**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one resident received adequate supervision and interventions to ensure their safety. Resident #131 admitted on [DATE] from the hospital with altered mental status suspecting underlying dementia with psych issue, and in need of a secure unit. On 4/11/25, the resident left through an alarmed exit door on the secured memory care unit. The alarm sounded on the exit door, however, staff did not visually verify the location of residents on the unit. On 4/19/25, Resident #131 smashed a window with a toilet tank lid, cried and said he/she wanted to leave and threatened to jump out the window. He/She was hospitalized for two days and returned on 4/21/25 with a diagnosis of severe urinary tract infection (UTI). When the resident returned, he/she was suppose to be on enhanced visual monitoring or 1:1 monitoring, neither of which were communicated to staff, and staff did not provide increased supervision. On 4/24/25 at approximately 5:45 P.M., staff noticed the resident missing after he/she was last seen at 5:00 P.M. Staff found the resident broke the window in his/her room and left the building. The resident was found approximately 1.6 miles away from the facility, down a high-traffic main road. Police brought the resident back approximately two hours after staff determined the resident was missing. Staff who were present at the time of the incident were unaware of the resident's prior elopement attempts. Observations showed the door alarms on the secured memory care unit failed to properly display which exit door was opened during a test of the alarm system on 5/22/2025. In addition, facility staff failed to implement care-planned interventions for two residents identified as high fall risk (Residents #15 and #67) and failed to use a gait belt during an assisted transfer for one resident (Resident #76). The sample was 19. The census was 74. The Administrator was notified on 5/22/25 at 12:47 P.M., of an immediate jeopardy (IJ) which began on 4/21/25. The IJ was removed on 5/23/25, as confirmed by surveyor onsite verification. Review of the facility's Wandering & Elopement policy, revised 10/24/22, showed: -Purpose: To enhance the safety of residents of the facility; -Policy: The facility will identify residents at risk for elopement and minimize any possible injury as a result of elopement; -Procedures included: -The resident's risk for elopement and preventative interventions will be documented in the resident's medical record, and will be reviewed and re-evaluated by the interdisciplinary team (IDT) upon admission, readmission, quarterly, and upon change in condition according to the Resident Assessment Instrument (RAI) guidelines; -IDT may consider interventions listed in the Elopement Risk Reduction Approaches form for residents identified to be at risk for elopement; -Response to Resident Elopement: --The Licensed Nurse most familiar with the incident will document in the resident's medical record how the elopement occurred; -Return of Resident: --The Licensed Nurse will initiate or update the resident's Care Plan and implement immediate intervention(s) to prevent further wandering/elopement by the resident; --The IDT, with input from the Licensed Nurse, will conduct a thorough review of the elopement, document its findings in the IDT notes, and update the Care Plan to prevent a recurrence. Review of the facility's Fall Management Program policy, revised, 10/24/22, showed: -Purpose: to prevent resident falls and minimize complications associated with fall through the development of a fall management program; -Policy: The facility will provide the highest quality in the safest environment for the residents residing in the facility; The facility has developed a fall management program that strives to prevent resident falls through meaningful assessments, interventions, education and reevaluation; -Procedure: -Assessment: -The Licensed Nurse will assess each resident for their risk of falling upon admission, quarterly and with a significant change in condition; -Based on the information gathered from the history of the assessment of the resident, the nursing staff and IDT, with input from the attending physician, will identify and implement interventions to reduce the risk of falls; -Care Planning: -The nursing staff will develop a plan of care specific to the resident's needs with interventions to reduce the risk of falls; -Universal fall prevention measures for all residents: -Orient the resident to their environment; -Position, call bell, urinal if applicable, and bedside stand within reach; -Keep walkways obstruction and spill free; -Place bed in lowest position with brakes locked; -Residents should wear non-skid footwear whenever out of bed; -Assist residents with toileting as appropriate; -Encourage use of assistive devices as appropriate. Review of the facility's Gait Belt policy, revised, 10/24/22, showed: -Purpose: To provide assistance to clinical staff when moving a resident from one place to another and to increase the safety of resident by allowing clinical staff members to grip it and keep the resident from falling; -Policy: A gait belt may be used for residents who are too weak to walk or stand alone, or requires assistance. Review of the facility's Communication-Call System policy, revised 10/24/22, showed: -Purpose: To provide a mechanism for residents to promptly communicate with nursing staff; -Policy: The facility will provide a call system to enable residents to alert the nursing staff from their beds and toileting/bathing facilities; -Procedure: Call cords will be placed within the resident's reach in the resident's room. 1. Review of Resident #131's pre-admission documentation, effective 4/9/25, showed: -Communication to post-acute referral provider from hospital: --Resident admitted to hospital on [DATE] with complaints of motor vehicle accident. Resident with history of dementia (a general term for memory loss and decline in other cognitive abilities, severe enough to interfere with daily life). Found by police walking up and down the road with his/her car in the ditch. Resident has unstable gait. He/She does not know where he/she is, the time/year/month. He/She does not know his/her medications. He/She cannot remember what happened; -Diagnoses included bipolar disorder (a mental health condition characterized by extreme mood swings, ranging from periods of intense highs (mania) to periods of deep lows (depression)) and depressive disorder (characterized by persistent low mood and a loss of interest in activities); -Assessment and plan, dated 4/9/25, showed altered mental status suspecting underlying dementia with psych issue; -Referral message from hospital to facility showed resident is in need of a secure unit; -Referral message from facility to hospital showed resident looks appropriate for secured unit. Review of the resident's medical record, showed: -admitted [DATE] to room on the 500 hall, the facility's secured memory care unit; -Diagnoses included unspecified dementia with agitation, bipolar disorder, depression, cognitive communication deficit, difficulty walking, and unsteadiness on feet; -admission assessment, dated 4/11/25 at 10:23 A.M., showed resident alert, oriented to person and place. Behaviors: wandering. Review of the resident's Wandering Risk Assessment, dated 4/11/25 at 10:33 A.M., showed: -Has history of wandering; -Medical diagnosis of dementia/cognitive impairment; diagnosis impacting gait/mobility or strength; -Has wandered within the home without leaving grounds; -Has wandered in the past month; -High risk to wander. Review of resident's nursing note, dated 4/11/25 at 2:50 P.M., flagged as late entry, showed: -The resident was brought through front door by laundry attendant. Police officers were present. Nurse and attendant did not know who the resident was and were taking precautions by calling 911. Resident opened the side door setting off alarm on 500 hall exit. Maybe 20 minutes before when I heard the alarm, I came and turned it off. I did a walk down the hall and didn't see anything out of the norm and continued with med pass. Maybe 15 minutes later is when they walked through the door. I confirmed with the officers and nurse that he/she was with us and returned him/her to the hall. Resident was in a good mood, just a bit confused; -No documentation the writer of the nursing note completed a head count upon hearing the door alarm on the 500 hall; -No documentation the physician or Nurse Practitioner (NP) were notified of the resident's elopement from the facility. Review of the resident's care plan, in use at the time of survey, showed: -Focus: Resident is an elopement risk/wanderer; -Goal, initiated 4/11/25: Resident's safety will be maintained through the review date; -Interventions, initiated 4/11/25: Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Resident prefers (blank). Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures, and memory boxes. During an interview on 5/22/25 at 7:33 A.M., the Director of Nursing (DON) said when the door alarms sounded on the secure unit on 4/11/25, staff should have checked the door and then completed a head count. After the resident eloped from the secure unit on 4/11/25, he/she was placed on 15-minute checks for one day. Documentation of the 15-minute checks should be uploaded into the resident's medical record. