**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and interviews with residents, facility staff, the Medical Director, the Lieutenant from the Police Department, resident's family friend, and the resident's responsible person (RP), the facility failed to protect the resident's right to be free from resident-to-resident abuse for 2 of 3 residents reviewed for abuse (Resident #15 and Resident #57). On 4/12/24 while completing morning rounds, Nurse Aide (NA) #6 found Resident #366 in Resident #15's room, lying on top Resident #15 while she was asleep in her bed, with his brief pulled down and his penis exposed. Resident #15's brief appeared to be sideways, undone on the left side, but was in place between her legs. Resident #366 was placed on one-to-one supervision at this time due to wandering and sexualized behaviors. Both residents were severely cognitively impaired. On 12/18/24 Resident #57 and Resident #36 (Resident #57's roommate) had their call light on and motioned for NA #1 to come into the room. Resident #36 spoke first and reported to NA #1 that Resident #366 came into the room took his pants off and got on top of Resident #57 and raped her. Resident #57 nodded her head in agreement and stated she told them to get off of her and get out of her room and they left. Both residents were assessed as cognitively intact. Resident #366 was supposed to be under one-to-one supervision at the time of the incident on 12/18/24 due to his continued wandering and sexualized behaviors and NA #2 left him unattended. A reasonable person would expect to be free from abuse in their own home and could experience altered mental condition, fear, anxiety, and depressed mood. The findings included: A. Resident #15 was admitted to the facility on [DATE]. Diagnosis included Alzheimer's disease, dementia, and muscle weakness. Review of the annual Minimum Data Set (MDS) dated [DATE] revealed Resident #15 was severely cognitively impaired and required substantial assistance for mobility and dependent on staff for transfers and toileting due to being incontinent of bladder and bowel. Resident #15 was also coded for having adequate hearing and vision, usually able to make herself understood, and usually able to understand others. Resident #366 was a [AGE] year-old male admitted to the facility on [DATE]. Diagnosis included a traumatic brain injury (TBI), altered mental status, and cognitive communication deficit. Review of Resident #366's facility face sheet dated 4/14/23 revealed Cleveland County Department of Social Services as his responsible person and guardian. Review of quarterly MDS dated [DATE] revealed Resident #366 was severely cognitively impaired, independent for mobility, supervision for transfers, partial assistance with toileting as he was always continent for bowels with frequent urinary incontinence. Resident #366 was also ambulatory, utilized a wheelchair for long distances, able to make himself understood, able to understand others, adequate vision, and no hearing deficits. Resident #366 was not coded for any wandering or behaviors. A telephone interview with NA #6 on 1/30/25 at 8:30 AM revealed she typically worked 11:00 PM to 7:00 AM on the locked memory care unit and was familiar with Resident #15 and the incident regarding Resident #366. She stated in April 2024 she worked in the locked memory care unit and while completing her morning rounds, she had entered Resident #15's room and saw Resident #366 on top of Resident #15 who was sleeping in her bed. NA #6 revealed Resident #366's pants and brief were pulled down with his penis exposed and Resident #15's brief was sideways, undone on the left side but still in place between her legs, her gown was pulled down, and her breasts were covered. NA #6 stated she immediately removed Resident #366 from Resident #15's bed, called for Nurse #6 to come to Resident #15's room, explained to Nurse #6 what happened and was then instructed for Resident #366 to be placed on one-to-one supervision. NA #6 revealed she assisted Resident #366 back to his room and stayed with him while Nurse #6 assessed Resident #15 and notified the Administrator. NA #6 stated after the incident, Resident #366 was moved from the memory care unit to a room on the regular hall and to her knowledge remained on one-to-one supervision. NA #6 revealed that prior to the incident with Resident #15, she was not aware of Resident #366 having any type of behavior and had never witnessed him display those types of sexualized behaviors. Attempted to contact Nurse #6 who was unable to be reached. Review of interdisciplinary team (IDT) progress note dated 4/12/24 revealed on the morning of 4/12/24 staff found Resident #366 in a severely cognitively impaired female resident's room (Resident #15). Resident #366 was observed lying on top of Resident #15 with his brief pulled halfway down and his penis exposed. Resident #15 was asleep at the time, but her brief was noted to be sideways, undone on the left side, but still in place between her legs. Resident #366 was immediately placed on one-to-one supervision which required him to always be in the staff's line of sight due to the sexualized and wandering behaviors. Resident #366 was also moved off the locked memory care unit to room [ROOM NUMBER] on B hall and one-to-one supervision to remain on-going. Review of the Medical Director progress noted dated 4/12/24 for Resident #15 revealed the following: Examination of Resident #15 due to history of a male resident [Resident #366] being on top of Resident #15 while she was in her bed. The Medical Director noted apparently around 6:30 AM a male resident [Resident #366] was found on top of Resident #15; his penis was out and Resident #15's brief was pulled to the side. According to the nursing staff, Resident #15 was asleep when they found her, was asleep when Medical Director went to see her, and remained asleep during Medical Director exam. Resident #15 had severe dementia. The Medical Director revealed to the best of his knowledge it did not seem that Resident #15 was penetrated at all, there were no scratch marks or other marks visible on Resident #15's hands, body, or in her vaginal area. Review of the Medical Director progress note dated 4/12/24 for Resident #366 revealed the following: Around 6:30 AM, Resident #366 was found on top of a female resident [Resident #15] with his penis exposed and Resident #15's diaper was also possibly pulled to the side. Resident #366 was pulled off Resident #15 immediately and apparently placed on one-to-one. This had never happened with Resident #366 before; he did not seem agitated at the time, and there had been no knowledge of any behaviors leading up to this problem. Resident #366 did have a long mental health history he was being treated for with no recent changes to his medications. Hospital evaluation recommended by psychiatric (psych) services. Resident #366 returned from his evaluation from the local hospital and per their report, Resident #366's computed tomography (CT) scan and bloodwork showed no evidence of any acute abnormalities, and his urinalysis was negative. The Medical Director noted Resident #366 exposed himself on the way back from the hospital which was totally abnormal behavior. Resident #366 presently has one-to-one supervision for safety risks for both residents and staff. The Medical Director revealed he spoke with the psych provider who recommended new medications and agreed with Resident #366's one-to-one supervision for his and other residents' safety. Review of facility 5-day investigation report completed by the previous Administrator dated 4/18/24 revealed their investigative findings included the following: On the morning of 4/12/24 while NA #6 was making her rounds on the locked memory care unit when she entered Resident #15's room and found Resident #366 on top of Resident #15 who was sleeping, with his pants and brief pulled halfway down exposing his penis. Resident #15's gown was on, her breasts were covered, and her brief was sideways, appeared to be undone on the left side, but still in place between her legs. NA #6 notified Nurse #6 and Resident #366 was removed from Resident #15's room, taken back to his room, and immediately placed on one-to-one supervision. Resident #15 was assessed by Nurse #6 with no findings and continued sleeping. Law enforcement, Department of Social Services, State, Medical Director, and Resident #15's RP was notified of the incident. The facility Medical Director completed a physical examination of Resident #15 that included thorough examination of the vaginal and peri areas and found no indication that any sexual contact had occurred. Resident #15's RP declined the facilities offer to send her out to the hospital for any further evaluations. Both Resident #15 and Resident #366 were severely cognitively impaired and resided in the facility locked memory care unit. Resident #366 was not admitted with this type of behavior and prior to this incident had not displayed any types of behaviors that would cause staff to be aware of the potential for this type of behavior. Resident #366 was sent out to the hospital emergency department for evaluation and returned with no issues noted. Resident #366 was removed from the locked memory care unit into a room on a regular hall, remained on one-to-one supervision, monitored by the Medical Director, and was being evaluated and treated by psych services. Resident #15 was monitored for any psychosocial changes, mental anguish, change in her demeanor, or alterations in her daily activities and no issues were noted and Resident #15 remained pleasant and cooperative and appeared to have no negative impact. All facility staff were educated on abuse and neglect policies and procedures, wandering residents, new behaviors, and one-to-one supervision process. The facility was not able to substantiate abuse or neglect against any residents, and the residents involved remained without any physical injury, mental harm, pain, or anguish. Review of Resident #366's care plan initiated on 4/12/24 revealed Resident #366 had exhibited inappropriate sexualized behaviors and was noted to continue sexualized behaviors such as masturbating while in bed with a goal to not exhibit any of these sexual behaviors any further through the next review. Interventions for Resident #366 included allowing privacy for masturbation in his room, new medications ordered for sexual behaviors and send out to emergency room for medical and psych clearance. Resident #366 also had a care plan approach for being an elopement risk and wanderer with goals of not leaving the facility unattended and maintaining his safety through the next review. Interventions for Resident #366 included one-to-one observation, monitoring locations, and documenting wandering behaviors. Attempted to contact the previous Administrator who was unable to be reached. B. Resident #36 was admitted to the facility on [DATE]. Diagnosis included chronic pulmonary obstructive disease (COPD) and muscle weakness. Review of quarterly MDS dated [DATE] revealed Resident #36 was cognitively intact with adequate vision and hearing, able to make herself understood, and able to understand others. Resident #57 was admitted to the facility on [DATE]. Diagnoses included mild dementia, Alzheimer's disease, chronic obstructive pulmonary disease (COPD), and muscle weakness. Review of admission Minimum Data Set MDS dated [DATE] revealed Resident #57 was cognitively intact and required partial assistance with mobility, substantial assistance with transfers, and substantial assistance with toileting as she was always incontinent for both bladder and bowel. Resident #57 was also coded for oxygen use and utilized a wheelchair for mobility, adequate vision and hearing, able to make herself understood, and able to understand others. Resident #102 was admitted to the facility on [DATE]. Diagnosis included COPD and type 2 diabetes. Review of admission MDS dated [DATE] revealed Resident #102 was cognitively intact with adequate vision and hearing, able to make herself understood, and able to understand others. Resident #366 was a [AGE] year-old male admitted to the facility on [DATE]. Diagnosis included a traumatic brain injury (TBI), altered mental status, and cognitive communication deficit. Review of Resident #366's facility face sheet dated 4/14/23 revealed Cleveland County Department of Social Services as his responsible person and guardian. Review of Resident #366's care plan revised on 6/11/24 revealed Resident #366 had exhibited inappropriate sexualized behaviors and was noted to continue sexualized behaviors such as masturbating while in bed with a goal to not exhibit any of these sexual behaviors any further through the next review. Interventions for Resident #366 included allowing privacy for masturbation in his room, new medications ordered for sexual behaviors and send out to emergency room for medical and psych clearance. Resident #366 also had a care plan approach for being an elopement risk and wanderer with goals of not leaving the facility unattended and maintaining his safety through the next review. Interventions for Resident #366 included one-to-one observation, monitoring locations, and documenting wandering behaviors. Review of quarterly MDS dated [DATE] revealed Resident #366 was severely cognitively impaired, independent for mobility, supervision for transfers, partial assist with toileting as he was always continent for bowels with frequent urinary incontinence. Resident #366 was also ambulatory, utilized a wheelchair for long distances, able to make himself understood, able to understand others, adequate vision, and no hearing deficits. Resident #366 was also coded for wandering and for physical and verbal behaviors towards others such as scratching, grabbing, threatening, screaming, cursing, or abusing others sexually. Review of facility incident report completed by the Administrator revealed on 12/19/24 at 1:30 AM the following information was reported: [Resident #36] rang her call bell to alert staff that someone had wandered into their room and attempted to climb onto the bed with her roommate [Resident #57]. [Resident #57] had a BIMS (brief interview for mental status) of 15 and stated no inappropriate touching had taken place. Investigation was underway. [Resident #57] was being placed on one-on-one temporarily. Nursing Home Administrator (NHA) and the Director of Nursing (DON) were in the facility to conduct full investigation and ensure resident's safety. [Resident #57] stated that she felt safe at the facility. The incident report also revealed law enforcement had been contacted on 12/19/24 at 3:00 AM. An interview with Resident #57 on 01/30/2025 at 4:09 PM revealed one night a black woman [Resident #366] had come into Resident #57's room, got on top of her, and tried to feel of her. When Resident #57 told the black woman [Resident #366] to get off and get the hell out of her room initially she would not get off her so Resident #57 used her hands fight to get her off and to leave. Resident #57 stated on that night she was wearing her gown but could not remember if her gown was pulled up or was down and Resident #57 did not recall if she was wearing a brief or not. A telephone interview was conducted with Nursing Aide (NA) #1 on 1/30/25 at 8:49 AM and revealed she was familiar with Resident #57 and the alleged incident regarding Resident #366. She stated on the evening of 12/18/24 she was scheduled to work 11:00 PM to 7:00 AM and was assigned to the A hall which included Resident #57's room. She revealed while reviewing her room assignments