**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to protect Resident #87 from physical restraint from Nurse Aide (NA #1). NA #1 grabbed Resident #87's wrists when the resident became combative during incontinent care and Resident #87 hit NA #1. Resident #87 was cognitively impaired and resided on the dementia care unit. Resident #87 had three skin tears the size of a half dollars to the left wrist, right elbow, and right arm and two bruises the size of tennis balls to bilateral lower forearms and wrists. This deficient practice affected 1 of 3 residents reviewed for abuse (Resident #87). The findings included: Resident #87 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia with agitation and anxiety disorder. Resident #87's admission Minimum Data Set assessment dated [DATE] revealed he was severely cognitively impaired with no psychosis, rejection of care, or instances of wandering. Resident #87 was coded as having other behavioral symptoms not directed towards others (physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal or vocal symptoms like screaming or disruptive sounds) as occurring 1-3 days during the lookback period. Resident #87 required extensive assistance with 1 person assist for toilet use, personal hygiene, and bathing. Resident #87's care plan updated on 01/23/23 revealed no care plan area for aggressive or combative behaviors. Resident #87 was care planned for wandering and putting objects in his mouth. A skin assessment dated [DATE] indicated that Resident #87 had a skin tear to his left forefinger that was cleaned and dressed. No other skin issues were noted on the assessment. The assessment was completed by Nurse #2. An interview via telephone was attempted with Nurse #2 on 07/14/23 but was unsuccessful. Resident #87's progress notes revealed the following note dated 03/08/23 at 8:21 PM written by Nurse #1, Heard certified nurse aide (NA #1) call for help. This writer walked into resident's room to see [NA #1] holding [Resident 87's] arms. Resident [#87] was kicking legs and yelling. [NA #1] reported [Resident #87] was conversant and was willing to let [NA #1] change brief. When he turned [Resident #87] toward him, [Resident #87] hit him in the nose with his fist. [NA #1] held arms to try to calm [Resident #87]. [Resident #87] started to calm and [NA#1] stepped away from [Resident #87]. Skin tears noted to bilateral arms with bruising to bilateral arms. Skin tears cleaned and dressed per protocol. An interview with NA #1 via phone on 07/11/23 at 12:43 PM revealed he remembered the incident and stated he was in Resident #87's room providing incontinence care with Resident #87 rolled onto his right side, suddenly, Resident #87 became combative and rolled back onto his back and NA #1's arms. NA #1 stated one of his arms was stuck between Resident #87's legs and his other arm was underneath Resident #87's back. NA #1 stated he had worked with Resident #87 before and had never had him become aggressive or combative with him while he provided care. He reported Resident #87 hit and struck him in the head and nose. NA #1 reported once he was able to get his arms loose, he held Resident #87's arms and began hollering for help from Nurse #1. NA #1 stated when Nurse #1 arrived at the room, she assisted him in getting Resident #87 calmed down and he let go of Resident #87's arms. NA #1 stated he observed skin tears on Resident #87's arms and stated he could not tell if the skin tears were from where he held Resident #87's arms or from where Resident #87 hit him. NA #1 stated he had received dementia and abuse training and reported he knew he should back away from aggressive or combative residents and reapproach them later. He also reported he finished his shift and stated he was not suspended after the incident. A skin assessment completed on 03/08/23 at 8:31 PM by Nurse #1 and reviewed on 03/09/23 by the Wound Nurse revealed Resident #87 was treated for a skin tear to his left wrist, a skin tear to his right elbow, and a skin tear to his right arm. An interview with Nurse #1 via phone on 07/11/23 at 2:47 PM revealed she remembered the incident with NA #1 and Resident #87 on 03/08/23, and stated NA #1 had called out for help while he was in Resident #87's room. She stated when she entered the room, NA #1 was standing by Resident #87's bed and was holding Resident #87 by his wrists. She reported NA #1 told her Resident #87 had become combative during incontinence care and had hit him in the nose and he held Resident #87's arms to prevent Resident #87 from hitting him. Nurse #1 stated she observed Resident #87 lying on his back with his arms extended towards the ceiling with NA #1 holding onto his both wrists. She stated she noted multiple skin tears to both of Resident #87's arms and she provided first aid. Nurse #1 described the skin tears as about the size of a half dollar and were located on both of Resident #87's forearms or wrists. Nurse #1 stated she reported the