**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure the resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 2 (Resident #2 and Resident #3) of 5 resident's reviewed for abuse.1. The facility failed to protect Resident #2 from mental and verbal abuse by Resident #3 when he threatened to cut off her foot with a hand saw and proceeded to saw a groove in the center of her top, front, walker bar.2. The facility failed to protect Resident #3 from neglect when he was able to obtain a hand saw from an unlocked maintenance closet.These failures could place residents at risk of abuse and neglect.An Immediate Jeopardy (IJ) was identified on 09/12/25. The IJ template was provided to the facility on [DATE] at 01:00 PM. While the IJ was removed on 09/13/25 at 12:08 PM the facility remained out of compliance at a severity level of no actual harm potential for more than minimal harm not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems. Plan of Removal of IJ will be included in findings.Findings Included:1. Record review of Resident #2's admission record dated 09/11/25 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Alzheimer's disease (a progressive disease that destroys memory and other important mental functions) with late onset, intermittent explosive disorder (repeated sudden outbursts of anger), psychotic disorder with delusions (severe mental illness including distorted beliefs) due to known physiological condition, and major depressive disorder (a mental disorder characterized by persistent low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities).Record review of Resident #2's admission MDS completed on 06/19/25 revealed a BIMS score of 10 which indicated moderately impaired cognition. Section GG Functional Abilities revealed Resident #2 used a walker. She was noted to require partial/moderate assistance to supervision/touching assistance across all ADLs. Record review of Resident #2's care plan initiated on 06/20/25 revealed she had the potential to be verbally aggressive and yell at other residents and staff related to dementia. Resident #2 was noted to receive antianxiety medication and antipsychotic medication.Record review of Resident #2's active orders revealed the following orders with corresponding start dates:07/30/25 risperiDONE Oral Tablet 0.25 MG (Risperidone) Give1 tablet by mouth at bedtime related to PSYCHOTICDISORDER WITH DELUSIONS DUE TO KNOWN PHYSIOLOGICAL CONDITION06/11/25 traZODone HCl Oral Tablet 50 MG (Trazodone HCl) Give 1 tablet by mouth at bedtime for Headache related to MAJOR DEPRESSIVE DISORDER, RECURRENT SEVERE WITHOUT PSYCHOTIC FEATURES09/11/25 Vistaril Oral Capsule 50 MG (Hydroxyzine Pamoate) Give 1 capsule by mouth every 04 hours as needed for anxiety for 14 Days2. Record review of Resident #3's admission record revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Parkinson's disease (chronic and progressive movement disorder that initially causes tremors in one hand and stiffness or slowing of movement) without dyskinesia (abnormality or impairment of voluntary movement), unspecified dementia (a group of thinking and social symptoms that interferes with daily functioning), major depressive disorder (a mental disorder characterized by persistent low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities), anxiety disorder (a group of mental health conditions characterized by excessive and persistent worry, fear, and nervousness that can significantly interfere with daily life), muscle wasting and atrophy (shrinkage or wasting away of tissue), muscle weakness, and other lack of coordination.Record review of Resident #3's quarterly MDS completed 09/05/25 revealed a BIMS score of 12 which indicated moderately impaired cognition. Section E Behavior revealed Resident #3 had no behaviors. Section GG Functional Abilities revealed he was independent across all ADLs. Section M Medications revealed he was receiving antidepressant, antiplatelet, and anticonvulsant medication.Record review of Resident #3's care plan completed on 09/08/25 revealed he was resistive to care r/t impaired cognition and he had potential to be physically aggressive throwing objects r/t behaviors. Resident #3 was noted to have potential to be verbally aggressive very rude and demanding r/t cognitive impairment. He had impaired cognitive function r/t dementia. He had a mood problem r/t MDD and declines to see psych. Interventions included administering medications as ordered, explain all procedures and orders prior to starting and allow time to adjust to changes, discuss inappropriate behaviors with resident when reasonable, monitor behavior episodes and attempt to determine underlying