at the A hall nurse desk she observed Resident #366 sitting in his wheelchair at the desk with his assigned one on one (NA #3). NA #1 stated when she went down the A hall, she saw that three resident call lights were on including Resident #57's room. She revealed after answering the first two call lights, she went in to answer Resident #57's call light around 11:17 PM and upon entering the doorway to the room she observed both Resident #57 and her roommate Resident #36 to be alert and awake and were motioning for her to come into their room. She stated when she entered the room, she noticed there was a brief lying on the floor near the trash can and a brief lying at the end of Resident #57's bed and she asked both residents what was going on in there. NA #1 revealed Resident #36 then informed her that she saw Resident #366 come into their room, took off his pants, got on top of Resident #57 and raped her and that Resident #57 told Resident #366 to get off of her and get the hell out of their room, so he got up and left. She stated Resident #57 was shaking her head in agreement with what her roommate Resident #36 was saying and then stated, I told them to get off of me and get the hell out of the room and they left. NA #1 revealed she pulled back Resident #57's comforter and observed Resident #57 was not wearing a brief, so she immediately stopped and began yelling out for assistance from the other nursing staff to stay with the residents while she went to inform the nurse what was just reported to her. She stated she was not able to get any other staff to come into the room at that time, so she called the Director of Nursing (DON), which she believed to be around 11:30 PM to let her know what had been reported to her by both residents and that Resident #57 was not wearing a brief. She stated while on the telephone with the DON, she informed her that she was on her way and for NA #1 to stay with the residents, not to leave the room, not to touch anything in the room, and not to provide any type of personal care or incontinence care to Resident #57. She revealed the DON also inquired where Resident #366 was, and she informed her the last time she had seen Resident #366 he was sitting in his wheelchair at the nurse's desk with his assigned one to one. NA #1 stated she stayed in the resident's room until the DON and Administrator arrived and they asked her to step out of the room while they spoke with both residents privately. She revealed as she was leaving the resident's room, Resident #366's roommate (Resident #102) whose room was located directly across from Resident #57 room, motioned for her to come into their room. She stated Resident #102 informed her that earlier in the evening his roommate Resident #366's one on one had left the room and Resident #366 had gotten up out of his bed and attempted to get into bed with him. NA #1 revealed Resident #102 stated he asked Resident #366 what he was doing which seemed to startle Resident #366 and he got up from Resident #102's bed and watched him walk across the hall to Resident #57's room. She stated Resident #102 revealed he saw Resident #366 bend down, remove his pajama pants, get on top of Resident #57 and was moving around. She revealed Resident #102 stated he then heard Resident #57 yell get off of me and to get out of her room and saw Resident #366 get off the bed, put his pajama pants back on, leave Resident #57's room and walk down the hall. NA #1 stated after speaking with Resident #102 she finished her rounds with her other residents, went to the nurse station and notified NA #3 what Resident #57, Resident #36, and Resident #102 had reported and NA #3 informed her that when she had come back from her break a little before 11:00 PM, she had observed Resident #366 walking down the hallway unattended without his one to one. She revealed while at the nurse's station she began writing her handwritten statement about what had been reported to her by the residents and what she had observed, when she was asked to go back into Resident #57 room to sit with her. She revealed when she arrived back at the room, Resident #57 was still not wearing her brief, had used the bathroom on herself and was complaining about feeling wet and her gown and bedding being wet. NA #1 stated she then contacted the DON who was still in the building and asked if she could provide Resident #57 incontinence care and the DON and the Administrator came back into Resident #57 room. She revealed she was asked to step out of the room again but assumed the DON had cleaned and provided Resident #57 incontinence care, because when she returned to Resident #57 room afterwards, she was wearing a clean brief, and her gown and bedding had been changed. Attempted to contact NA #2 by telephone and was unable to be reached. A telephone interview was conducted with NA #3 on 1/30/25 at 9:23 AM revealed she was familiar with Resident #57 and the alleged incident regarding Resident #366. On 12/18/24, NA #3 was scheduled to work 7:00 PM to 7:00 AM on the A hall and her shift assignment was to provide one-to-one supervision for Resident #366. NA #3 revealed resident one-to-one supervision included being within arm's reach while the resident was up or ambulating around the facility and while the resident was in their room or sleeping the one-to-one was to sit outside the room and maintain line of sight. NA #3 stated on the evening of 12/18/24 she had assisted Resident #366 with turning on his TV and getting ready for bed and then asked NA #2 who was agency staff but had worked at the facility for several months and was aware of the one-to-one supervision protocol to come down and relieve her for her break which NA #2 agreed. NA #3 revealed that as she was leaving to go to break at 10:27 PM according to her watch and the time clock she notified the A hall nurse who was sitting at the nurse's desk that she was going on break and NA #2 was covering Resident #366's one-to-one supervision. NA #3 stated when she returned from her break at 10:51 PM and rounded the corner to A hall she observed Resident #366 three doors down from his room, walking the hallway unattended, wearing his pajama pants and a t-shirt. NA #3 revealed she did not see NA #2 anywhere in sight, so she assisted Resident #366 back to his room where she noticed he was not wearing a brief which was not uncommon because he would take them on and off, got him into his wheelchair and took him to sit with her at the A hall nurse's desk. NA #3 stated right after the 11:00 PM shift change while she and Resident #366 were sitting at the nurse's desk, NA #2 came up to the desk and she informed NA #2 that upon her return from break she had found Resident #366 walking around the A hall unattended and NA #2 apologized stating that she had gone to answer another resident's call light and had left Resident #366 unattended. NA #3 revealed that sometime around midnight while she and Resident #366 continued to sit at the nurse's desk, the Administrator and DON came in and went down the A hall and a few minutes later NA #1 came up to her and told her that Resident #36 had reported to her that Resident #366 had come into her and Resident #57's room, removed his pajama pants, got on top of Resident #57 while she was lying in her bed and raped her, Resident #57 yelled at Resident #366 to get off her and to get out of her room and Resident #366 left the room and walked down the hall. NA #3 stated NA #1 reported that Resident #57 had agreed with everything her roommate, Resident #36, was saying. NA #3 reported that as NA #1 was leaving Resident #36 and Resident #57's room, was when Resident #366's roommate (Resident #102) had motioned for NA #1 to come into his room. Resident #102 then reported to NA #1 that when Resident #366's one-on-one left the room, Resident #366 attempted to get into his bed and when he asked him what he was doing he got up and left. Resident #102 stated he saw Resident #366 walk across the hall into Resident #57's room, remove his pants, get on top of Resident #57 who was lying in her bed, move around on top of Resident #57, and when he heard Resident #57 yell at Resident #366 to get off of her and to get out of her room, Resident #102 saw Resident #366 get off Resident #57, put his pants back on, leave the room, and walk down the hall. NA #3 revealed she then informed NA #1 that when she had returned from her break earlier that evening, she had witnessed Resident #366 walking around the A hall unattended 3 doors down from his room. NA #3 also informed NA #1 that NA #2 was supposed to be covering her break and providing one-to-one supervision for Resident #366 but had left him attended while she went to answer a call light. NA #3 recalled a few minutes later after speaking with NA #1, was when NA #1 was asked to go back into Resident #57's room. NA #3 revealed while the Administrator and DON were walking back up the hallway from Resident #57's room was when she informed both about when she had returned from her break, she found Resident #366 walking around the A hall three doors down from his room, he was unattended wearing only his pajama pants, t-shirt, and no brief. NA #3 also reported to the Administrator and the DON that NA #2 was supposed to be covering her break and providing one-to-one supervision to Resident #366, and while providing Resident #366's one-to-one supervision NA #2 went to answer a call light and left Resident #366 unattended. NA #3 stated that after she was informed what Resident #57 had reported, she asked Resident #366 what had happened while he had been walking around the hall, and he stated that he had gone in to get into bed with his wife and he was touching and kissing on her but she didn't like it and told him to get out, so he left. An interview with Resident #36 who on 1/29/25 at 12:40 PM revealed she recalled being roommates with Resident #57. When asked if anything had ever happened while she and Resident #57 had been roommates, she stated she did remember this one time where a black man had come into their room, got on top of Resident #57, she told them to get out and they left. She stated after that she believed Resident #57 moved rooms and nothing ever happened again. Resident #36 could not recall who she had spoken with on the night of the incident or any further details about the incident. A telephone interview with Resident #102 on 1/30/25 at 3:08 PM revealed on the evening of 12/18/24 he was lying in his bed, and his roommate Resident #366 was lying in his bed, when Resident #366's one-to-one staff left the room, Resident #366 got up out of his bed and tried to get into bed with him. Resident #102 stated it seemed to startle Resident #366 when he asked him what he was doing, and that was when Resident #366 got up from Resident #102's bed, left their room, walked across the hall, and into Resident #57's room. Resident #102 stated Resident #57's room was dark, but he was still able to see into the room with the hallway lights. Resident #102 revealed he saw Resident #366 remove his pants, get on top of Resident #57 while she was lying in her bed, and witnessed Resident #366 moving around on top of Resident #57. Resident #102 reported he could not tell if Resident #366 was wearing his brief or not while on top of Resident #57. Resident #102 stated he then heard Resident #57 tell Resident #366 to get off of her and get the hell out of her room and he saw Resident #366 exit off the left side of Resident #57's bed, walk around the end of the bed, put his pants back on, exit Resident #57's room, and walk down the hall. Resident #102 stated he would have used his call light to let staff know what had happened, but his call light had gotten tangled up and he couldn't find it. Resident #102 reported a few minutes later Resident #366's one-to-one came back into their room to get Resident #366's wheelchair, and appeared frazzled, so he did not tell her about what he had witnessed either. Resident #102 revealed a few minutes after Resident #366 one-to-one had come into his room, he saw NA #1 go into Resident #57's room and when he saw her leaving Resident #57 room was when he motioned for NA #1 to come into his room, and he told NA #1 what he had witnessed between Resident #366 and Resident #57, and then repeated this same information to the Administrator, and law enforcement. A telephone interview with Resident #57's friend on 01/30/2025 at 3:50 PM revealed she had been Resident #57 previous caretaker prior to her coming to the facility and continued to visit with her often. She stated on 12/26/24 she was visiting with Resident #57 when she suddenly became quiet, looked at her and said, I have something to tell you. Resident #57's friend stated she asked Resident #57 what she needed to tell her, and she said, I was raped. When asked what she was talking about, Resident #57 stated I was raped by a black woman [Resident #366], she got on top of me, and I had to tell her to get off me and out of my room. Resident #57's friend then asked if anyone had come into her room when this was going on and she said no. When she asked Resident #57 if she was ok and felt safe at the facility she said yes. Resident #57's friend stated she did not ask any further questions about the incident and Resident #57 had seemed fine, but it bothered her to think Resident #57 had gone through something like this. Review of physician progress note written by the Medical Director on 12/20/24 indicated he was asked to see Resident #57 for questions about an incident that happened the night before and was unclear whether Resident #366 had assaulted her. While the Medical Director was talking with Resident #57, she stated that nothing happened, but someone did come into her room. It was really unclear to the Medical Director whether she knew exactly what happened, but the incident was being investigated. Resident #57 did not seem to be more anxious now or change in her mental status from previous. In speaking with Resident #57 today, it did not appear like there had been any trauma that he could think of but obviously the whole incident had to be anxiety provoking, however, he could not get a real history of what happened. Again, there were no signs of believed trauma but certainly wanted her seen by mental health provider and discussed all of this with Resident #57's RP. During an interview with the Medical Director on 1/28/25 at 11:09 AM he stated that he was aware of the alleged incident with Resident #57 and Resident #366. He stated the date of his progress note 12/20/24 was when he was notified, and he assumed the incident had occurred the night before on 12/19/24 and was not made aware the incident had occurred on the evening of 12/18/24. He revealed he did speak with Resident #57's RP on 12/19/24 regarding a sleep medication the RP wanted stopped, but he could not recall if she had mentioned anything to him about the incident, he only recalled that he discontinued Resident #57's sleep medication as requested. The Medical Director stated he was asked on 12/20/24 regarding an incident where Resident #366 had come into Resident #57's room and gotten onto her bed, she asked him to leave her room and he did, and it was unclear if any type of assault had occurred. He revealed that when he saw Resident #57 on 12/20/24 he only attempted to speak with her about the incident, but did not complete any type of physical exam. He stated Resident #57 would not really give him any details about the incident, only that someone had come into her room, but he did not feel that she was showing any signs or symptoms that any type of trauma or injuries had occurred. The