incident to the Wound Nurse because of the injuries, and she also informed the Unit Manager and the Quality Assurance Nurse who came and assessed Resident #87. Nurse #1 stated when she informed the Unit Manager and the Quality Assurance Nurse, she was confident she let them know that she had seen NA #1's hands grasping Resident #87's wrists. Nurse #1 reported she had received training regarding combative residents and that staff were expected to remove themselves from combative residents and reapproach them later. An interview with the Wound Nurse on 07/11/23 at 12:14 PM revealed she viewed and treated Resident #87's wounds after the incident with NA #1. She reported Resident #87 had significant bruising to his lower arms and multiple skin tears. She stated she believed the skin tears were to Resident #87's lower arms and were large. She stated Resident #87's bruising to his lower arms was observed to be approximately the size of a tennis ball on both of Resident #87's arms. The Wound Nurse reported she cleaned the wounds with normal saline and covered them with 2 inches by 2 inches foam dressings. She reported the wound dressings would have been changed every 3 days until healed but stated she could not remember how long she treated the wounds. Review of physician orders revealed the following: 03/09/23- clean large skin tear to left lower forearm/wrist area with normal saline, apply xeroform (foam dressing) and a clear dressing every Tuesday, Thursday, and Saturday. 03/09/23-Clean skin tear to right lower forearm/wrist with normal saline, apply xeroform and cover with a clear dressing every Tuesday, Thursday, and Saturday. 03/09/23-Clean second skin tear to left lower forearm/wrist with normal saline, apply xeroform and a clear dressing every Tuesday, Thursday, and Saturday. 03/09/23-Clean pea sized skin tear to right elbow with normal saline, apply xeroform and cover with clear dressing every Tuesday, Thursday, and Saturday. 03/09/23-Clean large skin tear to right elbow with normal saline, apply xeroform and cover with clear dressing every Tuesday, Thursday, and Saturday. During an interview with the Unit Manager on 07/11/23 at 3:10 PM, she reported she was informed of the incident but was unsure if it was the day the incident occurred or the day after. She reported it was her understanding that Resident #87 had become combative during care and NA #1 had attempted to prevent Resident #87 from hitting him. Unit Manager reported she did not recall being informed that NA #1 had held Resident #87 by his arms or wrists but stated she was aware that there were multiple skin tears that required treatment following the incident. She reported staff had received training regarding combative or aggressive residents and that staff were expected to step away from the resident and reapproach at a later time. An interview with the Quality Assurance Nurse on 07/11/23 at 3:42 PM revealed Nurse #1 had approached her to come look at Resident #87's arms. She stated she was told that NA #1 had provided Resident #87 with incontinent care and during the care, Resident #87 had become combative and hit NA #1 in the nose. She stated NA #1 told her when he was hit in the nose, he reactively grabbed Resident #87's wrists to keep Resident #87 from hitting him again and resulted in multiple skin tears to Resident #87's lower forearms or wrists. She reported she questioned NA #1 why he grabbed Resident #87 and was told it was reactionary. The Quality Assurance Nurse reported NA #1 told her he released Resident #87's wrists when he began to calm down. She reported she observed the wounds to Resident #87 and that the skin tears seemed fresh. She also reported staff were educated to remove themselves from combative residents and to reapproach them later. An interview with the Director of Nursing (DON) on 07/11/23 at 3:16 PM revealed she was aware of an incident regarding NA #1 and Resident #87. She stated when she was informed of the incident, she began an investigation and when she spoke with NA #1 he reported he had gone into Resident #87's room to provide care and during that time, Resident #87 became combative and begun to swing and kick at NA #1. The DON stated she was not told that NA #1 had grabbed Resident #87's wrists. She did report that Resident #87 suffered multiple skin tears to his bilateral arms during the incident. The DON reported she did not believe the actions of NA #1 were abusive in nature and stated she had worked with NA #1 for a long time and was insistent that he did not willfully injure Resident #87. She stated she felt the incident was a reaction to having been hit in the nose. She stated she did not see how NA #1 could have done anything different and stated that the staff on the locked dementia unit were beat up by Resident #87 daily. The Director of Nursing stated NA #1 had received abuse and combative resident training and it was expected that he back away and reapproach later but insisted he did not