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/16/25, showed: -Moderate hearing difficulty; -Short and long term memory problem; -Severe cognitive impairment; -Cognitive skills for daily decision making: Severely impaired. Review of the resident's NP note, dated 4/16/25, showed: -Resident pulled out his/her urinary catheter on 4/15/25, was sent to the hospital, and returned to the facility promptly with antibiotics prescribed for seven days; -Diagnoses included Alzheimer's disease (the most common cause of dementia, a progressive neurological disorder that leads to memory loss, thinking difficulties, and changes in behavior) with late onset; -No documentation related to the resident's elopement from the memory care unit on 4/11/25. Review of the resident's NP note, dated 4/18/25, showed resident seen for effectiveness of antibiotics. Currently on antibiotics for UTI. Resident pulled out catheter this morning. Plan is to continue antibiotics from 4/18/25 to 4/28/25. Review of the resident's Situation, Background, Assessment, Request (SBAR, communication tool) communication form and progress note, dated 4/19/25 at 7:20 P.M., documented by Licensed Practical Nurse (LPN) FF, showed: -Situation: Resident broke full window with toilet lid cover out of room on secure unit on 4/19/25. Since this started, it has become worse. Resident attempting jumps out broken window. Nothing could have been done to change resident due to high-risk, suicide. This condition, symptom, or sign has not occurred before. Resident was agitated, increased anxiety; -Background: Primary diagnosis of dementia. Mental status changes include increased confusion and delirium (a temporary state of altered consciousness characterized by confusion, disorientation, and difficulty concentrating); -Assessment: The resident appears anxious, agitated, confused, alert and oriented x 2-3; -Request: Resident observed standing at window with toilet top, window observed broke and screen broken. Resident stated, I am going to jump, two times. Nurse yelled for other nurse on duty to assist. Other resident was able to deescalate resident and resident brought to nurse station and 1:1 sitter until Emergency Medical Services (EMS) and police arrived. Resident sent to hospital for psychiatric evaluation and treatment. Review of the resident's transfer to hospital summary, dated 4/19/25 at 9:38 P.M., showed LPN FF documented hospital specialist called facility and LPN gave information regarding resident's stay and exit seeking behaviors, behaviors since resident admission. During an interview on 5/21/25 at 9:43 P.M., LPN FF said he/she worked 7:00 P.M. to 7:00 A.M. on 4/19/25. During his/her shift, he/she heard glass break in one of the rooms on the memory care unit. He/She found the resident standing in front of the window with a toilet tank lid in his/her hands and the window broken. The resident was crying and said he/she wanted to leave. The resident was sent out to the hospital for a psych eval and came back a couple days later with a diagnosis of severe UTI. The resident was not on any kind of plan for increased monitoring. LPN FF was not aware the resident got off the secured unit on 4/11/25. This information was not communicated to him/her and would have been helpful to know when monitoring the resident. Review of the resident's hospital Discharge summary, dated [DATE], showed: -History of present illness (HPI): A few days ago, patient apparently ripped out his/her Foley (urinary catheter). He/She went to the hospital for an evaluation and he/she was placed on antibiotics. Earlier today, he/she got very agitated again and was screaming at staff. Apparently he/she took a toilet seat and broke a window and tried to escape. He/She apparently yelled that he/she is sick of it here, it is full of old people; -Hospital course: --Acute metabolic encephalopathy (alteration of brain function) - resolved; ---On admit, patient was confused, agitated, and apparently broke a window. Much improved after starting antibiotics for urinary infection on admit. Patient also has a significant psychiatric history with bipolar and depression; --Complicated UTI; --Bipolar disorder. Review of the resident's medical record, showed: -Resident readmitted to facility's secure memory care unit on 4/21/25; -No documentation related to increased supervision or other interventions related to safety for the resident following attempted elopement on 4/19/25. During an interview on 5/22/25 at 7:33 A.M., the DON said after the resident attempted to elope on 4/19/25, the resident was sent to the hospital and returned two days later. He/She was on antibiotics for a UTI and was supposed to be referred to a psychiatrist, but she is not sure that had happened, yet. The DON suggested using rounding sheets for the resident, and the resident should have been checked on every 15-minutes for 48 hours following the resident's return to the facility on 4/21/25. This need was discussed in the daily stand-up meetings. The resident's care plan should have been updated by the nurse within 24 hours of the attempted elopement, and should have shown updated interventions for elopement incidents. Review of the resident's Wandering Risk Assessment, dated 4/22/25 at 1:29 P.M., showed: -Has wandered aimlessly within the home or off the grounds; -Has wandered in the past month; -High risk to wander. Review of the resident's NP note, dated 4/22/25, showed: -Resident is a readmit to the facility. Sent to emergency department (ED) for confusion and agitation. Was treated for UTI. Long-term and short-term memory deficit; -Plan related to confusion arousals: Maintain dementia unit, psychotropic medication, and psych eval. Review of the resident's care plan, in use at the time of survey, showed: -No documentation of resident's elopement from secure memory care unit via unit doors on 4/11/25; -No documentation of the resident breaking the window using a toilet tank lid and expressions of wanting to leave the secure memory care unit on 4/19/25, and no new interventions identified related to the resident's behavior and supervision needs or physical environment. Review of the resident's behavior note, dated 4/24/25 at 7:53 P.M., showed LPN HH documented patient had increased behaviors during this shift and patient managed to elope out of facility by breaking his/her bedroom window and going through the window. During an interview on 5/21/25 at 5:24 P.M., LPN HH said he/she came in for his/her shift on 4/24/25 just before 6:00 A.M. During report, the night nurse did not mention anything about the resident's prior elopement attempts or that the resident was supposed to be on 1:1 monitoring. At around 5:45 P.M., the Certified Nurse Aide (CNA) reported he/she could not find the resident. LPN HH saw the resident about an hour prior to that, at around 4:45 P.M. LPN HH went to the resident's room and found the window had been busted out and the busted window screen was inside the room. There was shaving cream all over the place and the resident was gone. Staff started looking for the resident and the police and DON were notified. About an hour or so later, police located the resident at a restaurant off the main road outside of the facility. The resident was brought back to the facility and placed on 1:1 monitoring with the DON. 1:1 monitoring means staff should check the resident every 15 minutes. The DON said the resident was supposed to be on 1:1 monitoring, 15-minute checks, during the shift before the resident eloped, however, this was never reported to LPN HH or the CNAs who worked with him/her that day. No one knew the resident was supposed to be on 1:1 monitoring on 4/24/25, before the resident eloped from the facility. On the secure unit, the usual protocol is for staff to check residents every hour. Review of the police department investigative report, printed 4/29/25, showed: -Date/time received: 4/24/25 at 6:10 P.M.; -Subject information: Missing person. Subject has dementia and is hearing impaired; -Narrative: Responded to facility in reference to missing person. Prior to arrival, communications advised subject had broken his/her window and left the facility. Worker stated resident was last seen walking westbound on main road. Upon arrival, spoke with LPN HH, who stated he/she had last seen resident at 5:00 P.M. LPN HH stated he/she went to check on resident around 5:45 P.M. and discovered he/she was missing and his/her window had been smashed out. Resident had a history of escaping/attempting to escape the facility. Review of the facility's investigation into the resident's elopement on 4/24/25, reviewed on 5/22/25, showed: -Timeline of events: --5:00 - 5:20 P.M.: Staff discovered resident's window broken, management notified; --7:09 P.M.: Resident found by police department and enroute to facility. Review of Google Maps, showed approximate walking distance of 1.6 miles from the facility to the restaurant off the main road outside of the facility, where police located the resident. During an interview on 5/21/25 at approximately 2:15 P.M., CNA A said at around dinnertime on 4/24/25, he/she did a count of residents and could not find the resident. He/She saw the resident 30 to 45 minutes prior to this. He/She checked the resident's room and found shaving cream all over the window, the window broken with glass all over the floor, and the screen outside of the window. He/She reported it to the nurse and everyone started searching for the resident. The resident was gone for at least 45 minutes after that. Police found the resident at a restaurant down the main road outside of the facility. The resident was not on 1:1 or increased monitoring prior to this day. During an interview