Medical Director revealed to his knowledge Resident #57 had never showed any signs of increased anxiety or changes to her mental status and she was followed by psych services, and he was not aware of them noting any issues or concerns stemming from the incident. He stated Resident #366 was supposed to always be on one-to-one supervision due to sexualized behaviors, wandering, and an incident that occurred with another female resident earlier in the year. He revealed it appeared the one-on-one process failed allowing Resident #366 the opportunity to go into Resident #57's room which should have never been allowed to happen, Resident #366 was not suitable for skilled nursing level and not matter how much his medications were increased he would continue to require one-on-one super[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and resident, family member (RP), staff and Medical Director (MD) interviews, the facility failed to ensure safe securement per manufacturer recommendations of a resident during a van transport. Resident #1 flipped backwards in his wheelchair, hitting the van floor while being transported in the facility's transportation van when the transportation van drove over a speedbump located along the steep driveway leading to the facility. Resident #1 sustained a hematoma to the back of his head, a skin tear to his right hand and skin tear to his right wrist. This practice had the high likelihood of causing serious injury for 1 of 3 residents reviewed for accidents (Resident #1). The immediate jeopardy began on 12/21/23 when Resident #1 flipped backwards in his wheelchair hitting the transportation van floor. The immediate jeopardy was removed on 1/6/24 when the facility implemented a credible allegation of immediate jeopardy removal. The facility will remain out of compliance at lower scope and severity D (no actual harm that is immediate jeopardy) to ensure monitoring systems are put into place are effective. The findings included: Review of the manufacturer's instructions for the 4-point wheelchair securement system (the system used on the facility's transport van to secure residents who are seated in wheelchairs during transport) indicated the following instructions were to be followed: 1)center the wheelchair facing forward in the securement zone and lock wheelchair brakes, 2) attach 4 retractors into floor anchorage points and lock them in place with an approximate distance of 48-54 between the front and rear retractors. 3) completely pull out the arch webbing and attach J-hooks and compliant chair securement points near seat level at a 45-degree angle. 4) move wheelchair forward and backwards to remove webbing slack or manually tension webbing with retractor knobs. 5) make sure the chair's pelvic belt is buckled over the occupants hips 6) attach shoulder belt pin connector to pin located on the shoulder belt height adjuster 7) pull shoulder belt over occupants chest and attach shoulder belt pelvic connector to pin on pelvic belt and adjust shoulder belt height so it rest on the shoulder belt. 8) attach shoulder belt pin connector to pin on rear retractor closest to the wall 9) attach the removeable pelvic belt pin connector to pin on rear retractor closest to the aisle. 10) Pull the shoulder belt over the occupant's chest and buckle shoulder belt pelvic connector to remove pelvic belt. Resident #1 was admitted to the facility on [DATE] with diagnoses that included aftercare following surgery for acquired absence of the left lower extremity below the knee (surgical amputation), osteoarthritis and diabetes. A quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #1 was cognitively intact and required assistance for transfers and locomotion of his wheelchair. A nurse progress note dated 12/20/23 indicated Resident #1 was scheduled for a follow-up visit with the general surgeon on 12/21/23 at 4:40 PM. A nurse progress note dated 12/21/23 written by Nurse #1 indicated following the completion of a full body assessment, post a fall in the facility van, the on-call provider was notified of the injuries to Resident #1's head and right upper extremity. The on-call provider provided Nurse #1 with new orders to contact Resident #1's responsible party (RP) to determine if he/she wished to have further evaluation of Resident #1's injuries to include a computed tomography (CT) or be sent to the emergency room (ER). The note further indicated after Nurse #1 spoke to Resident #1 and his RP about the orders from the on-call provider, they both agreed to have Resident #1 monitored in the facility and not transfer him to the ER at that time. An incident report completed by Nurse #1 dated 12/21/23 at 5:30 PM indicated Resident #1 had returned to the facility following transport from an appointment. The report revealed Nurse #1 was notified that Resident #1 fell back in his wheelchair and landed on his back while in the parking lot of the facility. It further indicated Resident #1 notified Nurse #1 he fell out of his wheelchair backwards when something that held his wheelchair inside the van snapped out. The report detailed that Resident #1 was placed in a lift sling and placed back into his wheelchair and transported into the facility for further evaluation. A skin note dated 12/21/23 written by Nurse #2 indicated Resident #1 was assessed by herself and Nurse #1 which revealed a raised area at lower back of head that measured 2cm x 1.5cm without discoloration. A 2.5cm x2cm x 0.1cm superficial skin tear on top of his right hand that had scant amount of bleeding and a 1cm x 0.5cm x 0.1cm skin tear above right wrist area. Medication nurse aware and treatment was initiated. A document titled investigation questions handwritten by Nurse #2 dated 12/21/23 indicated Resident #1 fell while on the van on 12/21/23. It revealed Nurse #2 was in her car in the parking lot when the transportation van pulled up and she was notified by the Transportation Aide that Resident #1 had fallen due to the seatbelt on van which had snapped. An interview with Nurse #2 on 1/5/24 at 11:59 AM revealed she was present in her car in the facility parking lot speaking to Resident #1's RP and another staff member (she could not recall the staff member's identity) when the facility van containing Resident #1 pulled up near the traditional van parking spot outside the front door of the facility where she noticed the Transportation Aide exited the driver side of the van and yelled for her assistance when she stated, he fell. Nurse #2 stated she exited her car and quickly approached the facility van where she saw Resident #1 lying on his back with his wheelchair tipped backwards onto the van floor and his right foot dangling in the air. Nurse #2 indicated she started to assess Resident #1 and saw and felt a raised hematoma on the back of Resident #1's head near the base of his skull but saw no bleeding present at the time along with a skin tear to Resident #1's right hand and another skin tear to his wrist with minimal bleeding present. Nurse #2 explained following her assessment of Resident #1 she requested Nurse #1's assistance in the van. Then, she removed the wheelchair from beneath Resident #1's body and sat it in an upright position in the van. Nurse #2 indicated she finished her assessment before Nurse #1 arrived and requested the total body mechanical lift be brought to the van, then both she and Nurse #1 placed the lift sling under Resident #1's body, slid him to the edge of the van, secured his body in the mechanical lift and placed him back into his wheelchair then lowered him from the lift gate in his wheelchair and wheeled him to his room where a thorough assessment was completed and treatments were initiated, followed by notification of the on-call provider. Nurse #2 stated Resident #1 remained alert and oriented during the entire assessment and was assuring his RP that he was going to be okay and was not in any pain related to the fall. Nurse #2 stated while she was in the van, she was focused on performing an assessment of Resident #1's condition and did not notice the floor securement device placement but noticed the rear straps were loosely attached to the rear of the wheelchair (which she removed); however, she did notice a seatbelt looking thing hanging down from the top of the van that was not attached to the resident or his wheelchair. An interview with Nurse #1 on 1/5/24 at 11:59 PM revealed a staff member whom she could not identify notified her that Resident #1 had fallen in the transportation van and Nurse #2 had requested her assistance. Nurse #1 indicated she went to the front of the building and approached the transportation van where she saw Resident #1 lying on his back with Nurse #2 next to him. Nurse #1 stated Nurse #2 notified her Resident #1 had a knot (hematoma) on the back of his head and needed to be transferred via total body mechanical lift back to his room for further examination. Nurse #1 explained she and Nurse #2 placed the lift sling under Resident #1 and using the mechanical lift placed Resident #1 back into his wheelchair and transported him to his room and placed him in the bed. Nurse #1 stated she obtained Resident #1's vital signs and began neurological checks then notified the on-call provider. Nurse #1 explained the on-call provider gave orders that Resident #1 could have a CT performed or be transferred to the ER if Resident #1 or his RP requested further evaluation or if a change of condition occurred. Nurse #1 clarified the instructions with Resident #1 and his RP who chose not to go to the ER at that time. Nurse #1 further explained she stayed with Resident #1 for approximately 30 minutes following the incident without any change of condition, complaints of pain, or abnormal neuro checks. An interview with the Transportation Aide on 1/5/24 at 1:00 PM revealed she was the primary staff assigned for all resident transports for the facility since late November 2023. The Transportation Aide recalled on the early evening of 12/21/23, she transported Resident #1 from a surgical follow-up appointment to the facility; however, while driving up the inclined driveway to the facility, she passed over a speedbump and heard a clink and Resident #1 yell out. The Transportation Aide stated she immediately looked in her mirror located above her head and noticed Resident #1was no longer secured upright in his wheelchair but was lying on his back with his foot in the air. The Transportation Aide explained she asked Resident #1 if he saw any bleeding and when Resident #1 notified her, he did not see any obvious blood present, she told him she would move the transportation van closer to get assistance. The Transportation Aide stated without exiting the van to visualize Resident #1, she pulled the van to the top of the hill just outside the facility's front door where she saw Nurse #2 sitting in her parked car. The Transportation Aide stated she yelled at Nurse #2 for assistance and stated Nurse #2 immediately exited her car and approached the van where she began assessing Resident #1 who had a raised hematoma on the back of his head and a couple bleeding skin tears to his right hand and arm. The Transportation Aide stated when she got to the back of the van where Resident #1 was lying on his back, partially in his wheelchair, she noticed the floor securement straps were no longer attached to Resident #1's wheelchair and Resident #1 had partially came out of his wheelchair and was leaning on his side. The Transportation Aide indicated she thought, but could not be certain, before she began the transportation back to the facility, she had secured all straps (both shoulder and floor straps) tightly and that Resident #1's wheelchair was secured to the van. An observation with the Transportation Aide on 1/5/24 at 1:00 PM The Transportation Aide attempted to perform a reenactment of the steps that occurred which led to Resident #1's fall in the facility van on 12/21/23. The Transportation Aide made an attempt to secure a wheelchair (identified not to be Resident #1's personal wheelchair used on 12/21/23) containing a state surveyor to the van floor of which revealed the floor securement straps were placed on a declining bar along the bottom of the wheelchair in the front and back with difficulty as she struggled to be able to get around the lower extremities of the surveyor which were placed on the wheelchair pedals in order to reach the securement straps on the right side. The Transportation Aide attempted to attach the rear right strap from the left front portion of the wheelchair instead of from behind the chair. and she did not lock the right hand break which was obstructed by a folded bench seat on the right side of the wheelchair which allowed the front wheels of the wheelchair to be elevated off the floor with minimal force. A demonstration of how Resident #1 was positioned on the floor in the van reenacted by the Transportation Aide revealed Resident #1's wheelchair had tilted completely on its back pad and Resident #1's head was located near a metal locking groove strip near the lift gate at the rear of the van. The Transportation Aide acknowledged the wheelchair should not move when it is properly secured per manufacturers' guidelines. The Transportation Aide indicated her training was provided by a Former Transportation Aide briefly back in August 2023; however, she had not transported for several months following her training before she took over as the primary transpiration aide and she had not received any formal training with manufacturer's guidelines included. An interview with Resident #1 on 1/4/23 at 4:15 PM revealed he was lying in his bed following a urology appointment where he had been transported in the facility van by the Transportation Aide. Resident #1 elaborated that he had been transported by the Transportation Aide to a urology appointment since the incident on 12/21/23 and verified that an additional nurse aide (or another facility staff member) per IDT recommendations had not been present for the transport. Resident #1 explained he recalled the fall in the facility van on 12/21/23 following his follow-up visit to the surgeon office. Resident #1 stated when the van began to start up the incline hill outside the facility, it hit a speed bump going too fast and the straps from his wheelchair fell off the chair and he fell backwards striking his head on the floor of the facility van. An Interdisciplinary Team (IDT) progress note written by Nurse #2 dated 12/22/23 indicated the van was inspected by maintenance and the Administrator following the incident on 12/21/23. IDT recommended a nurse aide be with the transporter while transporting to all appointments. A typed note dated 12/21/23 signed by the Maintenance Assistant indicated he inspected the van and the securement devices in the van and did not find any deficiencies in the integrity of the equipment. An observation and interview with the Maintenance Assistant on 1/5/24 at 2:15 PM revealed he was present on 12/21/23 after the fall by Resident #1 occurred. The Maintenance Assistant indicated he made an observation of the van and the securement equipment for functioning on 12/21/23. The Maintenance Assistant indicated he did not find any concerns about the equipment and believed human error (straps were not placed in proper position and secured per manufacturer's guidelines by the Transportation Aide) in the attachment had occurred during the transport which caused the incident. The Maintenance Assistant demonstrated the proper attachment of the device to the wheelchair used on the date of the incident. The Maintenance Assistant