have another option with his arm being trapped. An interview with the Administrator on 07/11/23 at 4:39 PM revealed it was his understanding that NA #1 had gone into Resident #87's room to provide incontinence care and Resident #87 had become combative, hitting NA #1 in the nose. He stated he did not believe the actions of NA #1 was abusive as he did not believe they were willful. The Administrator stated he firmly believed there was no intent to hurt Resident #87 when NA #1 held Resident #87's arms during the incident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, staff and resident interviews the facility failed to remove Nurse Aide (NA) #1 from a resident care assignment after Nurse #1 witnessed the NA holding both of Resident #87's wrists to prevent the resident from hitting him when the resident became combative during care. In addition, the facility failed to identify, thoroughly investigate, and to report abuse to the state agency, Adult Protective Services, and local law enforcement for 1 of 3 residents (Resident #87) reviewed for abuse. The findings included A review of the facility's policy titled Abuse, Neglect, or Misappropriation of Resident Property Policy revised 03/10/17 revealed: Allegations of abuse, neglect, exploitation, or misappropriation of resident property and injuries of unknown origin will be investigated by the facility. The Administrator is responsible to direct the investigation process and to ensure that appropriate agencies are notified, as directed. The policy also dictated that the Administrator was responsible for ensuring incidents were reported to the appropriate local, state, and federal agencies, including the Nurse Aide Registry. The policy also stated that employees accused of being directly involved in allegations of abuse, neglect, exploitation, or misappropriation of property will be suspended immediately from duty pending the outcome of the investigation. Resident #87 was admitted to the facility on [DATE]. Resident #87's progress notes revealed the following note dated 03/08/23 at 8:21 PM written by Nurse #1, Heard certified nurse aide [NA #1] call for help. This writer walked into resident's room to see [NA #1] holding [Resident #87's] arms. Resident [#87] was kicking legs and yelling. [NA #1] reported [Resident #87] was conversant and was willing to let [NA #1] change brief. When he turned [Resident #87] toward him, [Resident #87] hit him in the nose with his fist. [NA #1] held arms to try to calm [Resident #87]. [Resident #87] started to calm and [NA #1] stepped away from [Resident #87]. Skin tears noted to bilateral arms with bruising to bilateral arms. Skin tears cleaned and dressed per protocol. An interview with NA #1 via phone on 07/11/23 at 12:43 PM revealed he was currently employed at the facility and remembered the 03/08/23 incident with Resident #87. NA #1 stated he was in Resident #87's room providing incontinence care shortly after his shift started at 3:00 PM. He reported the resident was rolled onto his right side when he (Resident #87) suddenly became combative and rolled onto his back and onto NA #1's arms. NA #1 stated one of his arms was stuck between Resident #87's legs and his other arm was underneath Resident #87's back. He reported Resident #87 hit and struck him in the head and nose. NA #1 reported once he was able to get his arms loose, he held Resident #87's arms and began hollering for help from Nurse #1. NA #1 stated when Nurse #1 arrived at the room, she assisted him in getting Resident #87 calmed down and he let go of Resident #87's arms. He reported he finished his shift providing resident care and stated he was not suspended after the incident. NA #1 reported he was not full time and his hours varied but he had worked at the facility for over 10 years. An interview with Nurse #1 via phone on 07/11/23 at 2:47 PM revealed she remembered the incident with NA #1 and Resident #87 on 03/08/23, and stated NA #1 had called out for help while he was in Resident #87's room. She stated when she entered the room, NA #1 was standing by Resident #87's bed and was holding Resident #87 by his wrists. She reported NA #1 told her Resident #87 had become combative during incontinence care and had hit him in the nose and he held Resident #87's arms to prevent Resident #87 from hitting him. Nurse #1 stated she observed Resident #87 lying on his back with his arms extended towards the ceiling with NA #1 holding onto his both wrists. She stated she noted multiple skin tears to both of Resident #87's arms and she provided first aid. Nurse #1 described the skin tears as about the size of a half dollar and were located on both of Resident #87's forearms or wrists. Nurse #1 stated she reported the incident to the Wound Nurse because of the injuries, and she also informed the Unit Manager and the Quality Assurance Nurse of what she observed. She stated they (Unit Manager and Quality Assurance Nurse) both came and assessed Resident #87. Nurse #1 stated when she informed the Unit Manager and the Quality Assurance Nurse, she was confident she let them know that she had seen NA #1's hands grasping Resident #87's wrists. Nurse #1 reported she could not remember if NA #1 was suspended or allowed to finish his shift after the altercation with Resident #87 on 03/08/23. An interview with the Quality Assurance Nurse on 07/11/23 at 3:42 PM revealed on 03/08/23 Nurse #1 had approached her to come look at Resident #87's arms. She stated she was told that NA #1 had provided Resident #87 with incontinent care and during the care, Resident #87 had become combative and hit NA #1 in the nose. She stated NA #1 told her when he was hit in the nose, he reactively grabbed Resident #87's wrists to keep Resident #87 from hitting him again and resulted in multiple skin tears to Resident #87's lower forearms or wrists. She stated she reported the incident to the Administrator since he was still at the facility at the time of the incident. She indicated she did not believe the actions of NA #1 were abusive in nature and that they were reflexive. An interview with the Director of Nursing (DON) on 07/11/23 at 3:16 PM revealed she was aware of an incident regarding NA #1 and Resident #87 that occurred on 03/08/23. She stated when she was informed of the incident by the Administrator on 03/08/23, she began an investigation. She indicated when she spoke with NA #1 he reported he had gone into Resident #87's room to provide care and during that time, Resident #87 became combative and began to swing and kick at NA #1. The DON stated she was not told that NA #1 had grabbed Resident #87's wrists. She reported that Resident #87 suffered multiple skin tears to his bilateral arms during the incident. The DON reported she did not believe the actions of NA #1 were abusive in nature and stated she had worked with NA #1 for a long time and was insistent that he did not willfully injure Resident #87. She stated she felt the incident was a reaction to having been hit in the nose. The Director of Nursing also reported due to her not believing the actions of NA #1 were abusive in nature, he was not suspended and was allowed to finish his shift. She also stated a 24 hour and 5 working day report was not completed and sent to the state agency. She indicated her investigation consisted of speaking with NA #1 and Nurse #1. During an interview with the Administrator on 07/11/23 at 4:39 PM, he reported he was made aware of the incident that occurred on 03/08/23 between Resident #87 and NA #1 shortly after it occurred. He stated he did not believe the actions of NA #1 were abusive in nature as there was no willful intent to cause injury to Resident #87. He stated he firmly believed that NA #1 had no intention to harm Resident #87 and that because of his belief, no 24 hour or 5 working day report was completed. He stated the police department was not called, nor was the information provided to the local department of social services. The Administrator verified that NA #1 was not suspended and was allowed to finish his shift on 03/08/23. The facility provided the following corrective action plan: 1. Resident #87 was having his brief changed, and CNA #1 turned him over. CNA #1 reports resident #87 suddenly started mumbling and hit CNA #1 hard in the nose. One of the CNAs' #1 arms was caught between resident #87 legs as he scissored his legs; the other arm was up under resident #87. CNA #1 knew he needed to back away but couldn't. He stated, I buried my head in his chest to keep him from hitting my face again. CNA #1 reported he did not know if the skin tears had happened when the resident hit him. CNA #1 stated he was yelling for the nurse to come help. He said, The resident was wild, he finally could back off when holding resident #87 wrist for a moment and pulling his other hand out from under resident #87 after the nurse came in the room. The nurse reports she heard CNA #1 call for help, she walked into the room and saw CNA #1 hold onto resident #87 arms, CNA #1 let go of resident #87 arms and placed them on the bed and CNA #1 was able to back away. The resident was kicking his legs and yelling. CNA #1 told the nurse that resident #87 was talking and was willing to let CNA #1 change his brief, and when he turned the resident back towards him, he hit him in the nose with his fist. CNA #1 stated he took hold of his arms to try and calm the resident so that he could back away. The nurse reports skin tears were noted on bilateral arms and right elbow. She could not determine how the skin tears happened, so she cleaned the areas and applied a dressing. The Quality Assurance (QA) nurse was asked to see the resident after the incident related to resident #87 skin tears; she explained resident #87 was being cooperative when all of a sudden, he became combative with CNA #1, the CNA #1 had his hand on the resident's arms. The QA nurse observed resident #87 out of his room, walking around in another resident's room and then in the Dining Room. The QA nurse saw the bandages on Resident #87 and saw he was not displaying any signs or symptoms of mental anguish. QA nurse notified the Administrator on 3/8/23. CNA #1 did not provide care to Resident #87 after the incident occurred on 3/8/2023 until he was re-educated on 3/9/2023. However, he did continue to work and care for other residents CNA #1 was educated through Relias related to caring for dementia residents with behaviors; the licensed nurse and another CNA provided the care for the remainder of the shift on 3/8/2023, to resident #87. All other residents were not assessed, and law enforcement was not notified. 