on 5/21/25 at 7:10 P.M., CNA B said he/she worked on the secure unit on 4/24/25 from 7:00 A.M. to 7:00 P.M. The resident was not on 1:1 monitoring during the shift. Close to dinnertime on 4/24/25, the other CNA saw the resident was missing. The other CNA went to the resident's room and saw the resident's window was broken. Staff searched for the resident, but could not find him/her. The police brought the resident back to the facility a couple hours later, just before CNA B's shift ended at 7:00 P.M. The resident told staff he/she covered his/her window in shaving cream to muffle the sound of the glass breaking. CNA B was not aware the resident had two prior actual or attempted elopement attempts. This information would have been good for staff to know. CNA B was later told the resident should have been on 1:1 monitoring during the day shift on 4/24/25, but this was never communicated to CNA B. 1:1 monitoring means checking the resident every 15 minutes. There are no set guidelines for completion of routine rounds on the memory care unit. Following the incident on 4/24/25, CNA B was not in-serviced on 1:1 monitoring or elopement protocol. During an interview on 5/21/25 at 9:43 P.M., LPN FF said on 4/24/25, he/she came in for his/her shift at 5:50 P.M., and an elopement code had just been called for the resident. He/She looked for the resident in the nearby neighborhood at 6:00 P.M., and one of the neighbors said he/she saw someone matching the resident's description about 45 minutes prior to that. Police returned the resident to the facility at around 7:30 P.M., before 8:00 P.M. During an interview on 5/22/25 at 7:33 A.M., the DON said on 4/24/25, the resident was not seen by staff for 45 minutes, which is too long for him/her to go in between checks. Staff should complete rounds every two hours on the secure unit. If residents exhibit behaviors, they should be checked more frequently. The DON, Assistant Director of Nurses (ADON), Administrator, Social Services Director (SSD), and MDS Coordinator determine interventions. Interventions are communicated to staff during daily stand-up meetings. The resident should have been checked more frequently on 4/24/25. The Administrator investigated the resident's elopement incidents and the DON did not see the statements obtained during the investigation. During an interview on 5/22/25 at 8:21 A.M., the Administrator said when the door alarms sounded on the memory care unit on 4/11/25, staff should have checked the doors and immediately completed a head count to determine who was missing. Once a resident was identified as missing, staff would have called the code to alert everyone to search for the missing resident. The resident's physician and responsible party should have been notified. After the resident eloped on 4/11/25, the Administrator spoke with the resident's family member, who said the resident still had his/her right mind. The family member said it was helpful for staff to talk to the resident about what he/she liked to do and to give the resident something to do. The Administrator spoke with some staff about their interactions with the resident and keeping him/her occupied. On 4/19/25, the Administrator conducted an investigation into the resident's elopement. While in the hospital for this incident, it was found the resident had a UTI. Upon the resident's return to the facility, staff was instructed to keep the resident on enhanced visuals. There are no policies or specific expectations for rounding on residents on the memory care unit. Two hours is an acceptable timeframe to complete rounds on residents on the memory care unit. Staff typically round on the residents and constantly watch them. To place a resident on enhanced visuals means to watch them more frequently than two hours, but there is no specific definition or expectation for more frequently. Enhanced visuals are more frequent than rounding every two hours, but less often than placing a resident on 1:1 monitoring. Enhanced visuals are not documented. 1:1 monitoring means staff should have visual on the resident at all times and keep track of their monitoring on a written log. The Administrator is not sure how long the resident was on enhanced visuals following the incident on 4/19/25, but the information is documented in the investigation she completed. Interventions, such as enhanced visuals, are communicated to staff through in-servicing. Interventions should be documented on a resident's care plan. Documentation of the in-servicing should be documented in the investigation she completed. On 4/24/25, the resident eloped by breaking the window in his/her room. When he/she came back to the facility, he/she was able to say why he/she eloped and how he/she used shaving cream on the window to reduce the noise of the broken glass. The Administrator investigated the elopement and found one of the CNAs who worked on 4/24/25 reported the incident to his/her family first, rather than the DON or Administrator. The investigations into the resident's elopements on 4/11/25, 4/19/25, and 4/24/25, are all in the same investigation file. Review of the facility's investigation file regarding the resident's elopements, provided 5/22/25 at approximately 11:55 A.M., showed: -No documentation related to the elopement on 4/11/25, including employee statements, physician notification, and in-service training; -No documentation related to the attempted elopement on 4/19/25, including employee statements and in-service training; -23 staff completed a questionnaire on 4/28/25 and 4/29/25 with the following questions: -What is the code for a missing resident; -Who do you report a missing resident to: -How often do you complete rounding on your residents; -No documentation related to in-service training with staff related to verification of resident locations on the unit upon door alarms sounding on the memory care unit, specific instruction for enhanced visual or 1:1 monitoring, or utilization of care plans to identify specific interventions for residents identified as high risk for elopement. During an interview on 5/22/25 at 9:45 A.M., the Medical Director said all residents on the memory care unit have dementia. When an exit door on the memory care unit is opened, the alarms at the doors should sound. When staff hear the door alarms, they should immediately check the doors to determine where the alarms are coming from. When the door alarm sounded after the resident's elopement on 4/11/25, staff should have conducted an immediate head count. He cannot recall being notified of this incident. He was notified of the resident's attempted elopement on 4/19/25. It would be expected for the resident to have been on an increased watch following this incident. At minimum, staff should have discussed with their supervisors what next steps should be taken to address the incident. Hourly checks for residents on the memory care unit could be ok for most residents, and should be more frequent for other residents, depending on the general understanding of the residents on the memory care unit. During an interview on 5/22/25 at 12:09 P.M., the Medical Director said the resident was not safe to be on his/her own. Upon admission, something told the facility right off the bat that the resident required placement on a memory care unit. During an interview on 5/22/25 at 2:47 P.M., Regional Nurse II said the Elopement Risk Reduction Approaches form referenced in the Wandering & Elopement policy is the same thing as the Wandering Risk Assessment. Regional Nurse CC said the facility did not classify the resident's elopement attempt on 4/19/25 as an elopement event; they classified it as a suicidal behavior event. The resident was cleared by the hospital's psychiatrist and additional monitoring was not needed when the resident returned to the facility because he/she had been cleared. During an interview on 5/23/25 at 11:35 A.M., Regional Nurse CC said the DON in-serviced all staff following the resident's elopement on 4/24/25. In-servicing with staff was ongoing and the exact dates of in-services are unknown. Review of the facility's in-service training documentation, provided on 5/23/25, showed: -12 staff signed in-service sheet for enhanced monitoring/1:1 monitoring on 4/24/25; -11 staff signed in-service sheet for elopement policy on 4/24/25; -10 staff signed in-service sheet for reporting on 4/24/25; -11 staff signed in-service sheet for elopement drill/missing resident drills on 4/24/25; -7 staff signed in-service sheet for Resident #131's placement on 1:1 monitoring on 4/24/25; -An employee list, dated 4/24/25, in which verbal I.S, documented next to the names of staff, undated, and NS documented next to the names of other staff who were not employed on 4/24/25. During an interview on 5/23/25 at 12:01 P.M., the DON said she verbally in-serviced some of the staff following the resident's elopement on 4/24/25. She could not recall the exact dates of the in-service training. During the in-service, she discussed the facility's elopement procedures. During an interview on 5/21/25 at 1:26 P.M., Housekeeper L said he/she has been employed by the facility for a few weeks. He/She is not sure what the protocol is for a missing resident or door alarms sounding. He/She has not been in-serviced on these topics. During an interview on 5/22/25 at 6:43 A.M., Nurse Aide (NA) K said he/she has been employed by the facility for five weeks and he/she just got access to resident care plans this week. Care plans tell staff exactly what is going on with residents and he/she would like to have access to these so he/she could know about the residents he/she is supposed to monitor. All residents on the memory care unit should be seen by staff every 15 minutes because of their wandering. During an interview on 5/22/25 at 7:11 A.M., NA JJ said he/she has been employed by the facility for a few weeks. All residents on the memory care unit have elopement tendencies. Residents on the memory care unit should be checked every 15 to 30 minutes. Staff know which residents should be on 1:1 or increased monitoring by learning their behaviors. He/She does not know if care plans are used by the facility. 