ensured bilateral hand brakes on the wheelchair were firmly locked in place, then he tightly secured four locking straps to the bottom frame of the wheelchair then placed a seatbelt like wrapping device across the surveyor and locked it to an extension belt near the rear floor of the van. When all straps were secured, the wheelchair did not allow for movement by the surveyor who was seated to represent Resident #1 for demonstration. The Maintenance Assistant indicated he had provided driver training to both the Transportation Aide and the Maintenance Director following the incident on 12/21/23. The Maintenance Assistant said he was trained by the former Transportation Aide on how to place the securement system to a wheelchair. An interview with the Maintenance Director on 1/5/24 at 3:45 PM revealed he had been the Maintenance Director since November 2023 but had no direct involvement in the incident which occurred on 12/21/23 involving Resident #1. The Maintenance Director stated he did not inspect the van for proper function following the incident and had not been asked to ride with the Transportation Aide before nor after the incident on 12/21/23 to monitor her driving or passenger securement safety. The Maintenance Director indicated that he received his driver and securement training from the Maintenance Assistant and had watched videos on the proper application of the securement system a week following the incident which occurred on 12/21/23. An interview with the Administrator on 1/5/24 at 2:15 PM revealed she was present at the facility on 12/21/23 when the incident involving Resident #1 occurred. The Administrator indicated she was immediately made aware of the incident and notified the Maintenance Assistant so proper inspection could be completed. The Administrator stated she and the interdisciplinary team (IDT) determined the accident was caused by an error in securement of each strap per the manufacturer's guidelines by the Transportation Aide. She indicated she expected all transports to be performed in a safe and secure manner. The Administrator indicated she was unaware that the intervention was included that a NA would be on all transports with the van driver and thought since the Transportation Aide was a NA that was sufficient. An interview with Resident #1's Responsible Party (RP) on 1/16/24 at 9:00 AM revealed she was present in the facility parking lot when the facility transport van returned Resident #1 from his surgical follow-up appointment on the evening of 12/21/23 as she was present at the appointment. Resident #1's RP stated she noticed the van begin up the driveway outside the facility and abruptly stop before it reached the normal parking area located adjacent to the front lobby of the building. The RP said she initially thought it was a little unusual but then the van proceeded on towards the top of the hill as normal. The RP explained when the van arrived and began to proceed towards the turn in just before reaching the front entrance, the van again abruptly stopped and she saw the Transportation Aide get out of the van and yell across the parking lot at a staff nurse who was in the parking lot. Resident #1's RP said she heard the Transportation Aide screaming He fell, Help, He fell. Resident #1's RP said she and the staff nurse both ran towards the facility van asking if Resident #1 was hurt. Resident #1's RP said she was on the phone with her daughter when the nurse opened the rear lift gate so she could get to Resident #1. Resident #1's RP said Resident #1 was lying on his back with his wheelchair partially under him with his one leg in the air. She said Resident #1's right portion of his torso was located adjacent to the metal lift gate and she stated his head was lying on the floor of the facility van but could not give details as to the location or recall the positioning upon her visualization. The RP stated she recalled snapping a picture of Resident #1 immediately following the accident and sending it to another family member, but the photo had since been deleted from her telephone. Resident #1's RP stated the staff nurses looked him over, then put him in his chair and took him to his room to put him to bed. Resident #1's RP said Resident #1 had a raised place on the back of his head and a couple gashes to his right hand, but he made the decision not to go for further evaluation and she respected his decision at that time. An interview with the Medical Director (MD) on 1/10/23 at 5:37 PM revealed he was made aware on 1/9/24 of the fall in the transportation van which occurred on 12/21/23. The MD indicated Resident #1 had the potential to sustain significant injury when involved in a motor vehicle accident (MVA). The facility Administrator was notified of immediate jeopardy on 1/5/24 at 12:21 PM. The facility provided the following plan for IJ removal. Credible Allegation of IJ Removal Plan for F 689 Accident and Hazards - Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. On 12/21/23 at approximately 5:00 p.m. Resident #1 was on the facility van returning from an appointment, when the Van Driver was coming up the hill of the parking lot when she went over the speed bump resident #1 went over backward in his wheelchair. Charge Nurse was notified that resident fell back in his wheelchair in the facility van. Van was sitting in the parking lot stopped. Resident was on his back with the wheelchair under his back and legs. The securement straps were noted to be loose at this time. The wheelchair was unlocked at base from van hooks then the wheelchair was gently moved out from under resident. Resident then assessed for injuries. He was alert and oriented x 3 the entire time. Resident was transferred back into the wheelchair with use of total lift, while on the van. Then Resident # 1 was assisted off the van and into his room, to bed for full body assessment. Resident assessed by nurse and suffered a skin tear to right hand measuring 2.5cm X 2.0cm x 0.1cm and a skin tear to his right wrist measuring 1.0 cm x 0.5 cm x 01 cm as well as a knot to the back of his head measuring 2 cm x 1.5 cm. First aid provided. Neuro checks were initiated on 12/21/23 at approximately 5:30 p.m. and continued until 12/25/23 without any negative findings. The physician was notified of the incident on 12/21/23 by the staff nurse. Recommendations received to continue to monitor, send resident to emergency department with condition change. Resident # 1 had a provider assessment completed on 12/28/23 with no new orders. Resident's responsible party was notified of the incident on 12/21/23 by staff nurse. The transport van was removed from service on 12/21/23 at 5:00 pm until it could be checked to ensure no broken parts or failures and a road test with the same wheelchair was conducted. The Maintenance Assistant completed this evaluation and road test immediately following the incident and found no issues or deficits noted with the securement system. No damage was noted to the straps of the securement system. The van was put back into service on 12/21/23 at approximately 6:00 pm. Immediately following the incident on the evening of 12/21/23 a return demonstration was completed with the Van Driver and the Administrator; it was determined that the root cause of the event was that the driver had failed to apply the securement system straps in the proper location on the wheelchair. Immediately following the incident on 12/21/23, the Van Driver received 1:1 education from the Maintenance Assistant, who is an alternate trained driver on proper resident securement, and she provided return demonstration of procedure (process for applying the securement system straps to the wheelchair). Training was per the manufacturer's driver training modules and included applying the securement system straps in the proper location on the wheelchair as outlined in the driver training modules. All residents that are transported in the facility van are at risk. An audit was completed on December 22, 2023, by DON of all residents who were transported in the last 30 days. Residents with BIMs greater than 11 were interviewed regarding transportation and any concerns related to safety during wheelchair van transportation. All residents who were transported within the last 30 days with a BIMs of 10 or lower had skin checks completed to ensure no injuries were noted. No concerns were identified through these interviews/audits. No other residents or concerns were identified as having any circumstances resulting in falls in the van. - Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. On 12/22/23, The Maintenance Assistant trained the Van Driver and the Maintenance Director on proper resident securement and resident safety. Training was per the manufacturer's driver training modules and included applying the securement system straps in the proper location on the wheelchair. All drivers (Van Driver, Maintenance Director and Maintenance Assistant) completed the Driver Training Program on 12/22/2023. Training was provided by the Regional Director of Operations. Training included review of policy and procedure for resident securement, proper handling of vehicles, use of safety equipment on board the vehicle, passenger safety and securement of passengers in vehicle. Training was per the manufacturer's driver training modules. The Van Driver resumed her duties after training and return demonstration on 12/21/23, however, on 1/5/24, the Van Driver completed return demonstration of resident securement and during this demonstration, sufficient securement was not ascertained due to the securing straps not being tight and the resident chair still moving while restrained with safety equipment. Following this failed return demonstration, the driver was removed from her responsibilities of driving the facility van. On 1/5/24, the two remaining drivers (The Maintenance Director and Maintenance Assistance) were educated by the Administrator on the process of securing a wheelchair into the van. This procedure now includes a 2-step process for ensuring the chair is immobile when preparing for transport. The 2 steps are as follows: - Test each of 5 straps by pulling on both the top and bottom of each strap to confirm that the strap is taut. - Attempt to move wheelchair forward, backward, and side to side to confirm that wheelchair does not move. If during either of the 2 steps the chair is mobile, the driver will cinch the securing straps to create more tension and complete the 2-step process again to ensure that the chair does not move prior to placing the vehicle in motion. The two remaining drivers (the Maintenance Director and Maintenance Assistant) were able to complete the new 2-step process effectively on 1/5/24. This was verified by the Administrator. No transportation occurred until the completion and validation of this training. Administrator will validate 5 resident transports weekly X 8 weeks to ensure the new 2-step process is utilized correctly and that proper securing of residents/wheelchairs in the transport van occurs prior to departure from the center. Alleged date of IJ removal: 1/6/24. On 1/16/24, the corrective action plan for immediate jeopardy removal effective 1/6/24 was validated by the following: Interviews with the Maintenance Staff revealed they were performing facility transports when additional assistance was needed, and an outside transportation company was now scheduled due to the former Transportation Aide being relived from her duties as Transportation Aide. The Maintenance Staff indicated they had received formal training on how to properly secure residents for a safe transport for manufacturer's guidelines and for each transport conducted by a member of the Maintenance Staff a Nurse Aide has been required to ride in the facility van for additional safety reasons. An observation was made of the local transportation company pick up a resident from the facility and a nurse aide accompanied the resident to their appointment. Transportation audit tools were reviewed and confirmed resident safety and securement in the transport van were completed by the Administrator.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff and physician assistant interviews, the facility failed to safely assist a resident without causing injury to 1 of 5 residents (Resident #86) reviewed for accidents. Resident #86 was left standing without assistance in her room and fell. Resident #86 sustained a laceration to the head and a right fractured hip. The findings included: Resident #86 was admitted to the facility on [DATE] with diagnoses that included Alzheimer ' s, hypertension, anxiety, age related osteoporosis, muscle weakness, and adult failure to thrive. Resident #86 resided in the facility ' s memory care unit. Review of Resident #86's care plan revised on 02/21/23 revealed the resident was at increased risk for falls due to deconditioning, poor communication, psychoactive drug use, and unaware of safety needs. The goal was for Resident #86 to not sustain serious injury through the review date. Interventions included anticipate and meet the resident's needs, ensure that the resident is wearing appropriate footwear when ambulating, and follow facility fall protocol. Review of Resident #86's quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #86 was severely cognitively impaired and required extensive assistance with one person assist for bed transfers, walk in corridor, and walk in room. The MDS further revealed that under balance during transitions and walking Resident #86 was coded for not being steady but able to stabilize without staff assistance. Review of Resident #86's undated [NAME] (a written plan of care for staff to know the needs of a resident). revealed Resident #86 was extensive assistance with one person assist for transfer and mobility. Review of incident report completed by Nurse #3 dated 10/25/23 revealed NA #3 ambulated Resident #86 to her room when NA #3 turned to shut the door and Resident #86 lost balance and fell on her right side. The report further revealed Resident #86 sustained a cut above right eyebrow measuring approximately 3 centimeters (CM) by 1/2 CM. The cut had a small amount of bleeding with light purple bruising and was cleaned and strips were applied. The report indicated Resident #86 remained at her baseline neurological status and unable to voice pain due to cognition during assessment. The note revealed Resident #86 was assessed and assisted to bed and neurological checks were initiated. The responsible party and Assistant Director of Nursing (ADON) were notified, and the resident was placed in the book to be followed up by the provider the next day. The report revealed immediate action taken was Resident #86 was assessed for injuries, wound care applied to laceration above right eye, and neurological check initiated. Predisposing physiological factors indicated Resident #86 was confused and had impaired memory. Review of progress note completed by Nurse #3 dated 10/25/23 revealed Nurse Aide #3 ambulated Resident #86 to her room when NA #3 turned to shut the door and Resident #86 lost balance and fell on her right side. The note further revealed Resident #86 sustained a cut above right eyebrow measuring approximately 3 centimeters (CM) by 1/2 CM. The cut had a small amount of bleeding with light purple bruising and was cleaned and strips were applied. The note indicated Resident #86 remained at her baseline neurological status and unable to voice pain due to cognition during assessment. The note revealed resident #86 was assessed and assisted to bed and neurological checks were initiated. The