2. On 5/30/23, Skin assessments were completed on all non-alert and oriented residents for signs or symptoms of abuse by the assigned nurse with a BIMS of 12 or below with no negative findings. On 5/30/23, Safe Surveys were completed for alert and oriented residents, with a Brief Interview of Mental Status (BIMS) of 13 or above by licensed staff. The Director of Nursing noted no areas of concern upon her review 3. On 3/9/23, an in-service was proactively scheduled and completed using the electronic learning system for CNA #1 on caring for dementia residents with behaviors. The in-service emphasizes while providing care to residents with dementia, they are to approach in a calm, quiet manner, explain all procedures they are going to do, and as they are doing them, if the resident becomes combative, they are to protect the resident from injury, remove themselves from the situation and get assistance from the Licensed Nurse. On 3/9/2023, Dementia unit staff, including nurses, CNA, agency staff, and contract staff, received an in-service related to the need for a 2-person assist for Resident #87 for the purpose of having a staff member present (not assisting with care) during care that could assist if the resident becomes combative in getting assistance from the licensed nurse or assisting the other staff member in safely exiting the resident's room for the protection of the resident in addition to Relias training for caring for dementia residents with behaviors. On 5/30/23, An in-service was conducted by the Quality Assurance Nurse, with 100% staff to include, administrative staff (Administrator, Director of Nursing and Department managers) nurses, nursing assistants, therapy staff, housekeeping, dietary staff, social worker, accounts receivable/payable, receptionist, maintenance, and admission staff regarding Abuse, Neglect, Misappropriation, to include; identification of abuse, protection of residents including suspending the identified staff immediately and removing from facility and assessing other residents for signs of abuse, reporting of Abuse to Administrator timely, external reporting to law enforcement, Adult Protective Services and Healthcare Personnel Registry the in-service also emphasized while providing care to residents with dementia they are to approach in a calm, quite manner, explain all procedures they are going to do and as they are doing them, if the resident becomes combative, they are to protect the resident from injury, remove themselves from the situation and get assistance from the Licensed Nurse The in-service included the definition and prevention of Abuse, Neglect, and Misappropriation. In-services were completed by 5/31/23. The RN Quality Assurance Nurse and the RN Staff Development Coordinator monitored for in-service completion; if a staff member did not attend the initial in-service, they were required to complete the in-service before their next scheduled shift. 4. On 5/30/23, a Performance Improvement Plan was developed for Abuse/Late Reporting and was reviewed and approved by the Quality Assurance Performance Improvement team (QAPI). The Administrator and the Director of Nursing will immediately review any allegations of abuse that are verbally and written reported based on progress notes review or through the resident concerns process, and ensure that resident protection by removing the accused staff member from the facility, assessing other residents for signs of abuse, reporting requirements including law enforcement, Adult Protection Services, Healthcare Personnel Registry to meet the F607 requirements utilizing the Abuse Action Checklist. As part of the facility's daily QA meeting, care rounds were completed by Departments managers and licensed staff to ensure ADL care was provided, to monitor behaviors for the Dementia Unit, and appropriate staff and resident interactions. Any findings were addressed immediately and brought to the morning QA meeting. The Unit Manager and Staff Development Coordinator observe care weekly in the dementia unit to monitor staff competencies in the care and treatment of residents. Concerns are discussed in the daily QA meeting. Daily QA meeting minutes are documented 5x weekly. The Nurse Consultant is contacted about incidents and allegations of abuse and