causes, and document behaviors and potential causes. Staff were instructed to give the resident 5-10 minutes when resistive to care before trying again and when he became agitated to intervene before the agitation escalated and guide him away from the source of distress. Staff were instructed to engage him calmly in conversation and if he became aggressive they were to walk calmly away and approach at a later time.Record review of Resident #3's active orders dated 09/11/25 revealed the following orders with corresponding start dates:05/18/25 Aspirin EC Tablet Delayed Release 81 MG (Aspirin) Give 1 tablet by mouth one time a day for Pain -Moderate11/20/24 Carbidopa-Levodopa Oral Tablet 25-250 MG(Carbidopa-Levodopa) Give 1 tablet by mouth five times a day related to PARKINSON'S DISEASE WITHOUT DYSKINESIA, WITHOUT MENTION OF FLUCTUATIONS09/03/25 clonazePAM Oral Tablet 0.5 MG (Clonazepam) Give 1 tablet by mouth three times a day related to ANXIETY DISORDER, UNSPECIFIED03/15/25 DULoxetine HCl Oral Capsule Delayed Release Sprinkle 30 MG (Duloxetine HCl) Give 1 capsule by mouth in the afternoon for dep03/14/25 DULoxetine HCl Oral Capsule Delayed Release Sprinkle 30 MG (Duloxetine HCl) Give 2 capsule by mouth at bedtime for dep related to MAJOR DEPRESSIVE DISORDER, RECURRENT, UNSPECIFIED07/30/25 Mirtazapine Oral Tablet 30 MG (Mirtazapine) Give 1 tablet by mouth at bedtime related to MAJOR DEPRESSIVE DISORDER, RECURRENT, UNSPECIFIED09/10/25 Vistaril Oral Capsule 50 MG (Hydroxyzine Pamoate) Give 1 capsule by mouth every 04 hours as needed for anxiety for 14 DaysRecord review of a referral order dated 09/10/25 revealed Resident #3 was being referred for Psychiatric Medication Management and Psychotherapy and Counseling Services.Record review Resident #3's progress notes from 03/11/25 to 09/12/25 revealed no mention of physical or verbal aggression toward another resident.During an observation and interview on 09/11/25 at 08:23 AM Resident #2 stated a male resident had a saw yesterday and threatened to cut off her feet and then cut on her walker. She gestured to the top, front bar of her walker.During an observation and interview on 09/11/25 at 08:36 AM Resident #2 was seen leaving ADON's office and stated she told ADON about the man threatening to cut off her feet with a saw.During an observation and interview on 09/11/25 at 08:36 AM ADON stated she was just told by Resident #2 about Resident #3 threatening her with a saw on 09/10/25.During an observation and interview on 09/11/25 at 08:41 AM ADM stated Resident #3 had a hand saw on 09/10/25. She stated, He took it out of the maintenance room is the only thing we can figure out. ADM stated CNA A and CNA B were working at the time and took the saw away from Resident #3. When asked if he used the saw to threaten Resident #2 and/or cut on her walker, ADM shook her head and stated, What you are going to find out is [name of Resident #2] doesn't tell the truth.During an interview on 09/11/25 at 08:50 AM CNA A stated regarding Resident #3 on 09/10/25, I mean he did have a saw but as soon as we seen him, we took it from him. He was rolling with the saw down the hall. She stated she did not hear him threaten Resident #2 or see him using the saw on Resident #2's walker. She stated she was trained regularly on recognizing and reporting suspected abuse and neglect. She stated she was to report suspected abuse and neglect to ADM.During an interview on 09/11/25 at 08:51 AM CNA B stated Resident #3 had a saw on 09/10/25 and he was using the saw on Resident #2's walker. She stated, You can look at her walker. There is proof. CNA B stated Resident #3 got the saw from the maintenance office. She stated she reported the incident to ADM and ADON as soon as the saw was taken away from Resident #3 on 09/10/25. She stated she was trained regularly on reporting suspected abuse and neglect and she was to report to ADM.During an observation and interview on 09/11/25 at 09:00 AM Resident #3 was lying in bed in his room. He stated he had a saw yesterday (09/10/25) and he got the saw from the shop (here he gestured with his left hand in the direction of the hallway which housed the maintenance office). Resident #3 was asked if he threatened to cut off a Resident #2's feet with the saw and he answered, Foot. He stated he threatened to cut off her foot. When asked if he used the saw on the female resident's walker, he said he did. During an observation on 09/11/25 at 09:03 AM of Resident #2's top, front walker bar revealed a small, shallow groove approximately 1.5 centimeters in length and 2 millimeters in depth with jagged edges.During an observation and interview on 09/11/25 at 09:04 AM Resident #2 