RP, on call provider, and Assistant Director of Nursing (ADON) were notified. The indicated Resident #86 was not sent out but was placed in the book to be followed up by the provider the next day. Review of progress note completed by the ADON dated 10/26/23 revealed Resident #86 was assessed by the provider and was ordered an x-ray of right arm and shoulder and was sent to the hospital. The note further revealed IDT recommended educating staff about safe transfers. Review of the x-ray results completed at the hospital on [DATE] revealed Resident #96 sustained a transverse fracture at the right femoral neck seen at its base with slight angulation and displacement. The note further revealed osteopenia is noted, bony pelvic structures appear intact, and left hip appeared to be normal. Review of hospital progress note dated 10/27/23 revealed Resident #86 was admitted to the hospital and was diagnosed with a right femur fracture and laceration above the right eye. The note further revealed Resident #86 ' s resident representative (RR) indicated Resident #86 was not ambulatory before the fall. Review of progress note dated 10/27/23 revealed Resident #86 was transferred back to the facility from the hospital and the resident sustained a hip fracture and urinary tract infection (UTI). The note further revealed Resident #86 is in bed and had a follow up appointment in 4 to 6 weeks with orthopedic. Review of progress note dated 10/29/23 revealed Resident #86 was admitted to hospice. Review of progress note completed by the Medical Director (MD) on 10/30/23 revealed Resident #86 was transported to the hospital for a fall. The note further revealed the resident was found to have a right sided hip fracture and would not be managed operatively and would return to the facility. The note indicated Resident #86 would be followed by hospice and all medicines had been discontinued other than comfort measures. An observation was conducted on 10/30/23 at 11:00 AM revealed Resident #86 was in bed with with her eyes closed. Observation further revealed laceration over the resident ' s right eyebrow to have green and purple bruising with three steri strips on it. An interview conducted with NA #3 on 11/02/23 at 3:50 PM revealed on 10/25/23 she had assisted Resident #86 back to her room to put her in the bed. NA #3 further revealed Resident #86 had a good day and was walking with little assistance. NA #3 was an extensive assistance with one person support which meant to have hands on the resident assisting them. NA #3 indicated she walked Resident #86 into her room and stopped at the sink and left Resident #86 unattended to close the bedroom door because the resident had a good day and seemed stable to stand alone. NA #3 indicated she does not recall why she did not assist Resident #86 to the bed before shutting the bedroom door. NA #3 stated as she closed the door Resident #86 lost balance and fell to the ground on her right side. NA #3 revealed Nurse #3 assessed Resident #86 and the resident showed no signs of pain or injury other than the laceration above the right eye. NA #3 on 10/26/23 Resident #86 was assessed by the provider in the facility and Resident #86 started to show signs of discomfort and was sent to the hospital to be further assessed. An interview conducted with Nurse #3 on 11/01/23 at 11:10 AM revealed Resident #86 was an extensive assist with one person for ambulating. Nurse #3 indicated Resident #86 ' s health and memory had declined in the last couple months. Nurse #3 further revealed on 10/25/23 NA #3 had assisted resident #86 to her room and left Resident #86 unassisted standing when shutting the resident's door. Nurse #3 indicated at that time Resident #86 fell to the floor on her right side. Nurse #3 revealed she was called to Resident #86's room and observed Resident #86 on her right side near the bathroom door. Nurse #3 revealed she assessed Resident #86, and the resident sustained a laceration above the right eyebrow but did not show indications of pain or other injuries. Nurse #3 indicated Resident #86 was assisted back to bed and the Medical Director (MD), RR, and ADON were notified. Nurse #3 stated Resident #86 did not complain of pain and neurological assessments were completed. An interview conducted with the ADON on 11/01/23 at 11:10 AM revealed she was not present at the time of the incident. The ADON further revealed Resident #86 was extensive assistance with one person assist for ambulating and transfers. The ADON stated NA#3 should have not left the resident unattended in her room. The ADON indicated prior to the incident on 10/25/23 Resident #85's health was declining and had become weaker. An interview conducted with the Director of Nursing (DON) on 11/01/23 at 1:45 PM revealed Resident #86 was unstable and required extensive assistance with one person for ambulation and transfers. The DON further revealed NA #3 should have not left Resident #86 unassisted while closing the bedroom door. An interview conducted with the Physician Assistant (PA) on 11/03/23 at 12:25 PM revealed Resident #86 ' s health had declined rapidly since the residents fall on 10/25/23. The PA further revealed Resident #86 had been admitted to hospice before and could not state the fall had caused the resident ' s rapid health decline. The PA indicated Residents #86's weakness and dementia had progressed prior to the incident on 10/25/23. An interview conducted with the Administrator on 11/03/23 at 12:25 PM revealed if Resident #86 was coded and documented for extensive with one person assist then NA #3 should not have left the resident unattended. The Administrator indicated she expected nursing staff to follow the [NAME] and what each Resident was coded for.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, resident and facility staff interviews, the facility failed to protect a cognitively impaired resident from physical abuse from an employee when a nurse aide (NA #5) put her hands on the resident's shoulders to get her to a seated position and slapped the resident on the side of her shoulder for 1 of 2 residents reviewed for abuse (Resident #57). NA #5 slapped Resident #57 in response to Resident #57 slapping at NA #5 resulting in Resident #57 holding her left arm as NA #5 walked away stating, I'm not going to take this off anyone. Immediate Jeopardy began on 08/11/22 when Resident #57, who had severe cognitive impairment, was physically abused by NA #5. The immediate jeopardy was removed on 10/26/22 when the facility provided and implemented an acceptable credible allegation. The facility remains out of compliance at a lower scope and severity of a D (isolated with no actual harm with potential for more than minimal harm that is not immediate jeopardy) to complete education and ensure monitoring systems put into place are effective. The findings included: Resident #57 was admitted to the facility on [DATE] with diagnoses that included dementia without behaviors. A review of Resident #57's quarterly Minimum Data Set assessment dated [DATE] revealed her to be severely impaired with no psychosis, behaviors, rejection of care, or instances of wandering. Resident #57 was coded as requiring extensive assistance with bed mobility, dressing, toilet use, and personal hygiene. She needed limited assistance with transfers, walking in the room, walking in the corridors, locomotion on and off the unit, eating, and bathing. Resident #57 was coded as having had 2 or more falls with no injury since her previous assessment. A review of the facility's investigation completed on 08/12/22 revealed Housekeeper #1 came to the Administrator on 08/12/22 stating she had witnessed NA #5 slap Resident #5 after trying to get her to sit down for the evening meal service on 08/11/22. The facility's investigation indicated the allegation to be unsubstantiated due to Housekeeper #1's lack of knowledge regarding Resident #57's behaviors and fall risks and that NA #5 was trying to get Resident #57 to sit down for her own safety. Review of Housekeeper #1's written statement from the investigation dated 08/12/22 read [Resident #57] was in the dining room at around 5:30 [PM] was standing up in the dining room. [NA #5], the CNA [Certified Nursing Assistant] told [Resident #57] to sit down. [Resident #57] stated she didn't want to sit down. [NA #5] assisted [Resident #57] in sitting down. [Resident #57] reached back and slapped [NA #5]'s arm [NA #5] then slapped [Resident #57] on the arm. During a telephone interview with Housekeeper #1 on 10/24/22 at 3:20 PM, she reported she was working on the hall where Resident #57 resided on the evening of 08/11/22. She stated she had walked into the dining room to gather trash and noticed NA #5 assisting Resident #57 in sitting down. She stated Resident #57 was telling NA #5 she did not want to sit down but eventually did and once Resident #57 sat down, she slapped NA #5. She stated NA #5 immediately slapped Resident #57 on the side of her left shoulder. Housekeeper #1 reported she heard the slap and stated she observed Resident #57 to hold her left arm. She stated NA #5 then walked out of the room and stated aloud, I'm not going to take that off of anybody. She reported she went home, was upset about what she had witnessed, spoke with a family member who worked at the facility who told her she needed to report it and stated she reported the incident the following day to the Administrator. During an interview with NA #5 on 10/20/22 at 3:18 PM, she reported she usually worked on the locked unit where Resident #57 resided. She stated she was aware of the allegation against her and denied slapping Resident #57. NA #5 reported she did try to encourage Resident #57 to remain seated due to her behaviors of attempting to get up and wander. She stated Resident #57 had a history of falling, so all staff had to keep a close eye on her. NA #5 reported Resident #57 had been up and down a lot that day and was refusing verbal requests by NA #5 to sit down and stay seated. She stated in trying to get Resident #57 to remain seated, she placed her hands on Resident #57's shoulders and stated, Come on [Resident #57], let's sit down. NA #5 reported Resident #57 sat down and swung her hand at her so NA #5 reported she thought to herself forget it and walked away and told Nurse #3 about the behavior. NA #5 provided a hands-on reenactment of the incident. During this reenactment NA #5 started by saying [Resident #57] time to sit down for dinner. She then proceeded to walk over to the surveyor, place both her hands on top of each of the surveyor's shoulders, tapping on the left shoulder and saying, Come on [Resident #57], let's sit down. NA #5 then reported Resident #57 sat down and slapped at her at which time, NA #5 reported thinking to herself, forget this and then stated she walked out of the dining room. During an interview with Nurse #3 on 10/20/22 at 6:43 PM, she verified she was working at the time the incident occurred. She reported she was unaware about the incident until the following day when she was questioned by the Administrator. She also reported NA #5 never reported any behaviors regarding Resident #57 to her on 08/11/22. During an interview with the Administrator on 10/20/22 at 1:53 PM, she reported she was made aware of the allegation on 08/12/22 in the afternoon when Housekeeper #1 came to her with the previous Environmental Services Director. She stated Housekeeper #1 reported she believed she had seen NA #5 slap Resident #57, however, the Administrator reported there were inconsistencies in the slap portion of the reported allegation. She stated she immediately began an investigation into the incident and unsubstantiated the allegation based on an interview with NA #5, the inability to find anyone else to corroborate what Housekeeper #1 had reported, and Housekeeper #1's lack of knowledge regarding Resident #57, her behaviors, and fall risk. The Administrator was notified of the immediate jeopardy on 10/24/22 at 7:30 PM The facility provided the following Credible Allegation of immediate jeopardy removal. o Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance * On 8/11/22 the facility failed to protect a resident with severe cognitive impairment from physical abuse during an interaction in the dining room. * Housekeeper #1 reported on 8/12/22 that in the dining room, she observed Resident #57 hitting Nurse Aide #5. Housekeeper #1 also reported that she then observed Nurse Aide #5 slap Resident #57 on the arm. *All other residents are at risk from suffering from the deficient practice, and residents with dementia and behaviors are at increased risk for abuse. On 10/24/22, all staff in all departments were interviewed by members of the interdisciplinary team (IDT) that consists of Administrator, Director of Nursing (DON), Assistant Director of Nursing, Unit Managers (ADON), Social Worker, Activities Director, Business Office Manager, Admissions Director, Rehab Manager, and Office Assistant, to determine if any other resident may have been affected and if they had observed and not reported any resident abuse. The interview included questioning whether staff members have any knowledge of resident abuse - (defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish) and that they understand the immediate reporting requirements to the Administrator and the Director of Nursing (DON) in the Administrator's absence. On 10/24/22, an audit of all residents with a Brief Interview of Mental Status (BIMS) of 10 or above, was completed by the Social Worker of designee to determine if they have experienced any type of resident abuse. No concerns were found. On 10/21/22 - 10/25/22, an audit consisting of thorough skin assessment of all residents with a BIMS of 9 or less was completed by licensed nurses to determine if there is evidence of abuse. No concerns were found. o Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete 0n 10/24/22, education was provided to the Administrator and DON by the Corporate Consultant, District Director of Operations, regarding the definition of abuse as defined in the abuse policy, the resident's right to be free from abuse. On 10/24/22, after being reeducated as outlined above, education for all staff was completed in person and via phone by the Administrator and DON. The education consisted of the following: The definition of abuse, neglect and misappropriation of property and the need to immediately notify their supervisor of all issues related to these infractions. Supervisors must inform the Administrator or DON immediately in person by phone and immediately separate the victim from and perpetrator, and that dementia residents are at increased risk of being the victim of these problems. Progressive characteristics of dementia (disorientation, withdrawal, mood and personality changes, and anxiety about symptoms), clinical challenges such as identifying pain, hunger, thirst, inability to express needs/wants, and other communication related symptoms of dementia that could cause a resident to have negative behaviors In addition to identification of these challenges, the education focused on tactics to deal with difficult behavior such as walking away to allow for de-escalation, providing time/place orientation, using a soothing tone of voice, providing gentle tactile cueing, use of gestures, offering distractions such activities, music, or person-centered strategies (pictures, personal memorabilia) Signs and symptoms of abuse in a dementia resident such as physical abnormality, withdrawal, loss of appetite, and general changes in patterns and psychosocial well-being Identification of caregivers who appear stressed or need a break from working in the dementia environment should also be brought to the immediate attention of the supervisor This training will be provided by the Administrator or the Human Resource Director to all agency staff and new employees upon hire during orientation. All facility staff in all departments, including as-needed and agency staff, received this training on 10/24/22-10/25/22 and all staff will continue to receive the training yearly thereafter. The Administrator and Human Resource Director were notified by the Regional Director of Operations of the need to provide this training to new hires on 10/25/22. Alleged IJ removal date is 10/26/22. On 10/27/22, the credible allegation of Immediate Jeopardy removal date of 10/26/22 was validated by onsite verification through facility staff interviews. The interviewed staff across all disciplines including nursing, office, housekeeping, dietary, and therapy revealed they had received in-service training regarding spotting, identifying, and reporting abuse. The also received in-service training regarding dementia care and how to handle adverse or difficult behaviors from residents with diagnoses of dementia.