from returning to the facility. They said they were also trained to notify the Maintenance Director immediately and place a staff member in the hall to monitor the doors until the MD changed the door entry/exit codes. Interview with the Administrator, on 06/24/19 at 7:17 PM, revealed when the facility terminated an employee the Maintenance Director would change all the facility's entry/exit codes within two (2) hours and track the code changes on a log. Per the Administrator, after the codes were changed, she and the Maintenance Director would round on all doors to ensure codes were working, as a second validation with their signatures after completed. They would keep a copy of all code changes in their Emergency Management Procedure book housed at each nursing station accessible to staff at all times. Record Review of the facility's Door Code Change Tracking Log, not dated, revealed it contained Door Locations, Date and Time code changes were made, Prior Code and New Code, the Initials of the Individuals verifying code changes were made, and Reason codes were change. 16. Telephone interview with the Chief Operating Officer (COO), on 06/24/19 at 4:15 PM, revealed he scheduled quarterly meetings with all Administrators, DONs, RDOs, and other Regional team members and at the last meeting held on 05/01/19, they were in-serviced on Abuse by the [NAME] President of Clinical Services. The COO stated Abuse training would be an on-going topic at their quarterly meetings. Their next meeting was scheduled on 07/23/19. Telephone interview with the Corporate Director of Education/VP of Clinical Services, on 06/24/19 at 4:22 PM, revealed she attended the Regional Quarterly Meeting held on 05/11/19 and in-serviced Administrators, DONs, RDOs, and other Regional team members on Abuse. She stated they covered all protocols of abuse and they took abuse allegations extremely serious. She also stated they completed a role-play on abuse and mock surveys to ensure the different types of abuse were covered. According to the Corporate Director of Education/VP of Clinical Services, she audited the facility's abuse investigation files to ensure abuse policies and procedures, which included ensuring the alleged perpetrator was immediately removed from the building. Telephone interview with the Director of Education/Corporate Trainer, on 06/24/19 at 5:09 PM, revealed she explained the Abuse Policy to the attendees at the Regional Quarterly Meeting held on 05/11/19, and they completed competency questions on abuse to ensure they retained the information she taught. In addition, she stated they reviewed all state survey results at the meetings for quality assurance purposes and gave direction as needed. 17. Interviews with several CNAs, LPNs, Housekeeping staff, Environmental staff, and Dietary Staff during the survey, on 06/20/19 through 06/24/19, revealed the Administrator and DON re-educated them to the facility's Abuse Policy, since their annual survey was completed. Staff stated they signed the Abuse Program Acknowledgement form and completed post-tests ensuring they comprehended the policy. Interviews with Staff hired after 05/01/19, confirmed they were educated on the facility's Abuse Policy. Interview with the Administrator, on 06/24/19 at 7:17 PM, revealed she rounded the facility and questioned staff on the abuse policy ensuring they comprehended the Abuse Policy by knowing the types of abuse and abuse reporting requirements that included knowing their chain of command. 18. Interview with the RDO, on 06/23/19 at 3:35 PM, revealed she continued to monitor the Administrator's understanding of the abuse investigation process. The RDO stated she gave the Administrator scenarios of abuse reporting and the Administrator demonstrated what actions she would take throughout her investigation of the abuse allegations. She also stated the Administrator comprehended the trainings she received on including pre-employment checks. Interview with the Administrator, on 06/24/19 at 7:17 PM, revealed the RDO monthly audited the facility's abuse investigative files to ensure she conducted a complete and thorough investigation, placed appropriate interventions, and took appropriate actions throughout the investigative process. 19. Interview with the RDO, on 06/23/19 at 3:35 PM, revealed she continued to audit and monitor all initial and final self-reported abuse incidents to ensure all were reported timely, resident safety was established immediately, the investigation was started immediately and thorough. 20. Telephone interview with the Corporate Director of Education/VP of Clinical Services, on 06/24/19 at 4:22 PM, revealed she reviewed and would continue review for three months, all the Administrator's investigative files to ensure the Administrator followed the Abuse policies and procedures when concluding the investigation. The Corporate Director of Education/VP of Clinical Services stated on 05/11/19, they received abuse training at the Regional Meeting. 