showed this surveyor where she was sitting in a recliner with next to the nurses' station when Resident #3 threatened to cut off her feet and then cut on the top, front bar of her walker. She stated, I got so scared!During an interview on 09/11/25 at 09:07 AM CNA K stated she was trained often on recognizing and reporting suspected abuse and neglect. She stated she was to report to her charge nurse or to ADM.During an interview on 09/11/25 at 09:08 AM HSK stated she was trained regularly on recognizing and reporting abuse and neglect. She stated she was to report any suspicion of abuse or neglect to ADM.During an interview on 09/11/25 at 09:19 AM RN C stated she was trained regularly on recognizing and reporting abuse and neglect. She stated she was to report any suspicion of abuse or neglect to ADM.During an interview on 09/11/25 at 01:57 PM LVN D stated she was trained regularly on recognizing and reporting abuse and neglect. She stated she was to report any suspicion of abuse or neglect to ADM.During an interview on 09/11/25 at 02:35 PM ADON stated on 09/10/25 around 4 or 5 PM Resident #3 had a hand saw. She stated she did not see him with the saw she just heard about him having it. She stated she received a phone call from LVN J on 09/10/25. LVN J told ADON it was reported to her (LVN J) Resident #3 had a hand saw that afternoon.During an interview on 09/11/25 at 02:43 PM ADM stated she was in the building on 09/10/25 when Resident #3 had a hand saw. She stated she did not see him with the hand saw but CNA A and CNA B told her about taking the saw from Resident #3. During an interview on 09/11/25 at 04:23 PM LVN G stated Resident #3 had a hand saw and was cutting on the top, front bar of Resident #2's walker and making fun with everyone who was in the common area that he could saw through the walker. She stated she went to his side and asked him to put the saw down because it was not his. During an interview on 09/11/25 at 04:23 PM LVN G stated she was trained regularly on recognizing and reporting abuse and neglect. She stated she was to report any suspicion of abuse or neglect to ADM.During an observation on 09/11/25 at 05:04 PM Resident #3 was wheeling himself into the front door after smoking in the courtyard. He had been in the courtyard with ADON but came back into the facility on his own.During an interview on 09/12/25 at 08:16 AM CNA H stated she was trained regularly on recognizing and reporting abuse and neglect. She stated she was to report any suspicion of abuse or neglect to ADM.During an observation and interview on 09/12/25 at 12:38 PM Resident #2 was in her room with the door shut. She stated she was staying in her room to avoid Resident #3. She stated she traded the walker Resident #3 used the saw on for another walker. Resident #2 stated, I started crying when I talked to my [family member] about the sawing.On 09/12/25 at 01:00 PM ADM and ADON were notified that an Immediate Jeopardy had been identified, IJ templates were provided, and Plan of Removal was requested.During an observation on 09/12/25 at 02:04 PM Resident #3 wheeled himself out the front door of the facility.During an interview on 09/12/25 at 03:27 PM Resident #2's family member stated Resident #2 called her last night (09/11/25) and told her about a male resident threatening to cut off her feet with a saw. She stated Resident #2 started bawling and crying while telling her about the incident. Resident #2's family member stated, [Resident #2] got scared. She (Resident #2) told me, ‘Listen to me, listen to me, I'm scared of this man.'During an observation and interview on 09/12/25 at 3:43 PM SW showed this surveyor psychosocial evaluations done on Resident #2 and Resident #3 on 09/12/25. She stated both residents seemed fine and calm today. SW stated Resident #2 said she was not anxious or afraid.During an interview on 09/12/25 at 04:29 PM MD stated of Resident #3, I believe he has had some behavioral issues, but I don't know to the full extent of them.The facility's Plan of Removal (as follows) was accepted on 09/12/25 at 08:12 PM.Plan of RemovalProblem: There is a need for immediate action due to the break in the facility's risk management process regarding abuse, neglect, and elopement. Specifically, the facility staff will need to address corrective action to prevent future incidents of elopement from occurring in the facility, especially when residents are exhibiting signs and symptoms of elopement. All residents who are high risk for elopement are at risk of the alleged defected deficiency.F600Resident obtained the hand saw due to the maintenance office being locked [sic]. The facility was neglectful in leaving the door