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to implement their abuse policies and procedures when a housekeeper observed physical abuse of a resident by nurse aide (NA) #5 and did not immediately report the abuse to a supervisor or any member of the administrative team, failed to protect the residents by allowing NA #5 to work the remainder of that shift and the following day, failed to complete a thorough of investigation of an allegation of abuse, and failed to report the allegation of abuse to the State Agency, local law enforcement, and adult protective services within the required timeframe for 1 of 2 residents reviewed for abuse (Resident #57). Immediate jeopardy began on 08/11/22 when Housekeeper #1 failed to report abuse to her supervisor or administrative team immediately after she observed NA #5 slap Resident #57. The immediate jeopardy was removed on 10/26/22 when the facility provided and implemented an acceptable credible allegation. The facility remains out of compliance at lower scope and severity of a D (isolation with no actual harm with potential for more than minimal hard that is not immediate jeopardy) to complete education and ensure monitoring system put into place are effective. Example 1.b. below is cited at lower scope and severity of a D. The findings included: 1a. Review of the facility's policy titled Abuse and Neglect Protocol last revised on 06/13/21 revealed the following steps to be taken in the event potential abuse was observed: Any staff member or personal affiliated with this facility who has witnessed or who believes that a resident has been a victim of mistreatment, abuse, neglect, or any other criminal offense shall immediately report, or cause a report to be made of, the mistreatment or offense. The policy further stated, Employees of this facility who have been accused of resident abuse shall be suspended from duty until the results of the investigation have been reviewed by the Director of Nursing/Designee or Administrator. The facility's abuse policy further stated Upon receiving reports of physical or sexual abuse, a licensed nurse or physician shall immediately examine the resident. Findings of an examination must be recorded in the resident's medical record. Regarding the investigation, the facility's policy stated The individual conducting the investigation will, at a minimum: e. Review the completed documentation forms; f. Review the resident's medical record to determine events leading up to the incident; g. Interview the person(s) reporting the incident; h. Interview any witnesses to the incident; i. Interview the resident as medically appropriate); j. Interview the resident's attending physician as needed to determine the resident's current level of cognitive function and medical condition; k. Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; l. Interview the resident's roommate, family members, and visitors; m. Interview other residents to whom the accused employee provides care or services; and n. Review all events leading up to the alleged incident. o. Preserve all audio and video recordings of incident, if available/applicable. Resident #57 was admitted to the facility on [DATE] with diagnoses that included history of falling, muscle weakness, and dementia without behaviors. A review of the facility's investigation completed on 08/12/22 revealed Housekeeper #1 came to the Administrator on 08/12/22 stating she had witnessed NA #5 slap Resident #5 after trying to get her to sit down for the evening meal service on 08/11/22. The facility's investigation indicated the allegation to be unsubstantiated due to Housekeeper #1's lack of knowledge regarding Resident #57's behaviors and fall risks and that NA #5 was trying to get Resident #57 to sit down for her own safety. There was no documented assessment of Resident #57, or any other resident NA #5 had contact with on 08/11/22. There was a lack of interviews and statements from staff and residents regarding NA #5 and any other potential abuse that may have occurred. The investigation also failed to include statements or interviews from Resident #57's family and visitors. Review of Housekeeper #1's written statement from the investigation dated 08/12/22 read; [Resident #57] was in the dining room at around 5:30 [PM] was standing up. NA #5 told [Resident #57] to sit down. [Resident #57] stated she didn't want to sit down. [NA #5] assisted [Resident #57] in sitting down. [Resident #57] reached back and slapped [NA #5]'s arm [NA #5] then slapped [Resident #57] on the arm. An interview with Housekeeper #1 on 10/24/22 at 3:20 PM, she reported she saw NA #5 slap Resident #57 on 08/11/22 after Resident #57 slapped NA #5 around 5:30 PM. She stated she did not report the incident until the following day because she did not know she needed to. She stated once she got home from her shift, she spoke with her daughter who told her she needed to tell the Administrator what she observed. Housekeeper #1 stated she informed the Administrator the following day when she came in for her shift at 2:00 PM about the incident. She stated she had not received any training prior to the incident regarding reporting guidelines for allegations of abuse. Review of in-service logs for Housekeeper #1 provided by the facility revealed she completed an in-service training titled Patient/Residents' Rights Abuse Neglect and Elder Justice Act Inservice in May of 2022. During an interview with NA #5 on 10/20/22 at 3:18 PM, she reported she usually worked on the locked unit where Resident #57 resided. She stated she was aware of the allegation against her and denied slapping Resident #57. NA #5 reported she did try to encourage Resident #57 to remain seated due to her behaviors of attempting to get up and wander. She stated Resident #57 had a history of falling, so all staff had to keep a close eye on her. NA #5 reported Resident #57 had been up and down a lot that day and was refusing verbal requests by NA #5 to sit down and stay seated. She stated in trying to get Resident #57 to remain seated, she placed her hands on Resident #57's shoulders and stated, Come on [Resident #57], let's sit down. NA #5 reported Resident #57 sat down and swung her hand at her so NA #5 reported she thought to herself forget it and walked away and told Nurse #3 about the behavior. During a follow up interview with NA #5 on 10/24/22 at 4:39 PM, she verified she finished her shift on 08/11/22 which ended at 11:00 PM. She also reported she worked the following day (08/12/22) from 3:00 PM until 11:00 PM. Review of NA #5's statement within the investigation dated 08/12/22 read I was trying to get [Resident #57] to sit down for supper several times. One of the times [Resident #57] elbowed me. I put my hands on her shoulders to get her to sit down, that's when she elbowed me, and I walked off. During an interview with the Director of Nursing on 10/20/22 at 10:47 AM, she reported the facility was made aware on 08/12/22 of an allegation by Housekeeper #1 that NA #5 was observed being a little rough with Resident #57. She reported she was not a part of the investigation and that it was completed by the Administrator. The Director of Nursing reported she believed the allegation was unsubstantiated and referred to the Administrator for further information. During an interview with the Administrator on 10/20/22 at 1:53 PM, she reported she was initially informed of the allegation when Housekeeper #1 came to her office with the previous Environmental Services Director on the afternoon of 08/12/22. The Administrator stated Housekeeper #1 informed her she had observed NA #5 slap Resident #57 on 08/11/22 at the dinner meal service after trying to get her to sit down. The Administrator stated she began an investigation immediately after being informed of the incident taking a statement from Housekeeper #1, NA #5, and speaking with Nurse #3. She also had the facility staff complete an in-service education on reporting guidelines and timeframes since the alleged slap occurred on 08/11/22 and was not reported until the following afternoon. The Administrator reported she asked Housekeeper #1 why she waited to report what she saw and was told that Housekeeper #1 went home, thought about the incident further and then decided she needed to report what she saw when she arrived for her shift on 08/12/22. She reported she investigated the allegation as an incident, and indicated it was not investigated as an allegation of abuse. The Administrator reported she was able to complete the investigation before NA #5 returned to the facility for her shift on 08/12/22 and stated she unsubstantiated the allegation due to Housekeeper #1 wavering in her description of the incident and the Administrator's belief that Housekeeper #1 was not aware of Resident #57's care needs and behaviors. The Administrator verified she did not report the allegation to local law enforcement or adult protective services and NA #5 completed her shift on 08/11/22 until 11:00 PM. An interview with the Housekeeping Director at the time of the incident was attempted by telephone call due to them being out of the facility at the time of the investigation but was unsuccessful. During an interview with Nurse #3 on 10/20/22 at 6:43 PM, she verified she was working on the hall where Resident #57 resided on 08/11/22 when the incident occurred. She reported no one came to her at any time and reported the alleged abusive behavior by NA #5 towards Resident #57. She stated any allegations of that nature should immediately be reported to her, the Director of Nursing, or the Administrator. The Administrator was notified of the immediate jeopardy on 10/24/22 at 7:30 PM On 10/26/22 at 5:27 PM, the facility provided the following Credible Allegation of Compliance: F607 o Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance On 8/11/22, the facility failed to follow the abuse policy in the areas of prevention, protection, reporting and training. *The facility failed to implement their abuse policies and procedures for preventing, reporting, protection, and training when in the dining room, Housekeeper #1 observed Resident #57 hitting Nurse Aide #5. Housekeeper #1 also stated that she then observed Nurse Aide #5 slap Resident #57 on the arm but did not report this incident to her supervisor until the next day. The perpetrator continued to work her shift in the special care unit. *All residents are at risk from suffering from the deficient practice, and residents with dementia and behaviors are at increased risk for abuse. On 10/24/22, an audit was completed by interviewing all residents with a Brief Interview of Mental Status (BIMS) of 10 or above by social worker and designees to determine who could alert staff to instances of abuse. Residents were interviewed for unreported abuse occurrences. No other residents were identified as being abused and not reported. On 10/21/22 - 10/25/22, an audit consisting of thorough skin assessment of all residents with a BIMS of 9 or less was completed by licensed nurses and designees to determine if there is evidence that they have experienced any abuse, including bruises of unknown origin or other unknown skin impairments. o Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete On 10/24/2022, all staff in all departments were interviewed by members of the interdisciplinary team (IDT) that consists of Administrator, Director of Nursing (DON), Assistant Director of Nursing, Unit Managers (ADON), Social Worker, Activities Director, Business Office Manager, Admissions Director, Rehab Manager, and Office Assistant, to determine if any other resident may have been affected and if they had observed and not reported any abuse. No concerns identified. Administrator was also reeducated on all components of the facility's abuse policy and how to identify abuse on 10/24/2022 by the District Director of Operations. Education included the definition of abuse, reporting requirements, the need to identify if other cognitively impaired residents had been abused, the need to protect other cognitively impaired residents by implementing skin assessments and monitoring for psychosocial changes by qualified individuals, as well as immediately separating the victim from the alleged abuser. The administrator was also educated on the progressive characteristics of dementia (disorientation, withdrawal, mood and personality changes, and anxiety about symptoms), clinical challenges such as identifying pain, hunger, thirst, inability to express needs/wants, and other communication related symptoms of dementia that could cause a resident to have negative behaviors. In addition to identification of these challenges, the education focused on tactics to deal with difficult behavior such as walking away to allow for de-escalation, providing time/place orientation, using a soothing tone of voice, providing gentle tactile cueing, use of gestures, offering distractions such activities, music, or person-centered strategies (pictures, personal memorabilia). Identification of caregivers who appear stressed or need a break from working in the dementia environment should also be brought to the immediate attention of the supervisor. The administrator was educated that this training should be completed with all new employees during the orientation process and with all staff on a yearly basis. On 10/24/22 and 10/25/22, after being reeducated as outlined above education for all staff was completed by the Administrator and DON. The education consisted of the following: The definition of abuse, neglect and misappropriation of property and the need to immediately notify the Administrator or DON of all issues related to these infractions. If Administrator or DON are not present in facility, supervisors must be notified, and they must inform the Administrator or DON immediately in person or by phone Staff members who observe situations of abuse should immediately intervene to prevent continued potential abuse to residents. The perpetrator should be removed from the situation and placed under 1:1 supervision until they can be removed from premises. Any individual observing an incident of resident abuse or suspecting resident abuse must immediately report such incident to the Administrator or Director of Nursing. The following information should be reported: a. The name(s) of the resident(s) to which the abuse or suspected abuse occurred b. The date and time that the