21. Interview with the Medical Director, on 06/24/19 at 5:25 PM, revealed the Administrator had called him to discuss the notification of immediate jeopardy on 06/21/19. He stated they discussed corrective actions and how to ensure residents were protected from abuse. Interview with the Administrator, on 06/24/19 at 7:17 PM, revealed she informed the Medical Director that all abuse deficiencies were elevated to immediate jeopardy on 06/21/19. During the meeting the Medical Director suggested the cameras outside the facility be fixed and to place monitors at each nursing station. She stated she contacted a company to come give the facility an estimate. 22. Review of the facility's QAPI Committee Meeting Minutes' Agenda and Sign-In Signature Sheet, dated 05/21/19, revealed QAPI Committee met to discuss their annual survey results. Review of the facility's AdHoc Quality Assurance Meeting's Agenda and Sign-In Signature Sheet, dated 06/22/19, revealed QAPI Committee met to discuss the identified concern regarding door codes were changed back to previous code changes. Interview with the Administrator, on 06/24/19 at 7:17 PM, revealed the QAPI Committee consisted of the Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), Social Services Director (SSD), Activity Director, Dietary Manager (DM), Maintenance Director, Environmental Services Director (ESD), Business Office Manager (BOM), admission Director and Medical Director. She stated the audit and monitoring results would be taken to the QAPI committee for review and if any patterns were identified an action plan would be developed and implemented to ensure issues were resolved. Interview with the Maintenance Director, on 06/24/19 at 3:54 PM, revealed he would attend the QAPI committee to discuss his door code changing log and other audits as required. Interview with the Admissions Director, Business Office Manager, Dietary Services Director, and Activities Director, on 06/24/19 at 6:00 PM, revealed they attended facility QAPI meetings and would review audits and monitoring to determine patterns in need of corrective action plans. Review of the Facility's policy titled Abuse Prevention Program, not dated, revealed the policy address the following components of abuse: Pre-employment Screening of Potential Employees, Orientation and Training of Employees, Identifying Abuse, Reporting Suspect/Alleged Abuse, Protecting Residents by s[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility implemented the following actions to remove Immediate Jeopardy: 1. On 03/26/19 at approximately 9:45 PM, a law enforcement officer escorted Certified Nursing Assistant (CNA) #13 out of the building and off the property. 2. On 03/26/19, the Administrator informed staff to immediately contact the police if CNA #13 attempted to re-enter again, after CNA #13 had re-entered the facility to retrieve alleged belongings and left. 3. On 03/26/19, Administrator suspended CNA #13, pending investigation, and then subsequently terminated her position on 04/02/19. 4. On 03/27/19, the Regional Director of Operations (RDO) interviewed Resident #52 related to possible safety concerns when CNA #13 returned to the facility and entered the resident's room to retrieve personal belongings, after local law enforcement had escorted her out of the facility on 03/26/19. 5. On 03/28/19, the Administrator, at the time of the incident that occurred on 03/26/19, ended their employment with the facility. 6. On 03/27/19 to 03/28/19, the Assistant Director of Nursing (ADON) and Interim Director of Nursing (IDON) conducted an in-service on the facility's Abuse Policy to the staff. Staff signed an Abuse Program Acknowledgment form verifying eighty-eight (88) staff members received training on abuse. The facility assured all newly hired staff would be educated on their Abuse Policy before they were permitted to work in the facility. 7. On 04/15/19, via email, the RDO educated the Administrator on the Abuse Prevention Policy including reporting of abuse, types of abuse, abuse prevention, investigation, and immediate intervention to ensure resident(s) safety upon hire. 8. On 05/10/19, the RDO interviewed Resident #11, to determine his/her mindset (related to fear, intimidation, or abuse) after the abuse incident that occurred on 03/26/19. 9. On 05/11/19, the RDO was educated by the Regional Nurse Consultant on the Abuse Prevention policy; including receiving background and pre-employment reference checks prior to staff starting their employment, conducting a thorough investigation, keeping resident(s) safe during the investigation, and timely reporting. 10. On 05/11/19, the Maintenance Director and Environmental Services Director changed the code on the entry/exit doors to decrease the risk of CNA #13 from entering the building during after hours in the future. 