unlocked. This has been addressed for the future by installing a self-locking door knob [sic]. This will ensure that no one can get into the maintenance office unauthorized again and removes the potential for future neglect or harm.All staff were re-educated on the facility's policies and procedures related to abuse & neglect.Staff directly involved in the incident received targeted retraining focused on compliance, resident rights, and recognition/prevention of neglect and abuse. Interventions: The administrator notified the medical director of Immediate Jeopardy 9/12/25 & Ad HOC completed on 8/22/2025. The following in-services were provided:o On 8/21/25 DON/ADON provided education to staff on Dementia Care: Mental Decline, elopement policy & exit seeking protocol, and wandering/elopement education prior to their next working shift.o On 8/21/25 DON/ADON provided education to charge nurses on wandering/elopement, dementia care: Mental Decline, elopement policy and exit seeking protocol prior to their next working shift.o All staff will be educated by DON/ADON prior to working their next shift with a completion date of 8/21/25. All NEW staff will be educated prior to working their first shift.o On 8/22/25 Admin and DON/ADON provided education to staff on how to identify residents at risk/high risk. DON/ADON completed audit on 8/21/25 to ensure Elopement Assessments have been completed according to protocol. Charge Nurses will complete an Elopement Risk Assessment quarterly, upon admit, and for exit seeking behaviors. The assessment will provide a score to indicate if they are at risk or high risk for elopement. ADMIN/DON will be responsible for ensuring a resident has 1:1 supervision when required and will monitor that it is being followed. For residents who score at risk/high risk for elopement on the elopement assessment, a shoe emblem will be placed above the name plaque for A bed and below the name plaque for B bed to help staff identify residents at risk/high risk for elopement. Charge nurses will be responsible for ensuring there is not a lapse in 1:1 during shift change and that the oncoming staff are aware of exit seeking behaviors from the prior shift. Charge nurse removed hand saw immediately. No harm to either resident. Charge nurse administered medication per doctors [sic] order and referral obtained for a psych consult. Automatic lock placed on maintenance door. Inservice started on hazardous areas, devices and equipment and to ensure these doors stay locked. Maintenance staff in serviced on keeping office door locked to ensure hazardous equipment is not [sic] accessible to residents. Psychosocial assessment completed on both residents. Care plans have been updated on both residents. DON/designee will review 5 random resident care plans weekly x 8 weeks to ensure safety risks are addresses. Adminiswtrator [sic] will audit all incident/accident logs weekly to ensure corrective action and follow-ups are completed. Results will be reported monthly to QAPI committee for review and trend analysis.Inservices [sic] began 9/12/25 and all staff to be inserviced [sic] prior to beginning shift.Monitoring the Plan of Removal (POR) included:On 09/13/25 record review revealed the in-services, Ad HOC meeting (on 09/12/25), physician and family notifications, care plan updates, psychosocial assessments on Residents #2 and #3 (dated 09/12/25 and showing no issues for either resident), order for antianxiety medication for Resident #3 (dated 09/10/25) facility incident report to state (dated 09/12/25), posting of abuse policy, referral for psych services for Resident #3(dated 09/10/25) and starting of Q-15 minute checks on Resident #3 were completed.Interview with ADM, DON, and ADON on 09/13/25 at 11:00 AM revealed all facility staff had received the in-services started on 09/12/25 regarding elopement and accidents/hazards. ADM stated ADON had been calling staff who were not in the building and following the calls by sending an email copy of the in-service. ADM and DON stated they had been trained by their corporate representatives on investigation and reporting of suspected abuse/neglect.Record review of the in-services provided to ADM and DON on 02/06/25 revealed they were trained on the definition of abuse, abuse policies and procedures, freedom from abuse, resident rights, behavior intervention and crisis, abuse prevention, injury of unknown origin, and reporting.Record review of the in-service provided to staff by corporate on 09/12/25 revealed staff were trained on proper reporting and timely report, abuse policies and procedures including abuse definitions, freedom from abuse, resident rights, behavior