incident occurred c. Where the incident took place d. The name(s) of the person(s) allegedly committing the incident, if known e. The name(s) of any witnesses to the incident f. The type of abuse that was committed (i.e., verbal, physical, sexual, neglect, etc.) g. Any other information that may be requested by management. Signs and symptoms of abuse in a dementia resident such as physical abnormality, withdrawal, loss of appetite, and general changes in patterns and psychosocial well-being The progressive characteristics of dementia (disorientation, withdrawal, mood and personality changes, and anxiety about symptoms), clinical challenges such as identifying pain, hunger, thirst, inability to express needs/wants, and other communication related symptoms of dementia that could cause a resident to have negative behaviors. In addition to identification of these challenges, the education focused on tactics to deal with difficult behavior such as walking away to allow for de-escalation, providing time/place orientation, using a soothing tone of voice, providing gentle tactile cueing, use of gestures, offering distractions such activities, music, or person-centered strategies (pictures, personal memorabilia). Identification of caregivers who appear stressed or need a break from working in the dementia environment should also be brought to the immediate attention of the supervisor. This training will be provided by the Administrator or the Human Resource Director to all agency staff and new employees upon hire during orientation. All facility staff in all departments, including as-needed and agency staff, received this training on 10/24/22-10/25/22 and all staff will continue to receive the training yearly thereafter. The Administrator and Human Resource Director were notified by the Regional Director of Operations of the need to provide this training to new hires on 10/25/22. Alleged IJ removal date is 10/26/22. On 10/27/22, the credible allegation of Immediate Jeopardy removal date of 10/26/22 was validated by onsite verification through facility staff interviews. The interviewed staff across all disciplines including nursing, front office, housekeeping, dietary, therapy, and maintenance, revealed the had all received in-service training regarding identifying and reporting allegations of abuse immediately. The facility had completed skin assessments of cognitively impaired residents and had completed interviews with cognitively intact residents. 1b. Review of the facility's policy titled Abuse and Neglect Protocol last revised on 06/13/21 revealed the following steps to be taken in the event potential abuse was observed: Any staff member or personal affiliated with this facility who has witnessed or who believes that a resident has been a victim of mistreatment, abuse, neglect, or any other criminal offense shall immediately report, or cause a report to be made of, the mistreatment or offense. The policy also specified reporting times, stating If an incident of suspected abuse occurs, facility shall report immediately, but not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury to the state agency. An immediate investigation will be made and a copy of the findings of such investigation will be provided to the state agency within 5 working days or as designated by state law. During an interview with the Administrator on 10/20/22 at 1:53 PM, she reported she was informed by a staff member that NA #5 had been aggressive towards Resident #57 and had slapped her. She reported she believed the Housekeeper was not aware of Resident #57's behaviors of constantly trying to stand up and pace, along with her fall risk, and may have misinterpreted NA #5's actions. The Administrator stated she investigated the allegation as an incident and not an allegation of abuse. She also verified she did not complete an initial report to send in, to the State Agency. The Administrator stated because she investigated the allegation as an incident and had resolved it, she did not believe she needed to notify the State Agency, law enforcement, or adult protective services, in writing, of the allegation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff, Nurse Practitioner, Medical Director #1, and Medical Director #2 interviews, the facility failed to provide necessary medical attention when staff were aware of signs and symptoms of a possible cardiac event. Medical Director #1 instructed Nurse #1 to administer a pain medication along with his regular scheduled morning medications. The resident experienced cardiac arrest and subsequently passed away. This occurred for 1 of 2 resident reviewed for death (Resident #407). Immediate jeopardy began on [DATE] when Resident #407 experienced signs and symptoms of a cardiac event and necessary emergent medical interventions were not provided. The immediate jeopardy was removed on [DATE] when the facility provided and implemented an acceptable credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity of Level D (no actual harm with the potential for more than minimal harm that is not immediate jeopardy) to ensure education was in place and monitoring systems that were put into place were effective. The findings included: Resident #407 was admitted to the facility on [DATE]. His diagnoses included fracture of T9-T10 (T= thoracic, the area of the body between the neck and abdomen) vertebra (small bones forming the backbone), atherosclerotic (build-up of fat, cholesterol, and other substances in and on the artery walls) heart disease and pain. He was admitted for rehabilitation services. Review of the medical record revealed Resident #407 had an order dated [DATE] for full code cardiopulmonary resuscitation (CPR). Review of Resident #407's hospital Discharge summary dated [DATE] revealed Resident #407 had a past medical history of coronary artery disease and a past surgical history of 3 vessel coronary artery bypass grafting (CABG) and cardiac stents. He was discharged on the following blood pressure, blood thinner and pain medications: clopidogrel (blood thinner) 75 milligrams (mg) by mouth once a day, lisinopril (used to decrease blood pressure) 20mg by mouth once a day, and metoprolol succinate (used to lower blood pressure) 100mg by mouth every night at bedtime and tramadol for pain. The discharge summary indicated that Resident #407 had fallen at home and fractured his thoracic vertebra and was discharged to the facility for therapy Review of Resident #407's admission Minimum Data Set (MDS) dated [DATE] revealed he was moderately cognitively impaired. Resident #407 was also coded for having no pain and no oxygen therapy was used during the assessment reference period. Review of Resident #407's care plan revealed he had a care plan in place for coronary artery disease and hypertension initiated on [DATE]. Interventions included monitor vital signs and administer medications as ordered. A telephone interview was conducted with Nurse #1 on [DATE] at 1:11 PM. Nurse #1 stated she remembered Resident #407 and recalled he had fallen at home prior to coming to the facility and fractured his back. Resident #407 was at the facility for therapy and had to wear a back brace when he was out of the bed. She revealed on the day Resident #407 coded ([DATE]) she had been passing medications on her hall, at approximately 9:30 AM, and the Receptionist advised her that Resident #407's family had called the facility and said that he was having difficulty breathing. Nurse #1 stated she immediately got her vital sign equipment and went to Resident #407's room where Resident #407 was on the telephone and did not appear to be in any distress. She took his vital signs, and his blood pressure was 140's over 80's, his respirations were a little high at 22, his pulse was 103 and his oxygen levels were low at 86-88%. Nurse #1 stated that Resident #407 had normal color to his skin, he was not diaphoretic and said that he felt like he couldn't breathe. He was grimacing a little bit, but was not clutching his chest, rubbing his arm or his jaw. Resident #407 told Nurse #1 that his back brace was uncomfortable. Nurse #1 stated to Resident #407 that she was going to speak to Medical Director #1 (MD) and was anything bothering him. Resident #407 stated that he had chest pressure that felt like an elephant was sitting on his chest. Nurse #1 stated she reported to Medical Director #1 and Nurse Practitioner (NP), who were both in the building, what Resident #407 had told her along with his vital signs that she had taken and the reports of having trouble breathing. She stated Medical Director #1 and NP discussed among themselves and Medical Director #1 asked her if Resident #407 had any pain medication. Nurse #1 stated she told Medical Director #1 that Resident #407 had an order for Tramadol for pain as needed. Medical Director #1 instructed Nurse #1 to give Resident #407 a Tramadol and monitor him. Nurse #1 stated she asked for clarification twice from Medical Director #1 that he only wanted her to give Resident #407 a Tramadol and both times was told yes, by Medical Director #1. She stated she told Medical Director #1 again that Resident #407 stated he felt like an elephant was sitting on his chest and again Medical Director #1 stated to give Resident #407 the Tramadol and he would see him later that day. Nurse #1 stated she heard the NP state to Medical Director #1 that this was the resident Nurse #1 was talking about, the NP was pointing at a name on the list of patients that needed to be seen that day and that instructed Medical Director #1 to go and see Resident #407. Nurse #1 stated she went back to the medication cart and got Resident #407's morning medications, and a Tramadol and administered them to Resident #407, he took them without difficulty. Nurse #1 stated that she again took Resident #407's vital signs and his respirations had come down a little bit to 21. She stated that Resident #407 told her that he felt better. He was not grimacing or sweating or complaining of pain. Nurse #1 asked Resident #407 if he could use his call light if he needed her and he said yes, and she told him that she would be outside his room and would watch for the call light as she passed medications to other residents. Nurse #1 revealed that around 11:00 AM the Physical Therapy Assistant (PTA) and Occupational Therapy Assistant (COTA) came to her medication cart and advised her that Resident #407 had a large emesis, but they had cleaned him up and assisted him back to bed and that Resident #407 felt better after he vomited. Nurse #1 stated she had charted the emesis and about 5-10 minutes later she had finished her medication pass and passed his room, she could see that he was breathing, his color was normal, he was not sweating, and his call bell was next to him. She stated she went to the nursing station and was charting when a family member came to the desk at around 12:00 PM and informed her that Resident #407 would not wake up and he was cold. She immediately got up and went to Resident #407's room. Upon entering the room, she felt Resident #407's chest, he was not breathing, and she listened to his heart with a stethoscope, and she could not hear a heartbeat. She stated she left the room and the Director of Nursing (DON) and Assistant Director of Nursing (ADON) were coming out of a room, next door to Resident #407's room. She advised them that Resident #407 did not have a heartbeat. They immediately checked his code status, obtained the crash cart, and Cardiopulmonary Resuscitation (CPR) was initiated. Code Blue (called when resident is without heartbeat) was announced overhead and 911 was called. She stated she did not see Medical Director #1 go into Resident #407's room prior to the Code blue. She did see the NP respond to the code blue and talk to the family. Nurse #1 stated Medical Director #1 called off the code blue after talking to the family in the hallway. Nurse #1 indicated that she was 100% sure that she had told both Medical Director #1 and the NP that Resident #407 had chest pain that felt like an elephant was sitting on his chest. Nurse #1 revealed if Medical Director #1 or NP had not been in the facility at the time that Resident #407 had complained of chest pain, she would have called 911 and sent him to the emergency room to be evaluated, but she had followed her chain of command. An interview was conducted with Nurse #2 on [DATE] at 11:04 AM. Nurse #2 stated she had completed her morning medication pass on her residents and went to assist Nurse #1 with her medication pass on [DATE]. She revealed during the medication pass a Nurse Aide came and advised her and Nurse #1 that Resident #407 had chest pain. Nurse #1 went and notified the NP and Medical Director #1, who were both in the facility. Nurse #1 stated that she had received an order from Medical Director #1 to administer Resident #407's regular medications and Tramadol. Nurse #2 stated she asked Nurse #1 why they were not administering nitroglycerin (common cardiac medication) to Resident #407, because it was her understanding if someone was experiencing chest pain a nitroglycerin was usually administered. Nurse #1 told her, The Doctor said to give tramadol and his routine medications. The routine medications and the Tramadol were administered between 10:30 AM- 11:00 AM. Nurse #2 stated she was not aware of Resident #407's medical history and had not taken care of him. She stated she went back to her hall after the medication pass was completed. An interview was conducted with the Physical Therapy Assistant (PTA) and Certified Occupational Therapy Assistant (COTA) on [DATE] at 11:21 AM. The PTA stated that he and the COTA had gotten Resident #407 up for the first time since his admission for therapy on [DATE] around 9:30 AM. They assisted him from laying down to sitting on the side of the bed. They applied his back brace and then Resident #407 transferred from the side of the bed to the wheelchair. He required very little assistance. Resident #407 did not complain of chest pain or shortness of breath at that time. Resident #407 was advised by the PTA that he and the COTA would be back in about an hour to assist Resident #407 back to bed. When they returned to the room approximately 30-45 minutes later, they observed a large amount of emesis on the floor. The PTA and COTA assisted Resident #407 back to bed, cleaned him up and positioned him for comfort. Resident #407 never complained of chest pain or shortness of breath. His color was normal, and he was not sweating. Resident #407 stated he felt better after he had vomited. The PTA and COTA notified Nurse #1 of Resident #407's emesis and she came in and took his vital signs, which were all normal. Review of the progress notes revealed a note dated [DATE] at 12:30 PM by Nurse #1, Patient not feeling well after therapy got him up this morning for the first time. Vital signs obtained and Nurse #1 spoke with the (former) Nurse Practitioner and Medical Director #1. Received an order to give regular medications and Tramadol (non-narcotic pain reliever) for discomfort from brace and getting up. Approximately 15-20 minutes later Nurse #1 rechecked Resident #407 and he advised Nurse #1 that he was not in pain. At approximately 11:00 AM, therapy advised Nurse #1 that Resident #407 had an emesis (vomit) and they laid him back down. Review of the progress note by the DON dated [DATE] at 1:03 PM revealed, During this shift at approximately 12 noon, called to Resident #407's room due to code blue status. Upon entering the room, resident found to be pulseless and non-breathing. CPR initiated immediately. Respirations being