will review all reportable incidents electronically in the medical record and through verbal communication by the Administrator and DON to ensure compliance with F 607. The Administrator reported the results of these monitoring tools to the Quality Assurance Committee, and any issues will result in a revision to the performance improvement plan. 5. Date of Corrective Action Completion 5/31/23. The state survey agency returned to the facility on [DATE] to validate the corrective action plan. The corrective action plan could not be validated as the facility failed to have sufficient evidence of care that was to be observed weekly on the dementia care unit to ensure staff were competent in the care and treatment of residents. The facility was asked to provide a credible allegation of IJ removal on 07/20/23. The facility provided the following IJ removal plan: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance; and On 3/8/23, Resident #87 was having his brief changed, and Certified Nursing Assistant (CNA #1) turned him over. CNA #1 reports Resident #87 suddenly started mumbling and hit CNA #1 hard in the nose. One of CNAs' #1 arms was caught between Resident #87 legs as he scissored his legs; the other arm was up under resident #87. CNA #1 knew he needed to back away but couldn't. He stated, I buried my head in his chest to keep him from hitting my face again. CNA #1 reported he did not know if the skin tears had happened when the resident hit him. CNA #1 stated he was yelling for the nurse to come help. He said, The resident was wild, he finally could back off when holding resident #87 wrist for a moment and pulling his other hand out from under resident #87 after the nurse came in the room. The nurse reports she heard CNA #1 call for help, she walked into the room and saw CNA #1 hold onto resident #87 arms, CNA #1 let go of Resident #87 arms and placed them on the bed and CNA #1 was able to back away. The resident was kicking his legs and yelling. CNA #1 told the nurse that resident #87 was talking and was willing to let CNA #1 change his brief, and when he turned the resident back towards him, he hit him in the nose with his fist. CNA #1 stated he took hold of his arms to try and calm the resident so that he could back away. The nurse reports skin tears were noted on bilateral arms and right elbow. She could not determine how the skin tears happened, so she cleaned the areas and applied a dressing. The Quality Assurance (QA) nurse was asked to see the resident after the incident related to resident #87 skin tears; she explained resident #87 was being cooperative when all of a sudden, he became combative with CNA #1, the CNA #1 had his hand on the resident's arms. The QA nurse observed resident #87 out of his room, walking around in another resident's room and then in the Dining Room. The QA nurse saw the bandages on Resident #87 and saw he was not displaying any signs or symptoms of mental anguish. QA nurse notified the Administrator on 3/8/23. CNA #1 did not provide care to Resident #87 after the incident occurred on 3/8/2023 until he was re-educated on 3/9/2023. However, he did continue to work and care for other residents. CNA #1 was educated through Relias related to caring for dementia residents with behaviors; the licensed nurse and another CNA provided the care for the remainder of the shift on 3/8/2023, to resident #87. All other residents were not assessed, APS was not notified, a report was not sent to the state agency and law enforcement was not notified on the day of the incident due to the incident note being identified as abuse. On 3/8/23, an investigation was initiated by the Quality Assurance Nurse and an incident report was completed related to the incident for the skin tears and bruise but it was not identified as abuse during the investigation. On 5/30/23, Skin assessments including resident # 87 were completed on all non-alert and oriented residents for signs or symptoms of abuse by the assigned nurse with a BIMS of 12 or below with no negative findings. On 5/30/23, Safe Surveys were completed by the Social Worker and Admission's Coordinator for alert and oriented residents, with a Brief Interview of Mental Status (BIMS) of 13 or above. The Director of Nursing noted no areas of concern upon her review. On 7/12/23, the Administrator suspended CNA #1 pending investigation. On 7/13/23, the Administrator reported the allegation to the Healthcare Personnel Registry, Adult Protective Services and Law Enforcement. On 7/14/23, skin assessments including resident # 87 were completed on all non-alert and oriented residents for signs or symptoms of abuse by the assigned License Practical Nurse (LPN) or Registered Nurse (RN) charge nurses with a BIMS of 12 or below with no negative findings to ensure no resident is currently at risk for abuse. There were no identified areas of concern during the audit. On 7/14/23, Safe Surveys were completed by the Social Worker for all alert and oriented residents, with a Brief Interview of Mental Status (BIMS) of 13 or above to ensure no residents are currently at risk for abuse. There was no identified area of concern during the audits. 