11. On 05/13/19, the Regional Director of Human Resources educated the Payroll Coordinator, per job description, related to facility's policy on pre-employment screenings. 12. From 05/13/19 to 05/14/19, the Payroll Coordinator with the assistance of the RDHR conducted a one hundred percent (100%) audit of Employee files. The audits included checking criminal backgrounds, references, abuse registry, and licensure and/or certification validations. 13. On 05/16/19, the RDO educated the Administrator on the timely reporting of abuse, investigation of abuse allegations, receiving background checks and conducting re-employment reference checks prior to employing staff. 14. From 05/28/19 to 06/06/19, the Social Service Director (SSD) conducted interviews with ten (10) residents regarding their overall satisfaction with facility services and whether they had any issues or concerns that needed addressing. 15. On 06/22/19, the Administrator educated the Maintenance Director on how to change the entry/exit door codes for three (3) door locks. The entry/exit codes would be changed when the Administrator notified the Maintenance Director that an employee was suspended related to abuse and/or neglect. According to the new procedure implemented by the facility on 06/22/19, the Administrator notified the Maintenance Director that the facility suspended an employee to decrease the risk of the suspended employee returning to the facility. The facility would notify the Maintenance Director ASAP, assign a staff person to the hallway to monitor exit doors until the codes were changed, and the Maintenance Director would change all entry/exit codes within two (2) hours of notification, which would ensure the overall safety and security of residents. 16. On 05/01/19, at the Quarterly scheduled meeting, the [NAME] President of Clinical Services, Chief Operating Officer, facilitated Abuse Training along with the Corporate Director of Education. The Chief Operating Officer scheduled Quarterly Meetings with all Administrators, Directors of Nursing, Regional Director of Operations and other Regional team members. In addition, Abuse Training would be conducted at each Quarterly Regional Meeting, on an on-going basis. 17. The Administrator and/or Designee would monitor staff understanding of the education by conducting staff interviews three (3) times a week for four (4) weeks regarding Abuse Prevention Program and monthly for three (3) months. The Administrator would add to the monthly in-service the Abuse Prevention education with questions and answer session to validate understanding; then on an on-going basis a segment of the Abuse Program would remain on the monthly in-service calendar. 18. The RDO would monitor the Administrator's understanding of the education by reviewing with the Administrator the initial report of an allegation of abuse to ensure a thorough investigation was conducted. Then would stay in contact with the Administrator throughout the investigation. The RDO would review the final report to ensure the investigation was complete and all aspects of the Abuse policy was followed; to include timely reporting, resident safety was ensured during the investigation, all interviews conducted, interventions were taken, and any other issues of abuse and/or neglect identified to ensure appropriate actions were taken and a thorough investigation completed. 19. The RDO and/or the Regional Nurse Consultant (RNC), on an ongoing basis would review all initial and final self-reported abuse incidents to ensure all were reported timely, resident safety was established immediately, the investigation was started immediately and conducted thoroughly. In addition, newly reported allegations discovered during the investigation was reported. 20. The [NAME] President of Clinical Services (VPCS) would review the investigative files and the recommended outcome made by the new Administrator and the RDO related to the self-reported incidences for three (3) months to ensure the Abuse policies and procedures were followed. 21. On 06/21/19, the Administrator reviewed with the Medical Director the change in scope and severity as it related to the immediate jeopardy tags. In addition, discussed actions to correct identified concerns. The Medical Director identified and directed the Maintenance Director and Administrator to fix surveillance cameras outside the facility's building and place monitors at each nursing station. 