interventions, behavior crisis, abuse prevention, injury of unknown source, thorough investigations for abuse and neglect and injury of unknown source, reporting of allegations of abuse to state and corporate, and reporting of allegations of abuse, neglect, and injury of unknown source to state.Record review of in-service provided to staff on 09/12/25 by ADON revealed staff were trained on Safe Storage, Random check to ensure maintenance doors are locked, Abuse/Neglect/Exploitation reviewed/posted, Investigating and reporting Incidents/Accidents, Appropriate assessments/interventions, Resident Rights.During an interview on 09/13/25 at 11:14 AM DA stated she was trained yesterday (09/12/25) on abuse and neglect. She stated she was to report any suspicion of abuse or neglect to ADM. She stated she was trained yesterday on recognizing if a resident was attempting to elope and intervening as necessary. DA stated she was trained on keeping hazardous items out of reach of residents and in locked compartments. During an interview on 09/13/25 at 11:16 AM LVN D stated she was trained yesterday (09/12/25) on abuse and neglect. She stated she was to report any suspicion of abuse or neglect to ADM. She stated she was trained on keeping hazardous items locked and out of resident reach and on recognizing residents at risk of elopement.During an interview on 09/13/25 at 11:18 AM CNA I stated she was trained yesterday (09/12/25) on abuse and neglect. She stated she was to report any suspicion of abuse or neglect to ADM. She stated she was trained on keeping hazardous items locked and out of resident reach and on recognizing residents at risk of elopement. CNA I stated she was trained to keep wipes and cleaning solutions locked in the cabinet or in the shower room and she was trained on her part if a resident was missing from the facility to include searching her unit and counting the residents on her unit.During an interview on 09/13/25 at 11:23 AM CNA B stated she was trained yesterday (09/12/25) on abuse and neglect. She stated she was to report any suspicion of abuse or neglect to ADM. She stated she was trained on her part if a resident eloped from the facility as well as on keeping hazardous items out of reach of residents.During an interview on 09/13/25 at 11:24 AM RN SUP stated she was trained today (09/13/25) on abuse and neglect. She stated she was to report any suspicion of abuse or neglect to ADM. RN SUP stated she has been trained on her responsibilities regarding reviewing incident accident reports and 24-hour report on the weekends. She stated she was trained on her part if an elopement took place and on keeping hazardous items out of reach of residents.During an interview on 09/13/25 at 11:27 AM [NAME] stated she was trained today (09/13/25) on abuse and neglect. She stated she was to report any suspicion of abuse or neglect to ADM. She stated she was trained on recognizing if a resident was trying to elope and on how to intervene. [NAME] stated she was trained on keeping hazardous items out of reach of residents.During an interview on 09/13/25 at 11:29 AM CNA H stated she was trained yesterday (09/12/25) on abuse and neglect. She stated she was to report any suspicion of abuse or neglect to ADM. She stated she was trained on keeping hazardous items out of reach of residents and locked in appropriate cabinets or rooms and on her part if a resident attempted or succeeded in eloping.During an interview on 09/13/25 at 11:32 AM CNA F stated she was trained yesterday (09/12/25) on abuse and neglect. She stated she was to report any suspicion of abuse or neglect to ADM. She stated she was trained on keeping dangerous items locked up and out of reach of residents. She stated she was trained on her part if an elopement occurred.During an interview on 09/13/25 at 11:35 AM RN C stated she was trained yesterday (09/12/25) and today (09/13/25) on abuse and neglect. She stated she was to report any suspicion of abuse or neglect to ADM. RN C stated she was trained on her part if a resident attempted or succeeded in eloping and she was trained on keeping hazardous items locked up and out of reach of residents.During an observation on 09/13/25 at 11:40 AM ADM demonstrated the new self-locking doorknob on the maintenance office by unlocking it with a key and closing the door again. It was locked. The new doorknob was smooth on the inside of the door with no locking or unlocking mechanism aside from the keyhole on the outside of the door.Record review on 09/13/25 of Resident #3's revised care plan revealed a note regarding the incident on 09/10/25 with the handsaw. Interventions included Q 15-minute checks as indicated and documenting any signs or symptoms of resident posing a danger to himself or others. Staff were to ensure the maintenance office door was locked at all times.Record review of facility policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program and dated April 2021 revealed the following: .The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: 1. Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to: a. facility staff; b. other residents; c. consultants; d. volunteers; e. staff from other agencies; f. family members; g. legal representatives; h. friends; i. visitors; and/or j. any other individual. 2. Develop and implement policies and protocols to prevent and identify: a. abuse or mistreatment of residents; b. neglect of residents; and/or c. theft, exploitation or misappropriation of resident property. Establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral, cognitive or emotional problems. 8. Identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property. 9. Investigate and report any allegations within timeframes required by federal requirements. 10. Protect residents from any further harm during investigations.Record review of facility policy titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating and dated April 2021 revealed the following: . All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Reporting Allegations to the Administrator and Authorities 1. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. 2. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility; b. The local/state ombudsman; c. The resident's representative; d. Adult protective services (where state law provides jurisdiction in long-term care); e. Law enforcement officials; f. The resident's attending physician; and g. The facility medical director. 3. Immediately is defined as: a. within two hours of an allegation involving abuse or result in serious bodily injury; or b. within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. Upon receiving any allegations of abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source, the administrator is responsible for detem1ining what actions (if any) are needed for the protection of residents. Investigating Allegations 1. All allegations are thoroughly investigated. The administrator initiates investigations. 2. Investigations may be assigned to an individual trained in reviewing, investigating and reporting such allegations. 3. The administrator provides supporting documents and evidence related to the alleged incident to the individual in charge of the investigation. a. Any evidence that may be needed for a criminal investigation is sealed, labeled and protected from tampering or destruction. 4. The administrator is responsible for keeping the resident and his/her representative (sponsor) informed of the progress of the investigation. 5. The administrator ensures that the resident and the person(s) reporting the suspected violation are protected from retaliation or reprisal by the alleged perpetrator, or by anyone associated with the facility. 6. Any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete. 7. The individual conducting the investigation as a minimum: a. reviews the documentation and evidence; b. reviews the resident's medical record to determine the resident's physical and cognitive status at the time of the incident and since the incident; c. observes the alleged victim, including his or her interactions with staff and other residents; d. interviews the person(s) reporting the incident; e. interviews any witnesses to the incident; f. interviews the resident (as medically appropriate) or the resident's representative; g. interviews the resident's attending physician as needed to determine the resident's condition; h. interviews staff members (on all shifts) who have bad contact with the resident during the period of the alleged incident; i. interviews the resident's roommate, family members, and visitors; j. interviews other residents to whom the accused employee provides care or services; k. reviews all events leading up to the alleged incident; and I. documents the investigation completely and thoroughly.On 09/13/25 at 12:08 PM ADM, DON, and ADON were informed the IJ was removed as of 12:08 PM. An IJ was identified on 09/12/25. The IJ template was provided to the facility on [DATE] at 01:00 PM. While the IJ was removed, the facility remained out of compliance at a level of no actual harm potential for more than minimal harm not immediate jeopardy at a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for 2 (Resident #2 and Resident #3) of 5 residents reviewed for abuse/neglect policy implementation.The facility failed to implement their abuse