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 3/9/23, an in-service was proactively scheduled by the Quality Assurance Nurse and completed using the electronic learning system for CNA #1 on caring for dementia residents with behaviors. The in-service emphasizes while providing care to residents with dementia, they are to approach in a calm, quiet manner, explain all procedures they are going to do, and as they are doing them, if the resident becomes combative, they are to protect the resident from injury, remove themselves from the situation and get assistance from the Licensed Nurse. On 3/9/23, The Quality Assurance Nurse conducted an inservice with Dementia unit staff, including nurses, CNAs, and contract staff, regarding needing a 2-person assist for Resident #87. One staff member will provide care, and the other staff will be available if the resident becomes combative to get assistance from the licensed nurse or to assist the other staff member in safely exiting the resident's room. In addition, Relias training was completed on Caring for Dementia Residents with Behaviors. The inservice was completed on 3/9/23. On 5/30/23, An in-service was conducted by the Quality Assurance Nurse, with 100% staff to include, administrative staff (Administrator, Director of Nursing and Department managers) nurses, nursing assistants, therapy staff, housekeeping, dietary staff, social worker, accounts receivable/payable, receptionist, maintenance, and admission staff regarding Abuse, Neglect, Misappropriation, to include; identification of abuse, protection of residents including suspending the identified staff immediately and removing from facility and assessing other residents for signs of abuse, reporting of Abuse to Administrator timely, external reporting to law enforcement, Adult Protective Services and Healthcare Personnel Registry. The in-service also emphasized while providing care to residents with dementia they are to approach in a calm, quite manner, explain all procedures they are going to do and as they are doing them, if the resident becomes combative, they are to protect the resident from injury, remove themselves from the situation and get assistance from the Licensed Nurse. The education was completed by 5/31/23. The RN Quality Assurance Nurse and the RN Staff Development Coordinator monitored for in-service completion; if a staff member did not attend the initial in-service, they were required to complete the in-service before their next scheduled shift. On 7/14/23, an inservice was conducted by the Assistant Director of Nursing on abuse with Administrative staff (Administrator, Director of Nursing, and Department Managers) nurses, nursing assistants, therapy staff, housekeeping, dietary staff, social worker, accounts receivable/payable, receptionist, maintenance, and admission staff to include removing the staff member immediately, notification of the Administrator and Director of Nursing, and abuse will not be tolerated. The inservices was completed on 7/14/23. After 7/14/23, any staff who has not worked and received the education will complete on their next scheduled shift. The Assistant Director of Nursing and Staff Development Coordinator will monitor staff completion of the in-service; if a staff member did not attend the initial in-service, they are required to complete the in-service before their next scheduled shift. Date of immediate jeopardy removal: 7/15/23 While onsite on 07/20/23 the IJ removal plan was validated. Resident #87's care plan was noted to have been updated on 03/09/23 to include the need for two staff members for all care provided. NA #1's education that occurred on 03/09/23 on providing care to dementia residents was reviewed. Education that was provided to all staff across all departments was reviewed along with staff sign in sheets to confirm receipt of abuse and neglect training that occurred on 05/30/23 was reviewed. Skin assessment of all residents that were not alert and oriented in the facility were done between 05/02/23 and 05/30/23 with no other significant findings noted. Alert and oriented residents were asked three questions on a safe survey regarding any other potential abuse situations with no pertinent findings. The facility's resident council was also educated on abuse and neglect and how to report any abuse during the meeting held on 05/24/23 with ten residents in attendance. Staff interviews across the nursing, activities, housekeeping, and administrative departments confirmed that they had received education regarding abuse and neglect on 05/30/23 and again on 07/14/23. The education included protection of residents by suspending the identified staff immediately and removing from facility. The facility's IJ removal date of 07/15/23 was validated.