22. The outcome of the monitoring of the education would be reported to the Quality Assurance Process Improvement Committee (QAPI). If any patterns were identified an action plan would be written by the committee; this action plan would be monitored weekly by the Administrator until resolved. The QAPI Committee consisted of the Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), Social Services Director (SSD), Activity Director, Dietary Manager (DM), Maintenance Director, Environmental Services Director (ESD), Business Office Manager (BOM), admission Director and Medical Director. The State Agency Validated the removal immediate jeopardy prior to exit on 06/24/19 as follows: 1. Review of the Law Enforcement Incident/Investigation Report, with a print date of 06/21/19, revealed on 03/26/19 at approximately 9:42 PM, a law enforcement officer came to the facility to investigate the incident of possible charges of Theft by Unlawful Taking Over $500 of Resident #11's missing monies. Record review of the facility Self Reportable Investigation Summary, not dated, revealed Licensed Practical Nurse (LPN) #8 immediately went to Resident #11's room upon hearing yelling, and removed CNA #13 from the room, the police entered the building and escorted the CNA off the property. Review of CNA #13's written statement, dated 03/27/19, revealed the police transported him/her to a gas station and left him/her there around 11:00 PM on 03/26/19. Interview on 6/23/19 at 10:45 AM, with the current Administrator, revealed staff informed her and per her review of the facility investigation a police officer with the badge number 6163 escorted CNA #13 out of the building on 03/26/19 around 9:45 PM. 2. Attempted telephone interview with the previous Administrator, on 06/20/19 at 4:00 PM, 06/23/19 at 11:00 AM, and 06/24/19 at 4:30 PM, revealed surveyor left a voice mail message to return call; however, the previous Administrator did not return the surveyor's call. Interview with Licensed Practical Nurse (LPN) #7, on 06/23/19 at 1:45 PM, revealed after CNA #13 returned and entered the building, on 03/26/19, staff were instructed not to let her back in the building to ensure resident safety. 3. Review of the facility's Personnel Change Form, dated 03/28/19, revealed CNA #13 was terminated on 04/02/19. Interview with Resident #11, on 06/22/19 at 4:30 PM, revealed he/she had not seen CNA #13 since the day of the incident. 4. Review of Resident #52's clinical record revealed the facility assessed the resident with a score of fifteen (15) on the Brief Interview of Mental Status (BIMS), on 02/09/19, indicating the resident was cognitively intact. Interview with the RDO, on 06/23/19 at 3:35 PM, revealed she interviewed Resident #52 on 03/26/19, and the resident voiced no safety concerns with facility staff. 5. Review of the facility's Personnel Change Form for the Administrator at the time of the incident, dated effective 03/28/19, revealed Administrator voluntarily surrender the Administrator position on 03/28/19. Attempted telephone interview with the previous Administrator, on 06/20/19 at 4:00 PM, 06/23/19 at 11:00 AM, and 06/24/19 at 4:30 PM, revealed surveyor left a voice mail message to return call; however, the previous Administrator did not return the surveyor's call. Interview with the current Administrator of the facility, on 06/23/19 at 10:30 AM, revealed the former Administrator ended their employment on 03/28/19. 6. Review of the facility's in-service training on Teaching Moment Regarding Abuse and Misappropriation, dated 03/27/19 and 03/28/19, revealed eighty-eight (88) staff members received training and signed an Abuse Program Acknowledgment form. Review of the facility's in-service training on Teaching Moment Regarding Abuse and Misappropriation, dated 04/01/19 through 06/20/19, revealed twenty-two (22) newly hired staff members received training and signed an Abuse Program Acknowledgment form. Interview with Certified Nursing Assistant (CNA) #14, on 06/23/19 at 12:00 PM, revealed she was educated on abuse types, when and to whom to report an abuse allegation. CNA #14 stated after staff were suspended they were not allowed back in the building and the codes to the doors were changed. Interview with CNA #15, on 06/23/19 at 12:15 PM, revealed the facility had recently re-educated her on the types of abuse and her responsibility to report immediately if witnessed. She stated if an employee was suspended, staff should not allow them back into the building and the door codes would be changed by Maintenance. Interview with CNA #16, on 06/23/19 at 12:30 PM, revealed she was knowledgeable of the types of abuse She stated if witnessed she would report to her supervisor immediately. CNA #16 stated the facility recently re-educated her on the abuse policy and if an abuse allegation was made against a staff member, they were suspended pending investigation and were not allowed back into the building. In addition, the management team would obtain statements from staff and then Maintenance would change the door codes to ensure resident safety. Interview with Housekeeper #1 and #2, on 06/23/19 at 12:45 PM, revealed the facility recently re-educated them on the abuse policy. They stated they would report abuse if witnessed or if an allegation of abuse was reported to them. Each stated if an allegation of abuse was made the