2. Observation on 5/22/25 at 9:09 A.M., showed the 400 and 500 halls located on the secure memory care unit, with exit doors located on both halls. Twelve residents were in the dining room. LPN F, CNA A, and CNA W, worked on the secure unit. During a test of the alarm, the exit door on the 400 hall opened at 9:09 A.M. The door opened without a 15-second delay. An alarm sounded at the panel at the nurse's station, but did not sound at the alarm box above the open door. Observation on 5/22/25 at 9:19 A.M., showed the alarm panel at the nurse's station showed 123. The Maintenance Director said the panel should indicate which door was opened, but currently, it was not showing the correct door. The Administrator said the exit doors on the 500 and 400 halls should be on 15-second delays and both doors should be alarmed. The Regional Maintenance Director said when either exit doors are opened on the 500 and 400 halls, [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to administer care in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well- being of each resident. The facility initiated the transfer of residents to other facilities, particularly within their corporation, without appropriate notice, reason or discharge planning (Residents #6, #7, #8, #100, #101, #104). Residents who had been transferred did not have their personal belongings and/or medically necessary equipment (Residents #100, #104 and #101). According to staff, residents had been heavily recruited by the Administration of a sister-facility to move, and had not initiated a move on their own. According to staff, residents had been moved to a sister facility due to this facility closing. In addition, the residents were provided meals on Styrofoam because dietary staff said they have been instructed to pack up everything and send it to another facility. The census was 27. The Administrator was notified on 4/28/23 at 3:15 P.M. of an Immediate Jeopardy (IJ), which began on 4/24/23. The IJ was removed on 4/29/23 as confirmed by surveyor onsite verification. Review of the facility's Transfer and Discharge (Including AMA) Policy, revised 9/1/21, showed: -Resident initiated transfer defined as a situation in which the resident or, if appropriate, the resident representative has provided verbal or written notice of intent to leave the facility; -Facility initiated transfer defined as a situation in which transfer or discharge which the resident objects to, did not originate through a resident's verbal or written request, and/or is not in alignment with the resident's stated goals for care and preferences; - The facility may initiate transfers or discharges in the following limited circumstances: a. The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility; b. The resident's health has improved sufficiently so that the resident no longer needs the care and/or services of the facility; c. The safety of the individuals in the facility is endangered due to the clinical or behavioral status of the resident; d. The health of the individuals in the facility would otherwise be endangered; e. The resident has failed, after reasonable and appropriate notice, to pay or have paid under Medicare or Medicaid for his or her stay at the facility; f. The facility ceases to operate; -For Anticipated Transfers or Discharges which the policy defines as initiated by the resident, the facility will ensure the following is documented: a. Obtain physicians' orders for transfer or discharge and instructions or precautions for ongoing care; b. A member of the interdisciplinary team completes relevant sections of the Discharge Summary. The nurse caring for the resident at the time of discharge is responsible for ensuring the Discharge Summary is complete and includes, but not limited to, the following: i. A recap of the resident's stay that includes diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology and consultation results. ii. A final summary of the resident's status. iii. Reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over the counter). iv. A post discharge plan of care that is developed with the participation of the resident, and the resident's representative(s) which will assist the resident to adjust to his or her new living environment. Review of the facility's Admission/Discharge To/From Report, showed 12 resident discharges to Sister Facility A from 4/24/23 to 4/27/23. 1. Review of Resident #100's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/3/23, showed the following: -Cognitively intact; -Special treatments while resident: Oxygen therapy; -At risk for pressure ulcers (Injury to skin and underlying tissue resulting from prolonged pressure on the skin): Yes; -Pressuring reducing device used for bed: Yes; -Diagnoses included respiratory failure, anxiety and depression; -Regarding the question Do you want to talk about the possibility of leaving this facility and returning to live and receive services in the community: No. Review of the resident's care plan, last revised on 4/11/23 and in use during the survey, included: -Focus: Residents' Rights are guaranteed by the Federal 1987 Nursing Home Reform Law. The law requires Skilled Nursing Facilities to promote and protect the rights of each resident, placing emphasis on individual preferences, dignity, and self-determination; -Goal: Resident's autonomy and dignity will be honored in the personal choices that he/she makes; -Interventions: The resident has the right to Accept and/or Refuse any medication, treatment, recommendation, or services that are offered. The Resident has the right to make independent informed choices to include: Personal decisions. Request reasonable accommodation of needs and preferences. Participation in community activities. Management of own financial/personal affairs; -Focus: Resident wishes to stay here long-term; -Goal: Resident will continue to express satisfaction with living arrangements through the review period. -Interventions: Discuss with resident and/or family/guardian any concerns that the resident might have regarding current living arrangements. Discuss with resident and/or family/guardian any concerns that they might have regarding long-term placement. Evaluate discharge and long-term care goals quarterly and as needed. Provide community resources to resident and/or family/caregiver as needed/requested; -Focus: Resident has an activities of daily living (ADL) self-care performance deficit related to bilateral lower extremity amputee; -Intervention: Allow resident to participate in decision making in regards to meeting his/her personal care needs and ADL task; -Focus: Resident has the potential for pressure injury development related to immobility and history of pressure ulcers; -Goal: Resident will have intact skin, free of redness, blisters or discoloration; -Interventions: Educate the resident/family/caregivers as to causes of skin breakdown. Resident uses a low air loss mattress (LAL, a mattress designed to prevent and treat pressure wounds). LAL mattress in place with U rails (used for repositioning). Review of the resident's physician order sheet (POS), showed: -An order dated, 4/27/23, may transfer to sister facility with medication including narcotics; -No order for a LAL mattress; -No order for U rails. Review of the resident's progress notes, showed: -A Social Service note, dated 4/27/23 at 11:05 A.M., showed writer (Senior Clinical Liaison from the corporate office) spoke with resident/responsible party regarding choice of facility to transfer if he or she or family member chose to do so. Spoke with resident and verbalized understanding that he/she can freely stay at this facility or transfer to another facility of choice, other sister facilities. All assistance, including transfer of medications and personal belongings will be provided for a smooth transition. Resident verbalized understanding that he/she can reach out to the staff for questions or concerns that he/she may have after this meeting/conversation. Patient chose to move to Sister Facility A; -A note, dated 4/27/23 at 6:13 P.M., showed the resident was transferred to Sister Facility A by facility transportation. All of the resident's medications, medication list and face sheet went with the resident. The resident's belongings were sent as well. Report was given to accepting facility. Physician aware. Review of the resident's medical record, showed: -No documentation the resident initiated or requested to transfer or discharge to another facility; -No documentation the transfer or discharge was necessary for the resident's welfare the resident's needs could not be met in the facility, the resident's health had improved sufficiently so that the resident no longer needed the care and/or services of the facility, the safety of the individuals in the facility were endangered due to the clinical or behavioral status of the resident, the health of the individuals in the