delivered via ambu-bag (self-inflating bag to provide positive pressure ventilation to patients who are not breathing) with high flow oxygen. NP in and aware of current situation. Family in building are aware of situation. CPR stopped at 12:19 PM after confirmation to stop CPR by NP. Resident pronounced dead at this time. Medical Director (Medical Director #1) in house and spoke with family regarding same. An interview was conducted with the DON on [DATE] at 3:24 P. The DON stated she remembered Resident #407 as she had admitted him to the facility on [DATE]. She stated she had been at a meeting when she heard code blue called over the loudspeaker, she responded to the code blue in Resident #407's room. His code status was verified, and he was a full code and CPR was initiated. The DON stated that the NP had come into the room during the code and was relaying messages from the family to the team that was performing the code blue. 911 was called and they responded but were not needed as the family decided to stop CPR. Medical Director #1spoke to the family after the code, she did not remember seeing Medical Director #1 in the room during the code. The DON stated per Nurse #1's written statement, Nurse #1 had told the MD #1 and NP that Resident #407 was experiencing chest pain that felt like an elephant was sitting on his chest, and that Nurse #1 had heard the NP tell the MD #1 that Resident #407 was on his list of residents to be seen that day. The DON indicated that routine practice was if someone had a significant cardiac history and was experiencing chest pain, that she would immediately call for help, apply oxygen and call for an ambulance. An interview was conducted with the ADON on [DATE] at 11:12 AM and confirmed she was familiar with Resident #407. The ADON revealed she had been in a meeting in a room next to Resident #407's room on the morning of [DATE] when Nurse #1 came in the room and asked her to come to his room, that she was unable to find a pulse on Resident #407. Upon entering Resident #407's room, she observed a male visitor attempting to find a pulse on Resident #407. She stated she checked for a pulse and was not able to auscultate (hear) a pulse. She checked Resident #407's code status and he was a full code, CPR was initiated. ADON indicated that the NP was present during CPR and spoke with the family. She stated she did not see the MD #1 during CPR. A telephone interview was conducted with Medical Director #1 on [DATE] at 10:03 AM. He stated he had been the Medical Director for the facility since [DATE] through [DATE]. Medical Director #1 stated he made rounds at the facility once a week and had been at the facility on [DATE] when Resident #407 had a cardiac arrest but had not evaluated Resident #407 prior to the code. He stated that Resident #407 was on his list to be seen that day for an admission assessment. Medical Director #1 stated he had reviewed Resident #407's medical record after the code and he had a significant cardiac history but had no cardiac notes or evaluation of his cardiac history. Medical Director #1 revealed when Nurse #1 came and told him that Resident #407 had pain, he was not the only resident that had to be seen, and that he had thought the pain was coming from the back brace and getting up with therapy. He stated, I was not the first person that the Nurse should have reported Resident #407's pain to, there was the DON, NP, other Nurses, and Nurse Aides that she should have reported to first. Medical Director #1 stated that all the residents in a nursing home had pain and he had other residents to see. He revealed he could not recall the exact events of Resident #407's cardiac event, but remembered he had a back brace. Medical Director #1 revealed he could not remember if Nurse #1 had told him that Resident #407 had chest pain that felt like an elephant was sitting on his chest and had emesis but recalled back pain. He stated he did not address every pain because he had a lot to do, and he was only there once a week. Medical Director #1 further stated he saw Resident #407 during the code and after, but not before, and spoke to the family twice after the code. He revealed if he had known prior to Resident #407's cardiac arrest that he had a significant cardiac history, he would have had the nurse call 911, because there was very little he could do outside of the hospital during a cardiac arrest, there was no epinephrine (cardiac drug) in the facility to use in a code, but he would have got Emergency Medical Services (EMS) involved and sent him to the hospital. Review of the Nurse Practitioner (NP) note dated [DATE] revealed Code Blue initiated at approximately 12:00 PM due to patient having no pulse or respirations. Facility staff performed CPR (cardio-pulmonary resuscitation) and EMS (Emergency Medical Services) were requested. After approximately 15 minutes of CPR, while family members that were present spoke with patient's responsible party via telephone, it was requested that facility staff stop CPR. A telephone interview was conducted with the Nurse Practitioner (NP) on [DATE] at 11:12 AM. The NP stated she had been the facility's Nurse Practitioner for about a year and saw residents in the facility Monday-Friday. She stated she thought she had seen Resident #407 at least once prior to his cardiac event on [DATE]. She explained that upon Resident #407's admission she had briefly seen him and reconciled his medication, but it was the Medical Directors responsibility to conduct a History and Physical on Resident #407. She stated on [DATE], while she and Medical Director #1 were discussing which residents had to be seen that day, Nurse #1 came into the room and advised them that Resident #407 was having chest pain, what his vital signs were and that he had just gotten up for the first time with therapy with a back brace on. The NP stated Medical Director #1 advised Nurse #1 to give him some pain medication and that he would see Resident #407 that day. She revealed she did not evaluate Resident #407 prior to his cardiac event, because she had her own list of residents to see that day and she thought Medical Director #1 was going to evaluate him. She stated she pointed to the list of resident names and to Resident #407's name, and said, see this is the man she is talking about, you need to see him first. The NP stated she believed that Resident #407 needed to be seen immediately and pointed to the list of resident's names. The NP stated she left to go and see her assigned residents and responded to the code blue when it was an overhead page. The NP stated she had wrongly assumed Medical Director #1 would go see Resident #407 first, and since they were in the building, they should have gone to Resident #407's bedside and evaluated him. The NP stated that Nurse #1 had responded appropriately to Resident #407's chest pain, by reporting it to the Medical Director #1 and NP that were in the building. The NP stated that the classic signs of a cardiac event was chest pain, diaphoresis (sweating profusely) and emesis. NP revealed these signs or symptoms could have been a side effect of the tramadol, but that either way, it required a bedside evaluation of the resident and listening to the resident's heart with a stethoscope. Review of a statement the NP executed on [DATE] indicated that the NP was working at the facility on [DATE] and was familiar with Resident #407 who had been admitted to the facility for rehabilitation following a vertebral fracture. The NP confirmed she was present when Nurse #1 reported Resident #407 was expressing that he had unspecified pain. The NP declared that Nurse #1 did not convey to her on [DATE] that Resident #407 had chest pain or pain that felt like an elephant was sitting on his chest. The NP confirmed that she was interviewed by state surveyor on [DATE]. During the interview with the state surveyor the NP explained it had not been conveyed that Resident #407 was complaining of chest pain specifically and could not offer an opinion on whether Resident #407's outcome could have been different if he would have been seen immediately. In the declaration the NP stated that Nurse #1 or other staff did not alert her to the urgency of Resident #407's pain complaints. The NP indicated no one at the facility asked for Resident #407 to be sent out to the hospital for further evaluation or treatment. An interview was conducted with Medical Director #2, by telephone, on [DATE] at 12:26 PM. The MD stated she had only been the Medical Director for a few days, and she was not familiar with Resident #407. She revealed that one of the first things that needed to be done when a resident complained of chest pain was to go and do a bedside assessment. Medical Director #2 stated she would have checked his blood pressure, pulse, oxygen saturation level, and description of his pain. If the resident was hemodynamically stable, then she would send the resident to the emergency room for an evaluation and if not, then provide urgent care at the bedside. Medical Director #2 further stated the best procedure was to send the resident to the emergency room for an evaluation. She stated the resident needed to be assessed well, and that it depended on the resident, their medical history, the assessment on whether to administer nitroglycerin or another pain medication. The Administrator was notified of the immediate jeopardy (IJ) on [DATE] at 6:54 PM. The facility provided the IJ removal plan: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. On [DATE] at approximately 9:00am, Resident #407 complained of heaviness in chest and trouble breathing. The licensed nurse notified the medical providers that were in the facility. Pain medication was given as ordered by the medical provider. Shortly after medication given, the resident expressed that he felt better. Approximately 9:20am, the physical therapist placed the residents TLSO -Thoracis Lumbar Sacral Orthoses (Back brace) on and the resident was assisted out of bed by the physical therapist and the resident tolerated the transfer without complaints. 10:50am the licensed nurse observed that the resident had vomited. The resident was assisted back to bed by the licensed nurse and the physical therapist and the TLSO brace was removed. The resident was repositioned in bed with head of bed elevated and the resident's upper body and face were bathed. At approximately 11:04am, the licensed nurse left the room, and the resident was resting comfortably with no further complaints of pain or discomfort. The family came to visit at approximately 12 noon and notified the nurse that the resident would not wake up. The licensed nurse assessed the resident and determined that he was not breathing and did not have a pulse. CPR (Cardio/Pulmonary Resuscitation) was initiated by the licensed nurses and the resident subsequently passed away and pronounced at 12:19pm. - All residents who exhibited a decline in condition at the facility and were not sent out who expired were at risk of being affected by the alleged deficient practice. An audit of all residents who had expired at the facility was completed by the Regional Director of Clinical Services at 7:44 pm. 3 other residents were identified as expiring at the facility in the 30 days prior to the incident and through today. [DATE] through [DATE]. A review of the medical record of those residents revealed that two were hospice residents and one with general decline refusing dialysis with significant past medical history. There are no current residents exhibiting cardiac symptoms. This reveals no other residents have been affected by the alleged deficient practice. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. - All facility physicians and extenders, Nurse Practitioner and physician assistants received training on [DATE] by the Chief Medical Officer, to include how to respond and initiate medical treatment for residents that express and exhibit signs and symptoms of a cardiac event including an assessment by provider when possible or a transfer to another level of care. Medical Practitioners hired after [DATE] will receive education upon hire during new hire orientation by the physicians group Associate Director of Quality and Education. Regional Director of Clinical Services educated the Director of Nursing on [DATE], to include how to respond and initiate medical treatment for residents that express and exhibit signs and symptoms of a cardiac event such as chest pain that may feel like pressure, tightness, pain, squeezing or aching, pain or discomfort that spreads to the shoulder, arm, back, neck, jaw, teeth or sometimes the upper belly, cold sweat, and nausea/vomiting, including an assessment by provider when possible or a transfer to another level of care. The nurse may act independently and send the resident to the hospital in an emergency. All licensed personnel including Licensed Practical nurses and registered nurses were provided the information to include Identifying signs and symptoms of a possible cardiac event such as chest pain that may feel like pressure, tightness, pain, squeezing or aching. pain or discomfort that spreads to the shoulder, arm, back, neck, jaw, teeth or sometimes the upper belly, cold sweat, and nausea/vomiting, including an assessment by provider when possible or a transfer to another level of care. The nurse may act independently and send the resident to the hospital in an emergency. This education was completed on [DATE] by the Director of Nursing. Licensed nurses, to include agency staff and newly hired nurses will be educated prior to accepting assignment and/or during new hire orientation. The Director of Nursing was advised by the Regional Director of Clinical Services on [DATE] that all staff who had not been educated would need to be required to have the above in-service education prior to the start of their next scheduled shift. The Director of Nursing will be required to monitor and ensure all licensed staff receive this education by maintaining a log of education. All nurse aides and non-nursing staff to include contracted and agency staff present were educated by the Director of Nursing, ADON and nursing supervisor on [DATE], to continue to immediately report any complaints of pain or changes in condition to the licensed nurse. Contracted staff, nurse aides and agency staff will be educated prior to accepting assignment and/or during new hire orientation. The Director of Nursing was advised by the Regional Director of Clinical Services on [DATE] that all staff who had not been educated would need to be required to have the above in-service education prior to the start of their next scheduled shift. The Director of Nursing will be required to monitor and ensure all licensed staff receive this education by maintaining a log of education. Alleged date of IJ removal: [DATE]. Medical Practitioner interviews revealed they had been re-educated on how to appropriately respond to cardiac situations and watched a video again reiterating the steps to take when a resident was experiencing cardiac issues. All clinical staff and non-clinical staff verbalized understanding of signs and symptoms of residents experiencing cardiac issues. All staff were able to verbalize the signs of symptoms and who to report them to if a resident should experience them and how to respond if the appropriate medical attention was not delivered to call emergency medical services. The education sign in sheets were reviewed as well as the audits conducted to ensure no other residents were affected by the deficient practice. The facility's IJ removal date of [DATE] was validated.