employee would be suspended and not allowed back into the building until the investigation was completed. Also that the door codes would be changed to ensure resident safety. Interview with Dietary Staff #1, on 06/23/19 at 12:50 PM, revealed the facility recently trained her on abuse, required her to take a test and sign an acknowledgment form that she understood the abuse policy and facility expectations. She also stated if an employee was suspended, they were not allowed back in the building and the door codes were changed. Interview with CNA #12, on 06/23/19 at 12:55 PM, revealed the facility recently provided training on the abuse policy, that she had to take a test and sign an acknowledgement statement saying she understood the policy. She stated the facility had a strict abuse policy and, if suspended, staff were not allowed back in the building, while the investigation was on going. CNA #12 stated the Administrator would have the Maintenance Director change the door lock codes to ensure resident safety and prevent the suspended employee from gaining entry into the facility by using the code. Interview with CNA # 17, on 06/23/19 at 1:10 PM, revealed if a staff member threatened a resident, staff would protect the resident and report the incident immediately. In addition, a suspended staff member was not allowed back in the building. CNA #17 stated the facility trained her recently on the abuse policy. She stated she had to sign an acknowledgement sheet and take a test to ensure she understood the policy. Interview with LPN #1, on 06/23/19 at 1:38 PM, revealed the facility required he re-read the abuse policy, take a test and sign an acknowledgement statement that he understood his responsibility. He stated if he received a report of abuse, he would immediately protect the resident by removing the employee from the building. LPN #1 stated he would then report the incident to the Administrator and other appropriate authorities if needed. In addition, the staff would monitor doors until the Maintenance Director could change the code on the locks to ensure resident safety. Interview with Licensed Practical Nurse (LPN) #7, on 06/23/19 at 1:45 PM, revealed she had recent training on the abuse policy. She stated she was responsible for reporting allegations of abuse, keeping the resident safe, removing the alleged perpetrator form the building and not allowing them back in. LPN #7 stated after suspending the alleged perpetrator the doors would be monitored by assigned staff, until the Maintenance Director could change the door codes to ensure resident safety. Interview with LPN #4, on 06/23/19 at 1:50 PM, revealed it was her responsibility to report and protect residents from all types of abuse. She stated all staff recently were required to attend abuse training after the incident with Resident #11. LPN #4 stated she would call the Administrator immediately after an allegation of any type of abuse. She would remove the employee and not allow them back in the building. She stated until the door codes were changed she would assign staff to monitor all exit doors. Interview with the Environmental Services Director, on 06/24/19 at 4:48 PM, revealed the previous DON trained her on abuse, reporting abuse, and residents' safety after the annual survey. Attempted telephone interview the Interim Director of Nursing (IDON), on 06/24/19 at 5:00 PM, revealed surveyor left a voice mail message to return call, however, no one answered and a voice mail message was left to return call. However, the surveyor did not receive a returned call. Attempted telephone interview with the Assistant Director of Nursing (ADON), on 06/24/19 at 6:53 PM, revealed surveyor left a voice mail message to return call; however, the surveyor did not receive a returned call. 7. Interview with the RDO, on 06/23/19 at 3:35 PM, revealed she trained the Administrator on Abuse, via email, by emailing her the abuse policy to read. The RDO stated she later sent the Administrator a questionnaire related to the abuse policy that the Administrator completed and returned to her. Interview with the Administrator, on 06/24/19 at 7:17 PM, revealed the RDO trained her on the facility's abuse policy. The Administrator stated she also received abuse training from the Director of Education at Regional Office Quarterly Meeting conduct on 05/11/19. Review of the RDO's email correspondence to all administrators in the region, dated sent on 06/14/19 at 9:25 PM, revealed she sent an email telling the administrators that surveyors were verifying facility investigations began immediately and that they were thorough. She attached the Abuse Policy, Incident Report Form, and an Example of Investigation Summary for them to refer to when completing abuse investigations. 