facility would otherwise be endangered, the resident had failed, after reasonable and appropriate notice, to pay or have paid under Medicare or Medicaid for his/her stay at the facility or that the facility planned to cease operation; -No documentation of information about or referrals to other facilities provided to the resident; -No documentation of a post discharge plan of care that was developed with the participation of the resident, and the resident's representative(s) to assist the resident to adjust to his/her new living environment. During an interview on 4/28/23 at 6:33 A.M., Employee E said he/she witnessed Administrator H tell Resident #100 the facility was closing and the resident could move to Sister Facility A. The resident was concerned about therapy, and Administrator H said all the therapy staff would be moving to Sister Facility A. The resident said he/she needed a few days to think about it and talk to his/her family. Administrator H said the resident had a day to make the choice. There was going to be a barbeque and party at Sister Facility A on 4/28/23 and Administrator H didn't want the resident to miss it. The employee did not hear Administrator H give any other options. The employee did not hear the resident agree to move. The resident called his/her family member who left work to come to the facility to find out what was going on. During an interview with the resident and family member on 4/28/23 at 12:10 P.M., the family member said he/she had no clue how this all came to be. He/she called the facility on 4/27/23 and the person at the front desk said the resident was in therapy and then said the resident was moving to a different facility that day. The family member missed the last two hours of work because he/she had to go to the facility to figure out what was going on. When the family member arrived, there were boxes in the resident's room. At that point, no one had said where the resident was going. The resident moved that night to Sister Facility A. Upon arrival, the resident's room did not have an LAL mattress. The Senior Clinical Liaison said the LAL mattress would be delivered to Sister Facility A on 4/28/23, so the resident had to sleep on a regular mattress. The resident has had serious pressure ulcers in the past and the family member is very concerned about the resident's skin. The family member said the whole experience was shocking and very upsetting. The family member would've preferred the resident move somewhere closer to him/her. The family member had to take the day off work to help the resident adjust to the new facility. The resident started crying when asked if he/she wanted to move to Sister Facility A. The resident said he/she agreed to move because staff said they were all moving to Sister Facility A. This was not the resident's idea. Staff approached him/her about moving. During an interview on 5/1/23 at 11:47 A.M., the Director of Nursing (DON) said the resident never had an order for a LAL mattress. The family requested it, but there was never an order. The family was present when the resident's items were transported to Sister Facility A. During an interview on 4/28/23 at 2:38 P.M., Administrator H said Corporate Consultant C told her she needed to go to the facility because residents had questions about Sister Facility A. She did not know how the residents became curious about her facility. She was told to go and follow up with residents about questions. She talked to the resident who expressed interest in the sister facility. The resident said he/she wanted to move. Administrator H denied telling the resident he/she had to make a decision so they wouldn't miss the barbeque. Medical equipment should be in place when a resident moves in. Personal items should also accompany residents when they move in. Most of the residents who transferred to Sister Facility A got a bulk of their personal items the same day they moved in. She knew a LAL mattress was on order for the resident, but could not recall seeing one in the resident's room at Sister Facility A. 2. Review of Resident #104's quarterly MDS, dated [DATE], showed: -admission date 5/17/22; -Moderate cognitive impairment; -No behaviors; -No wandering; -Diagnoses included: anxiety, depression, schizophrenia (a disorder that affects the way a person thinks, feels and behaves) and post-traumatic stress disorder (PTSD, a disorder in which a person has difficulty recovering after a terrifying event); -Regarding the question Do you want to talk about the possibility of leaving this facility and returning to live and receive services in the community: No. Review of the resident's care plan in the electronic medical record (EMR), showed: -Focus: Resident wishes to stay here long term, date initiated 5/22/22; -Interventions: Discuss with resident and/or family/guardian any concerns that the resident might have regarding current living arrangement; discuss with resident and/or family/guardian any concerns that they might have regarding long-term placement; encourage social interactions and participation in activities with others that have similar interests; -Focus: Residents' Rights are guaranteed by the Federal 1987 Nursing Home Reform Law. The law requires skilled nursing facilities to promote and protect the rights of each resident, placing emphasis on individual preferences, dignity, and self-determination, date initiated 5/22/22; -Goal: The resident's autonomy and dignity will be honored in the personal choices that they make; -Interventions: The resident has the right to accept and/or refuse any medication, treatment, recommendation, or services that are offered, the resident has the right to be fully informed of care and environment which included advance plans of a change in rooms/roommates; the resident has the right to be treated with consideration, respect, and dignity; -Focus: The resident has the potential to be physically aggressive related to anger, poor impulse control and striking out at another resident, date Initiated: 4/19/2023; -Interventions: Resident will be provided physical and verbal cues to alleviate anxiety; give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff member when agitated; give the resident as many choices as possible about care and activities; Resident was sent to the ER for a psych evaluation and returned with no new orders, on one-on-one supervision at this time, restarted on Depakote (seizure medication that can also treat certain psychiatric disorders); monitor/document/report as needed (PRN) any signs/symptoms of resident posing danger to self and others; psychiatric/psychogeriatric consult as indicated; when the resident becomes agitated: Intervene before agitation escalates; guide away from source of distress; engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later. Review of the discharge progress note, dated 4/27/23 at 7:51 P.M., showed the resident was transferred to a sister facility by facility transportation. All of the resident's medications, medication list and face sheet went with the resident. The resident's belongings were sent as well. Report was given to accepting facility. Physician aware. Review of the social service note, dated 4/27/23, showed writer (Senior Clinical Liaison) spoke with resident/responsible party regarding choice of facility to transfer if he or she or family member chose to do so. Spoke with resident and verbalized understanding that he/she can freely stay at this facility or transfer to another facility of choice, other sister facilities. All assistance, including transfer of medications and personal belongings will be provided for a smooth transition. Resident verbalized understanding that he/she can reach out to the staff for questions or concerns that he/she may have after this meeting/conversation. Patient and power of attorney (POA) have chosen to go to a sister facility. Review of the resident's medical record, showed: -No documentation the resident initiated or requested to transfer or discharge to another facility; -No documentation of information about or referrals to other facilities provided to the resident; -No documentation of a post discharge plan of care that was developed with the participation of the resident, and the resident's representative(s) to assist the resident to adjust to his/her new living environment. During an interview on 4/28/23 at 12:15 P.M., the resident's POA said he/she has known the resident for 21 years and helps the resident with decisions. The facility contacts him/her when the resident has a change of condition. Someone from the facility called him/her on 4/27/23 and said they were moving the resident to another facility that day. The staff member said the resident needed more care and the facility did not have enough staff to care for the resident. The POA knew the resident had been involved in a recent altercation and wondered if it had something to do with that. The staff member did not give the POA an option of where to move the resident and just said that the resident would be moving to a sister facility. The staff member said they were packing up the resident's stuff and would transfer him/her on the bus. The resident is confused about the move and was in someone else's room this morning. They sent his/her TV but not the power cord, so the resident cannot watch TV. The POA thinks the resident would have preferred to stay at the original facility because he/she was comfortable there and knew where places like the dining room were located. During an interview on 4/28/23 at 2:30 