policy when Resident #3 obtained a hand saw from an unlocked maintenance closet and used it to threaten Resident #2 and to saw a groove into the top, front bar of Resident #2's walker.This failure could place residents at risk of abuse and neglect occurring and/or continuing.An Immediate Jeopardy (IJ) was identified on 09/12/25. The IJ template was provided to the facility on [DATE] at 01:00 PM. While the IJ was removed on 09/13/25 at 12:08 PM the facility remained out of compliance at a severity level of no actual harm potential for more than minimal harm not immediate jeopardy at a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems. Plan of Removal of IJ will be included in findings.Findings Included:1. Record review of Resident #2's admission record dated 09/11/25 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Alzheimer's disease (a progressive disease that destroys memory and other important mental functions) with late onset, intermittent explosive disorder (repeated sudden outbursts of anger), psychotic disorder with delusions (severe mental illness including distorted beliefs) due to known physiological condition, and major depressive disorder (a mental disorder characterized by persistent low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities).Record review of Resident #2's admission MDS completed on 06/19/25 revealed a BIMS score of 10 which indicated moderately impaired cognition. Section GG Functional Abilities revealed Resident #2 used a walker. She was noted to require partial/moderate assistance to supervision/touching assistance across all ADLs. Record review of Resident #2's care plan initiated on 06/20/25 revealed she had the potential to be verbally aggressive and yell at other residents and staff related to dementia. Resident #2 was noted to receive antianxiety medication and antipsychotic medication.Record review of Resident #2's active orders revealed the following orders with corresponding start dates:07/30/25 risperiDONE Oral Tablet 0.25 MG (Risperidone) Give1 tablet by mouth at bedtime related to PSYCHOTICDISORDER WITH DELUSIONS DUE TO KNOWN PHYSIOLOGICAL CONDITION06/11/25 traZODone HCl Oral Tablet 50 MG (Trazodone HCl) Give 1 tablet by mouth at bedtime for Headache related to MAJOR DEPRESSIVE DISORDER, RECURRENT SEVERE WITHOUT PSYCHOTIC FEATURES09/11/25 Vistaril Oral Capsule 50 MG (Hydroxyzine Pamoate) Give 1 capsule by mouth every 04 hours as needed for anxiety for 14 Days2. Record review of Resident #3's admission record revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Parkinson's disease (chronic and progressive movement disorder that initially causes tremors in one hand and stiffness or slowing of movement) without dyskinesia (abnormality or impairment of voluntary movement), unspecified dementia (a group of thinking and social symptoms that interferes with daily functioning), major depressive disorder (a mental disorder characterized by persistent low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities), anxiety disorder (a group of mental health conditions characterized by excessive and persistent worry, fear, and nervousness that can significantly interfere with daily life), muscle wasting and atrophy, muscle weakness, and other lack of coordination.Record review of Resident #3's quarterly MDS completed 09/05/25 revealed a BIMS score of 12 which indicated moderately impaired cognition. Section E Behavior revealed Resident #3 had no behaviors. Section GG Functional Abilities revealed he was independent across all ADLs. Section M Medications revealed he was receiving antidepressant, antiplatelet, and anticonvulsant medication.Record review of Resident #3's care plan completed on 09/08/25 revealed he was resistive to care r/t impaired cognition and he had potential to be physically aggressive throwing objects r/t behaviors. Resident #3 was noted to have potential to be verbally aggressive very rude and demanding r/t cognitive impairment. He had impaired cognitive function r/t dementia. He had a mood problem r/t MDD and declines to see psych. Interventions included administering medications as ordered, explain all procedures and orders prior to starting and allow time to adjust to changes, discuss inappropriate behaviors with resident when reasonable, monitor behavior episodes and attempt to determine underlying causes, and document behaviors and potential causes. Staff were instructed to give the resident 5-10 minutes when resistive to care before trying again and when he became agitated to intervene before the agitation escalated and guide him away from the source of distress. Staff were instructed to engage him calmly in conversation and if he became