8. Review of the facility's Social Services Behavior Assessment forms for Resident #11, dated 03/26/19, 03/27/19, and 03/28/19, revealed the previous ADON assessed the resident's behavior on 03/26/19, as angry about money stolen; on 03/27/19, as tearful and stated found out his/her aunt was ill; and on 03/28/19 with no negative behaviors. Interview with the RDO, on 06/23/19 at 3:35 PM, revealed she interviewed Resident #11 on 05/10/19, and he/she displayed and voiced no concerns of fear or intimidation related to the incident that occurred on 03/26/19. Observation of Resident #11, on 06/22/19 at 4:30 PM, revealed the resident was in bed playing a video game. During interview, the resident smiled continuously even when questioned about the alleged incident of abuse. The resident did not appear intimidated, nor were there any visible bruises or injuries. Interview with Resident #11, on 06/22/19 at 4:30 PM, revealed he/she was originally upset regarding the incident, before the facility reimbursed the money. The resident stated the previous Administrator came and questioned him/her about the incident and how he/she felt about it, but since it was usually early in the morning when he/she did not talk much. 9. Interview with the RDO, on 06/23/19 at 3:35 PM, revealed she received abuse training from the Regional Director of Education/Nurse Consultant at Regional Office Quarterly Meeting conduct on 05/11/19. She said the training included receiving background and pre-employment reference checks, prior to staff starting their employment; conducting a thorough investigation; keeping resident(s) safe during the investigation; and reporting abuse investigations timely. Telephone interview with the Director of Education/Corporate Nurse Consultant Trainer, on 06/24/19 at 5:09 PM, revealed she explained the Abuse Policy to the attendees at the Regional Quarterly Meeting held on 05/11/19, and they completed competency questions on abuse to ensure they retained the information she taught. 10. Attempted telephone interview with the previous Maintenance Director, on 06/22/19 at 10:00 AM, revealed surveyor left a voice mail message for him to return call; however, he never returned surveyor's call. Interview with the Environmental Services Director, on 06/24/19 at 4:48 PM, revealed she assisted the previous Maintenance Director with changing the door entry/exit codes shortly after the annual survey. She said she assisted him by reading the on-line directions while he physically changed the codes. She stated the previous Director of Nursing trained her on abuse on 05/11/19. 11. Attempted telephone interview, on 06/24/19 at 6:27 PM, with the previous Payroll Employee was made, however, no one answered and a voice mail message was left to return call. Attempted telephone interview, on 06/24/19 at 6:37 PM, with the Regional Director of Human Resources was made, however, no one answered and a voice mail message was left to return call. 12. Attempted telephone interview, on 06/24/19 at 6:27 PM, with the previous Payroll Employee was made; however, no one answered and a voice mail message was left to return call. Attempted telephone interview, on 06/24/19 at 6:37 PM, with the Regional Director of Human Resources was made; however, no one answered and a voice mail message was left to return call. Review of the facility's Employee Tracking Audit Tool, not dated, revealed the facility-tracked employees' certification/license, criminal history, references, TB assessments, and abuse registry checks upon hire and annually thereafter. Review of seven (7) sampled employee files, on 06/21/19 at 10:00 AM, revealed the facility employee files contained certification/license, criminal history, references, TB assessments, and abuse registry checks. Interview with the Business Office Manager, on 06/24/19 at 6:00 PM, revealed she began employment with the facility on 11/28/18, and started completing pre-employment checks. She stated she was trained by the RDO to complete reference, criminal background, licensee/certification, abuse registry, and Office of Inspector General checks on all potential employees before allowing them to work in the facility. Interview with the Administrator, on 06/24/19 at 7:17 PM, revealed she audited all new hire employee files to ensure reference, abuse registry, licensure/certification and other mandated pre-employment requirements were met. In addition, she directed the DON to verify all employee TB assessments were completed. 