P.M., Corporate Consultant C said she spoke with the resident's POA on 4/27/23. The resident needed more assistance and their sister facility has a memory care unit, so the resident could have more one-on-one care. She did not tell anyone, family/resident, they had to leave that day, but she did tell them they had transportation available that day. She told the POA there were other memory care units in the area, but did not provide anyone a list. 3. Review of Resident #101's quarterly MDS, dated [DATE], showed: -Cognitive skills for daily decision making: Independent, decisions consistent/reasonable; -Independent with most ADLs; -Diagnoses included heart failure, anxiety and depression. Review of the resident's care plan, last revised on 4/11/23, and in use during the survey, showed: -Focus: Residents' Rights are guaranteed by the Federal 1987 Nursing Home Reform Law. The law requires Skilled Nursing Facilities to promote and protect the rights of each resident, placing emphasis on individual preferences, dignity, and self-determination; -Goal: Resident's autonomy and dignity will be honored in the personal choices that he/she makes; -Interventions: The resident has the right to Accept and/or Refuse any medication, treatment, recommendation, or services that are offered. The Resident has the right to make independent informed choices to include: Personal decisions. Request reasonable accommodation of needs and preferences. Participation in community activities. Management of own financial/personal affairs. Review of the resident's medical record, showed: -A progress note, dated 4/14/23, showed the resident was sent to the hospital for evaluation and treatment. He/she was her own responsible party; -No documentation the resident initiated or requested to transfer or discharge to another facility; -No documentation the transfer or discharge was necessary for the resident's welfare the resident's needs could not be met in the facility, the resident's health had improved sufficiently so that the resident no longer needed the care and/or services of the facility, the safety of the individuals in the facility were endangered due to the clinical or behavioral status of the resident, the health of the individuals in the facility would otherwise be endangered, the resident had failed, after reasonable and appropriate notice, to pay or have paid under Medicare or Medicaid for his/her stay at the facility or that the facility planned to cease operation; -No documentation of information about or referrals to other facilities provided to the resident; -No documentation of a post discharge plan of care that was developed with the participation of the resident, and the resident's representative(s) to assist the resident to adjust to his/her new living environment; -No documentation regarding the resident's belongings being transported to a new facility. During an interview on 4/28/23 at 10:07 A.M., the facility Social Services Director (SSD), said the resident went to the hospital and was now at Sister Facility A. She did not know how long the resident had been at the new facility because the resident transferred from the hospital. Observations of the resident's room on 4/28/23 at 9:23 A.M. and 5/1/23 at 9:33 A.M., showed the resident's closet contained clothing, a flat screen TV on his/her bedside table next to his/her bed and personal items on top of the night stand and personal items inside the drawers. Review of the resident's admission MDS, dated [DATE], showed an admission date of 4/25/23 to Sister Facility A. During an interview on 5/1/23 at 11:47 A.M., the DON said the resident's items had been packed up and were in the front lobby waiting to be transported to Sister Facility A. She did not know when the resident was admitted to the new facility. 4. Review of Resident #6's medical record, showed: -The resident is his/her own representative; -Medical diagnoses included: Non-traumatic extradural hemorrhage (a collection of blood between the outer layer of the brain and inner skull), syncope (light headedness affecting consciousness) and collapse, and cognitive communication deficit; -A progress note on 4/24/23 at 1:26 P.M., from Social Services, stating the resident had been approached and given the choice to either stay at the facility or transfer to another facility of choice, including other sister facilities; -A progress note on 4/24/23 at 3:52 P.M., stating the resident had been transferred to Sister Facility A. Some of the resident's belongings were transferred at that time, with the rest of his/her belongings to be transferred over to the sister facility, over the course of the coming week; -No discharge notice found in the record; -No discharge summary found in the record. During an interview on 4/25/23 at 2:36 P.M., the resident said he/she was approached by a member of the corporate team on 4/24/23, asking him/her if he/she would like to transfer to another facility. At that time, the Administrator for Sister Facility A, Administrator H, was in the building and encouraged the resident to transfer to Sister Facility A, as they had a friendly relationship when Administrator H worked at the facility in the past. The resident said he/she decided to transfer to Sister Facility A, with his/her roommate for a change of scenery. The resident said he/she did not initiate the conversation regarding the transfer. 5. Review of Resident #8's medical record, showed: -The resident is his/her own responsible party; -Medical diagnoses included: Bipolar disorder (a mental disorder characterized by periods of depression and periods of abnormally elevated mood), major depressive disorder, anxiety disorder, and unspecified hearing loss; -A progress note on 4/24/23 at 1:35 P.M., from Social Services, stating the resident had been approached and given the choice to either stay at the facility or transfer to another facility of choice, including other sister facilities; -A progress note from 4/24/23 at 3:49 P.M., stating the resident had been transferred to Sister Facility A with some of his/her belongings and all medications; -No discharge notice found in the record; -No discharge summary found in the record. During an interview on 4/25/23 at 2:36 P.M., the resident said he/she was approached by a member of the corporate team on 4/24/23, asking him/her if he/she would like to transfer to another facility. The resident decided to transfer to Sister Facility A because his/her roommate, Resident #6, was transferring there and the two had a great relationship while rooming together at the facility. 6. Review of Resident #7's medical record, showed: -The resident is not his/her own responsible party; -Medical diagnoses included: acute and chronic respiratory failure (failure of the lungs to properly oxygenate the organs), unspecified heart failure, congenital hydrocephalus (a neurological disorder caused by an abnormal buildup of cerebrospinal fluid in the cavities within the brain), and schizophrenia (a disorder that affects a person's ability to think, feel and behave clearly). -A progress note on 4/24/23 at 1:27 P.M., from Social Services, stating the resident had been approached and given the choice to either stay at the facility or transfer to another facility of choice, including other sister facilities; -A progress note on 4/24/23 at 3:55 P.M., stating the resident had been transferred to Sister Facility A with all medications; -No discharge notice found in the record; -No discharge summary found in the record. During an interview on 4/25/23 at 2:34 P.M., the resident said he/she did not remember the origin of the conversation regarding his/her transfer, but decided to transfer to Sister Facility A for a change of scenery, and liked the outdoor space at the facility. The resident was unable to remember the name of the individual at the facility who offered him/her the choice to transfer to Sister Facility A. During an interview on 4/25/23 at 11:27 A.M., the individual designated in the medical record as the resident's responsible party said he/she had not been notified of the resident's transfer and was not consulted prior to the transfer occurring. He/She was not surprised, as communication from the facility regarding the resident is often sparse and infrequent. 7. Review of Resident #5's quarterly MDS, dated [DATE], showed: -No cognitive impairment; -Independent with all ADLs; -Diagnoses included high blood pressure, diabetes and depression. During an interview on 4/28/23 at 6:50 A.M., the resident said he/she and other residents feel hoodwinked. Administrator H had been coming to the facility to talk to residents about moving to her facility. The resident does not want to move. Corporate Consultant C told him/her last week he/she had the choice of moving to Sister Facility A or B. The resident had to decide in a week. Then Corporate Consultant C said the resident could stay as long as he/she wanted. Corporate Consultant C said the building will stay open, but moving residents will help fill beds for other sister facilities. This facility was under receivership and the corporation will no longer be able to operate the building. The resident thinks the corporation wants all the residents who complain to leave. The resident is very irritated with the corporation. It is very chaotic and everyone is upset. 