13. Interview with the Administrator, on 06/24/19 at 7:17 PM, revealed she was trained by the RDO on abuse reporting and auditing all new hire employee files to ensure reference, abuse registry, licensure/certification and other mandated pre-employment requirements were met. 14. Review of the facility's Resident Interview forms, not dated, revealed the SSD conducted resident interview questionnaires 05/28/19 through 06/06/19, related to how they felt about their treatment, services, and safety at the facility. The forms noted the residents replied they felt safe in the facility. Interview with Social Services Director, on 06/23/19 at 11:40 PM, revealed she interviewed residents and documented the interviews on a Resident Interview form on 05/28/19 through 06/06/19. She stated the residents voiced no concerns related to staff treatment or their overall safety at the facility. Interviews with Resident #35 at 8:10 AM, Unsampled Resident A at 8:15 AM, and Unsampled Resident B at 8:22 AM, on 06/21/19, revealed they felt safe at the facility and had no concerns related to abuse. The residents stated if they felt someone treated them badly they would report it immediately to the nurse on duty or the Administrator. 15. Immediately after the door codes were changed, the Administrator and the Maintenance Director would round to confirm changes of codes were effective. The Maintenance Director documented door code changes on a Door Code Tracking Tool to ensure no prior codes were duplicated. Review of an In-Service Record, dated 06/22/19, revealed the Administrator trained the Maintenance Director on how to re-code door key locks. The training included information from Secure Care Advantage 1000, [NAME] Simplex 1000 Series, and Door Guard IEI. Interview with the Maintenance Director, on 06/24/19 at 3:54 PM, revealed the Administrator/DON/ADON would notify him if they terminated and/or suspended an employee and he would change the door entry/exit codes within two hours of notification. He said they developed a log to track all door code changes and the logs would be housed at each nursing station and in his office. According to the Maintenance Director, the log would be reviewed at QAPI. The Maintenance Director further stated on 06/22/19, he changed all door entry/exit codes and logged them in on the tracking sheet, per the Administrator. The Maintenance Director stated the Administrator trained him on how to change the entry/exit door codes for three (3) door locks and he read the facility's security manual, which also gave direction on entry/exit door codes. Interview with the Admissions Director, Business Office Manager, Dietary Services Director, and Activities Director, on 06/24/19 at 6:00 PM, revealed the Administrator trained them to immediately remove the alleged perpetrator from the facility premises. They stated if the alleged perpetrator threatened to harm anyone, they were supposed to notify local law enforcement to keep them from returning to the facility. They said they were also trained to notify the Maintenance Director immediately and place a staff member in the hall to monitor the doors until the MD changed the door entry/exit codes. Interview with the Administrator, on 06/24/19 at 7:17 PM, revealed when the facility terminated an employee the Maintenance Director would change all the facility's entry/exit codes within two (2) hours and track the code changes on a log. Per the Administrator, after the codes were changed, she and the Maintenance Director would round on all doors to ensure codes were working, as a second validation with their signatures after completed. They would keep a copy of all code changes in their Emergency Management Procedure book housed at each nursing station accessible to staff at all times. Record Review of the facility's Door Code Change Tracking Log, not dated, revealed it contained Door Locations, Date and Time code changes were made, Prior Code and New Code, the Initials of the Individuals verifying code changes were made, and Reason codes were change. 16. Telephone interview with the Chief Operating Officer (COO), on 06/24/19 at 4:15 PM, revealed he scheduled quarterly meetings with all Administrators, DONs, RDOs, and other Regional team members and at the last meeting held on 05/01/19, they were in-serviced on Abuse by the [NAME] President of Clinical Services. The COO stated Abuse training would be an on-going topic at their quarterly meetings. Their next meeting was scheduled on 07/23/19. Telephone interview with the Corporate Director of Education/VP of Clinical Services, on 06/24/19 at 4:22 PM, revealed she attended the Regional Quarterly Meeting held on 05/11/19 and in-serviced Administrators, DONs, RDOs, and other Regional team members on Abuse. She stated they covered all protocols of abuse and they took abuse allegations extremely serious. She also stated they completed a role-play on abuse and mock surveys to ensure the different types of abuse were covered. According to the Corporate Director of Education/VP of Clinical Services, she audited the facility's abuse investigation files to ensure abuse policies and procedures, which included ensuring the alleged perpetrator was immediately removed from the building. Telephone interview with the Director of Education/Corporate Trainer, on 06/24/19 at 5:09 PM, revealed she explained the Abuse Policy to the attendees at the Regional Quarterly Meeting held on 05/11/19, and they completed competency questions on abuse to ensure they retained the information she taught. In addition, she stated they reviewed all state survey results at the meetings for quality assurance purposes and gave direction as needed. 