8. During an interview on 4/28/23 at 6:27 A.M., Nurse H said he/she has heard the building was supposedly sold and then it wasn't. Staff were called last Thursday to choose a different location at sister facilities to work. He/she then came to work on 4/24/23 and residents were leaving. Residents have been given the choice of moving to a sister facility or they can stay. A timeframe for moving had not been given. During an interview on 4/28/23 at 6:33 A.M., Employee E said staff were told on 4/20/23 or 4/21/23 that staff were going to Sister Facility A and to carry on as is. The employees' payroll also switched to Sister Facility A with no explanation of what was really happening. He/she had heard the building was closing because of the budget, management and state. Administrator H from Sister Facility A started taking residents to her facility earlier in the week. Residents who could advocate for themselves could choose which sister facility they wanted to move to. Residents with dementia or who couldn't advocate for themselves went to Sister Facility A. It also seemed like insurance played a role. Residents who were on Medicare A or B went to Sister Facility A. Families and residents have asked the employees what was going on, but no one has any information to provide. During an interview on 4/28/23 at 7:25 A.M. [NAME] K said today was the last day for dietary staff. A new company was starting tomorrow, 4/29/23. [NAME] K and other dietary staff were going to Sister Facility A. During an interview on 4/28/23 at 8:45 A.M., Housekeeper I said he/she was told by the DON and Human Resources the building was being shut down on 4/28/23. Staff were given the option to stay or go to Sister Facility A. Residents were given the option to stay or go to a sister facility. He/she is going to start work at Sister Facility A on 5/1/23. During an interview on 4/28/23 at 9:32 A.M., the Director of Rehab (DOR) said she received a call last Thursday or Friday from the [NAME] President of Therapy. She was told staff were being redistributed and could move to Sister Facility A. An option to stay was not presented. She was then told on 4/27/23 the facility will continue to provide therapy as long as there were residents. There was confusion about what was happening with the building. Most residents who receive Medicare A have been moved to Sister Facility A. Residents have not requested to move because they wouldn't know to ask to move. It has been a very abrupt occurrence. Residents have not been given a choice. Administrator H has been at the facility and heavily recruiting residents to move to Sister Facility A. The DOR thought the building was closing, but as the week progressed, there had only been more confusion. During an interview on 4/28/23 at 10:07 A.M., the SSD said she had not been involved in any of the recent resident transfers to Sister Facility A. That was something the SSD would normally coordinate. Corporate staff were handling it and she had not been involved in any of those conversations. The option to transfer was presented by corporate staff. Residents and families seemed confused after being approached by corporate staff. She has seen the Senior Clinical Liaison's name, but doesn't know what she does within the company. She told anyone who had come to her with questions that they can stay there, move to a sister facility or to another facility. During an interview on 4/28/23 at 11:07 A.M., the Administrator said the building was leased and the company was trying to decide what to do with it. They would hopefully know today whether or not the company would keep the building. If the corporation kept the building, the plan was to get the census down to a size to allow construction to be done on halls not occupied by residents. Staff went around and informed residents and families that the options were to stay, transfer to a sister facility or to a[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one resident (Resident #2) was free from abuse when Certified Nurse Aide (CNA) E grabbed the resident's arm and threatened to break it which caused bruising to the resident's arm and caused him/her to be scared of the employee. The incident was witnessed by staff, who failed to report the abuse. CNA E finished working his/her shift and returned the next day, prior to the resident reporting the abuse and the facility beginning their investigation. The sample was five. The census was 41. The Administrator was notified on 4/5/23 at 1:22 P.M. of an Immediate Jeopardy (IJ) past-noncompliance which began on 1/25/23. The facility conducted an investigation and immediately in-serviced staff on 1/26/23 regarding abuse. The facility instituted corrective measures on 1/26/23 including termination of CNA E's employment with the facility. The IJ was corrected on 1/26/23. Review of the facility's Abuse, Neglect and Exploitation policy, revised 9/22/22, showed: -Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of property; -Definitions: --Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Abuse also includes the deprivation of an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse, including abuse facilitated or enabled through the use of technology; --Physical abuse includes, but is not limited to hitting, slapping, punching, biting, and kicking. It also includes controlling behavior through corporal punishment; --Mental abuse includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation; -Policy Explanation and Compliance Guidelines: --The facility will develop and implement written policies and procedures that: --- Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property; ---Include training for new and existing staff on activities that constitute abuse, neglect, exploitation, and misappropriation of resident property, reporting procedures, and dementia management and resident abuse prevention; --The facility will provide ongoing oversight and supervision of staff to assure that its policies are implemented as written. Review of CNA E's time sheet, showed: -On 1/25/23, employee worked 9:45 A.M. to 6:42 P.M.; -On 1/26/23, employee worked 8:37 A.M. to 10:13 A.M. Review of Resident #2's significant change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/13/22, showed: -Brief Interview for Mental Status (BIMS) score of nine out of a possible 15, showed the resident with moderate cognitive impairment; -Behavioral symptoms and rejection of care not exhibited; -Limited assistance of one person physical assist required for eating; -Upper extremity impairment on one side; -Diagnoses included stroke, hemiplegia (paralysis on one side of the body) or hemiparesis (weakness on one side of the body), generalized muscle weakness, need for assistance with personal care, altered mental status, and cognitive communication deficit. Review of the resident's BIMS evaluation, dated 1/26/23, showed a score of 15, which showed the resident cognitively intact. Review of the resident's care plan, in use at the time of survey showed: -Focus: Resident has an activities of daily living (ADL) self-care performance deficit with eating, toileting, transfers, bed mobility and dressing with one to two assist as needed; -No documentation indicating the resident exhibits behaviors or makes false accusations. Review of the facility's initial self-report, submitted to the Department of Health and Senior Services (DHSS) on 1/26/23, showed: -Reporting category: Abuse; -Date and time of alleged incident: 1/26/23 at 9:45 A.M; -Resident involved: Resident #2; -Staff involved: CNA E; -Summary: Certified Occupational Therapy Assistant (COTA) reported the following to the Administrator, DON, Assistant Director of Nurses (ADON), and Social Services Director (SSD). COTA was working with resident and remarked on a new bruise and scratch on the resident's upper right arm. When asked where it came from, the resident said in the dining hall, CNA E grabbed his/her arm and hit him/her in the forehead. Resident described the specific incident that occurred when CNA E grabbed his/her arm very tightly and twisted it while digging his/her nails in. Resident said he/she was fearful because CNA E told him/her, If you ever breathe a word to anyone, you're dead. The resident was afraid to report sooner because of the threat made by the employee. Review of COTA's statement, dated and submitted to DHSS on 1/26/23, showed on 1/26/23, the resident explained an incident occurred last night, 1/25/23, in the dining area at dinner. The resident states a person hit him/her on the forehead, grabbed his/her arm and twisted it, and dug his/her nails into the resident's arm. The person took the resident's food away and grabbed his/her stuffed animal dog and threatened to shred it. The bruise on the resident's right arm above the elbow is a darker red/purple color and there is a scratch. Review of the resident's progress notes showed: -Nurse's note, dated 1/26/23 at 10:24 A.M., in which Director of Nurses (DON) C documented physician notified of new bruises and skin tears. Wound nurse will conduct full body assessment; -Skin/wound note, dated 1/26/23 at 11:12 A.M., in which the Wound Care Nurse (WCN) documented a skin assessment was conducted. The resident had a new bruise to the inner portion of his/her right arm, 0.8 centimeters (cm) x 3.0 cm x 0 cm. The resident denied pain; -Nurse's note, dated 1/26/23 at 11:16 A.M., in which the WCN documented she spoke with the resident regarding the incident that occurred. The resident said he/she was fearful. The WCN assured the resident there was no need to feel fearful; that the person was no longer in the building. For comfort, the resident was given his/her stuffed dog. Observation on 4/5/23 at 9:45 A.M., showed the resident sat in a reclining chair with a stuffed toy dog underneath his/her left arm and shoulder. During an interview, the resident said a person was mean to him/her one time. The person threw his/her arms all around and threw his/her dog on the floor. The person grabbed his/her arm. The resident was unable to recall additional information specific to the incident. During an interview on 4/5/23 at 10:24 A.M., Housekeeper F said he/she was in the dining room during dinner when he/she saw CNA E sitting at a table with the resident. The resident said he/she wanted to eat and CNA E told the resident he/she had to wait. The resident asked for his/her juice and CNA E grabbed the resident's arm and said, If you reach for that juice again, I'm gonna break your arm. The resident tried to pull his/her arm back and looked at CNA E like he/she could not believe what just happened. The resident has some confusion, but he/she knows when something is wrong. Housekeeper F left the dining room, finished his/her work and left for the day. He/She did not report the incident to anyone, because he/she was stunned and shocked by what he/she saw. The next day, Administration asked about the incident and he/she provided a statement. If he/she could do the situation over again, he/she would have reported the incident to a supervisor when it happened. During an interview on 4/6/23 at 2:42 P.M., CNA G said a couple months ago, he/she observed an employee in the dining room, arguing with the resident. The resident was getting upset because he/she wanted his/her drink and the employee was holding it back. The resident does not eat much, but does like to drink. He/She has a stuffed toy dog and the employee kept taking it away from him/her. CNA G tried to tell the employee to stop. He/She did not report the incident that day. The ADON called CNA G about it the next day, and CNA G told the ADON what he/she saw. During an interview on 4/5/23 at 9:51 A.M., the COTA said while doing therapy with the resident in his/her room one morning, the COTA noticed a red bruise on the resident's upper right arm, approximately 2.0 inches (in) x 1.0 in, with a large red scratch within the bruise. The COTA asked the resident what happened, and he/she said in the dining room the night before, someone pushed his/her meal tray away and hit him/her in the forehead. The person twisted his/her arm and threatened to shred his/her toy dog. The person told the resident if he/she ever spoke of it, he/she would never see the light of day. The resident was very calm, but upset, when describing the incident. He/She described the incident in detail and was able to answer questions appropriately. Sometimes the resident has confusion, but overall, his/her memory was pretty good. The resident was able to remember things discussed in therapy weeks before. After the resident described the incident, the COTA reported it to the SSD and Administrator A (the previous Administrator of the facility). Administrator A, the COTA, the SSD, and the previous DON (DON C), met with the resident in the front office. The resident reported his/her account of what happened in the same exact way he/she did earlier. He/She was unable to recall the name of the person who twisted his/her arm, but provided a physical description that matched CNA E. During an interview on 4/5/23 at 10:37 A.M., the SSD said around 9:00 A.M. on 1/26/23, the COTA came to her office and reported the resident said someone grabbed his/her arm and hit him/her in the head. The person was mean to the resident's toy dog, took it away, and told the resident he/she could not have it back. The SSD observed a bruise and small cut on the resident's arm. The SSD reported the allegation to Administrator A. Administrator A, DON C, the ADON, the SSD, and the COTA interviewed the resident. The resident repeated the same exact story he/she gave to the COTA. The resident had some memory issues, but he/she repeated the same account of events, even when the same question was asked in a different way. The resident did not know the name of the person who grabbed him/her, but provided a physical description that matched CNA E. The resident was nervous about the employee finding out he/she told about what happened. The SSD interviewed other residents and Resident #5 said he/she witnessed the incident. Resident #5 was very cognitively intact. Review of Resident #5's quarterly MDS, dated [DATE], showed a BIMS score of 15, which showed the resident cognitively intact. During an interview on 4/5/23 at 10:54 A.M., Resident #5 said he/she could not recall the date or the name of the employee involved, but he/she saw an employee throw Resident #2's stuffed toy dog on the floor in the dining room. Resident #5 picked up the dog and handed it to Resident #2. The employee said no, Resident #2 could not have the dog, and put the dog back on the floor. What the employee did was cruel. During an interview on 4/5/23 at 11:13 A.M., the WCN said on 1/26/23, she was called to the SSD's office, where Administrative staff were sitting with Resident #2. The resident had already been interviewed and said someone hit him/her. The ADON asked the WCN to complete a skin assessment and they brought the resident to his/her room. During the skin assessment, the WCN observed about three bruises, approximately the size of dimes, on the inside of the resident's upper arm. The ADON asked the resident about what happened and the resident said someone hit him/her. He/She said something about his/her dog being dropped. The resident had a stuffed toy dog he/she uses as a pillow. The resident considers the dog as a friend. It would be antagonistic and abusive to threaten or take away the resident's dog. During the skin assessment, CNA E passed down the hall and stopped in the doorway to the resident's room. The resident said CNA E was the person who hit him/her. During an interview on 4/5/23 at 11:25 A.M., the ADON said she was present during Administration's interview with the resident on 1/26/23. The resident said at the table in the dining room, an employee bumped the resident in the head and scratched his/her arm. The employee took the resident's stuffed toy dog and threw it on the floor. The resident had a stuffed toy dog that the resident used as a pillow and considered as a friend. The resident had some confusion and his/her cognitive status fluctuated, but his/her story that day was consistent. The resident gave a physical description of the employee that matched CNA E. After the resident's interview, the ADON and the WCN took the resident to his/her room for a skin assessment. The ADON observed a scratch on the resident's upper arm. The resident had not had any recent falls. CNA E stopped at the resident's doorway and the ADON asked him/her if he/she had a snack for the resident. CNA E said no, he/she did not have anything for the resident because the resident hit him/her in the head. The resident said, No, you hit me and took my dog. The resident said CNA E was the person who hit him/her. The allegations made by the resident would be considered abuse. If staff witnessed a coworker being abusive, the ADON would have expected staff to immediately report the situation to the Administrator. An alleged perpetrator should be separated from the resident and suspended pending investigation in order to protect all residents from potential further abuse. During an interview on 4/6/23 at 8:21 A.M., CNA E said a couple months ago, he/she was feeding Resident #2 at dinner. The resident had use of one of his/her arms and not the other. The resident knocked CNA E's hand out of the way, causing CNA E to drop the spoon. The resident hit CNA E in the face, so CNA E grabbed the resident's arm and blocked it. CNA E denied withholding food from the resident, hitting the resident, threatening the resident, or taking the resident's stuffed toy dog. After dinner, CNA E continued working the rest of his/her shift and clocked out around 6:00 P.M. He/She worked for several hours the next morning before he/she was let go by the Administrator. During an interview on 4/6/23 at 12:02 P.M., DON C said on 1/26/23, the SSD made her and Administrator A aware of an allegation of abuse. They interviewed the resident, who said a person dug his/her nails into the resident's arm. DON C observed two small scratches on the resident's upper arm. During an interview on 4/6/23 at 1:25 P.M., Administrator A said she was the facility's Administrator at the time of the incident in January 2023. On the morning of 1/26/23, the COTA and the SSD notified her and DON C of an allegation of abuse. They interviewed the resident, who provided a vivid description of what occurred. The resident said an employee grabbed his/her arm and did something to his/her dog. He/She was fearful of the employee finding out he/she reported because the employee had threatened him/her. The resident's story was clear, consistent, and did not waiver. The resident can be confused at times and completely lucid at other times. The SSD completed a BIMS on the resident that day, which showed a score of 15. The resident had a scratch and bruise on his/her arm. He/She provided a detailed description of the employee, which matched the description of CNA E. While the ADON and the WCN completed a skin assessment on the resident, CNA E walked by the room and the resident pointed at him/her and said CNA E was the one who hit him/her. CNA E was suspended and provided a written statement about some form of incident with the resident. Based on the investigation, Administrator A substantiated the allegation of abuse. MO00213191