17. Interviews with several CNAs, LPNs, Housekeeping staff, Environmental staff, and Dietary Staff during the survey, on 06/20/19 through 06/24/19, revealed the Administrator and DON re-educated them to the facility's Abuse Policy, since their annual survey was completed. Staff stated they signed the Abuse Program Acknowledgement form and completed post-tests ensuring they comprehended the policy. Interviews with Staff hired after 05/01/19, confirmed they were educated on the facility's Abuse Policy. Interview with the Administrator, on 06/24/19 at 7:17 PM, revealed she rounded the facility and questioned staff on the abuse policy ensuring they comprehended the Abuse Policy by knowing the types of abuse and abuse reporting requirements that included knowing their chain of command. 18. Interview with the RDO, on 06/23/19 at 3:35 PM, revealed she continued to monitor the Administrator's understanding of the abuse investigation process. The RDO stated she gave the Administrator scenarios of abuse reporting and the Administrator demonstrated what actions she would take throughout her investigation of the abuse allegations. She also stated the Administrator comprehended the trainings she received on including pre-employment checks. Interview with the Administrator, on 06/24/19 at 7:17 PM, revealed the RDO monthly audited the facility's abuse investigative files to ensure she conducted a complete and thorough investigation, placed appropriate interventions, and took appropriate actions throughout the investigative process. 19. Interview with the RDO, on 06/23/19 at 3:35 PM, revealed she continued to audit and monitor all initial and final self-reported abuse incidents to ensure all were reported timely, resident safety was established immediately, the investigation was started immediately and thorough. 20. Telephone interview with the Corporate Director of Education/VP of Clinical Services, on 06/24/19 at 4:22 PM, revealed she reviewed and would continue review for three months, all the Administrator's investigative files to ensure the Administrator followed the Abuse policies and procedures when concluding the investigation. The Corporate Director of Education/VP of Clinical Services stated on 05/11/19, they received abuse training at the Regional Meeting. 21. Interview with the Medical Director, on 06/24/19 at 5:25 PM, revealed the Administrator had called him to discuss the notification of immediate jeopardy on 06/21/19. He stated they discussed corrective actions and how to ensure residents were protected from abuse. Interview with the Administrator, on 06/24/19 at 7:17 PM, revealed she informed the Medical Director that all abuse deficiencies were elevated to immediate jeopardy on 06/21/19. During the meeting the Medical Director suggested the cameras outside the facility be fixed and to place monitors at each nursing station. She stated she contacted a company to come give the facility an estimate. 22. Review of the facility's QAPI Committee Meeting Minutes' Agenda and Sign-In Signature Sheet, dated 05/21/19, revealed QAPI Committee met to discuss their annual survey results. Review of the facility's AdHoc Quality Assurance Meeting's Agenda and Sign-In Signature Sheet, dated 06/22/19, revealed QAPI Committee met to discuss the identified concern regarding door codes were changed back to previous code changes. Interview with the Administrator, on 06/24/19 at 7:17 PM, revealed the QAPI Committee consisted of the Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), Social Services Director (SSD), Activity Director, Dietary Manager (DM), Maintenance Director, Environmental Services Director (ESD), Business Office Manager (BOM), admission Director and Medical Director. She stated the audit and monitoring results would be taken to the QAPI committee for review and if any patterns were identified an action plan would be developed and implemented to ensure issues were resolved. Interview with the Maintenance Director, on 06/24/19 at 3:54 PM, revealed he would attend the QAPI committee to discuss his door code changing log and other audits as required. Interview with the Admissions Director, Business Office Manager, Dietary Services Director, and Activities Director, on 06/24/19 at 6:00 PM, revealed they attended facility QAPI meetings and would review audits and monitoring to determine patterns in need of corrective action plans. Review of the Facility's policy titled Abuse Prevention Program, not dated, revealed the policy address the following components of abuse: Pre-employment Screening of Potential Employees, Orientation and Training of Employees, Identifying Abuse, Reporting Suspect/Alleged Abuse, Protecting Residents by sep[TRUNCATED]