aggressive they were to walk calmly away and approach at a later time.Record review of Resident #3's active orders dated 09/11/25 revealed the following orders with corresponding start dates:05/18/25 Aspirin EC Tablet Delayed Release 81 MG (Aspirin) Give 1 tablet by mouth one time a day for Pain -Moderate11/20/24 Carbidopa-Levodopa Oral Tablet 25-250 MG(Carbidopa-Levodopa) Give 1 tablet by mouth five times a day related to PARKINSON'S DISEASE WITHOUT DYSKINESIA, WITHOUT MENTION OF FLUCTUATIONS09/03/25 clonazePAM Oral Tablet 0.5 MG (Clonazepam) Give 1 tablet by mouth three times a day related to ANXIETY DISORDER, UNSPECIFIED03/15/25 DULoxetine HCl Oral Capsule Delayed Release Sprinkle 30 MG (Duloxetine HCl) Give 1 capsule by mouth in the afternoon for dep03/14/25 DULoxetine HCl Oral Capsule Delayed Release Sprinkle 30 MG (Duloxetine HCl) Give 2 capsule by mouth at bedtime for dep related to MAJOR DEPRESSIVE DISORDER, RECURRENT, UNSPECIFIED07/30/25 Mirtazapine Oral Tablet 30 MG (Mirtazapine) Give 1 tablet by mouth at bedtime related to MAJOR DEPRESSIVE DISORDER, RECURRENT, UNSPECIFIED09/10/25 Vistaril Oral Capsule 50 MG (Hydroxyzine Pamoate) Give 1 capsule by mouth every 04 hours as needed for anxiety for 14 DaysRecord review of a referral order dated 09/10/25 revealed Resident #3 was being referred for Psychiatric Medication Management and Psychotherapy and Counseling Services.Record review Resident #3's progress notes from 03/11/25 to 09/12/25 revealed no mention of physical or verbal aggression toward another resident.During an observation and interview on 09/11/25 at 08:23 AM Resident #2 stated a male resident had a saw yesterday and threatened to cut off her feet and then cut on her walker. She gestured to the top, front bar of her walker.During an observation and interview on 09/11/25 at 08:36 AM Resident #2 was seen leaving ADON's office and stated she told ADON about the man threatening to cut off her feet with a saw.During an observation and interview on 09/11/25 at 08:36 AM ADON stated she was just told by Resident #2 about Resident #3 threatening her with a saw on 09/10/25.During an observation and interview on 09/11/25 at 08:41 AM ADM stated Resident #3 had a hand saw on 09/10/25. She stated, He took it out of the maintenance room is the only thing we can figure out. ADM stated CNA A and CNA B were working at the time and took the saw away from Resident #3. When asked if he used the saw to threaten Resident #2 and/or cut on her walker, ADM shook her head and stated, What you are going to find out is [name of Resident #2] doesn't tell the truth.During an interview on 09/11/25 at 08:50 AM CNA A stated regarding Resident #3 on 09/10/25, I mean he did have a saw but as soon as we seen him, we took it from him. He was rolling with the saw down the hall. She stated she did not hear him threaten Resident #2 or see him using the saw on Resident #2's walker. She stated she was trained regularly on recognizing and reporting suspected abuse and neglect. She stated she was to report suspected abuse and neglect to ADM.During an interview on 09/11/25 at 08:51 AM CNA B stated Resident #3 had a saw on 07/10/25 and he was using the saw on Resident #2's walker. She stated, You can look at her walker. There is proof. CNA B stated Resident #3 got the saw from the maintenance office. She stated she reported the incident to ADM and ADON as soon as the saw was taken away from Resident #3 on 09/10/25. She stated she was trained regularly on reporting suspected abuse and neglect and she was to report to ADM.During an interview on 09/11/25 at 09:00 AM Resident #3 was lying in bed in his room. He stated he had a saw yesterday (09/10/25) and he got the saw from the shop (here he gestured with his left hand in the direction of the hallway which housed the maintenance office. Resident #3 was asked if he threatened to cut off a Resident #2's feet with the saw and he answered, Foot. He stated he threatened to cut off her foot. When asked if he used the saw on the female resident's walker, he said he did. During an observation on 09/11/25 at 09:03 AM of Resident #2's top, front walker bar revealed a small, shallow groove approximately 1.5 centimeters in length and 2 millimeters in depth with jagged edges.During an interview on 09/11/25 at 09:07 AM CNA K stated she was trained often on recognizing and reporting suspected abuse and neglect. She stated she was to report to her charge nurse or to ADM.During an interview on 09/11/25 at 09:08 AM HSK stated she was trained regularly on recognizing and reporting abuse and neglect. She stated she was to report any suspicion of abuse or neglect to ADM.During an interview on 09/11/25 at 09:19 AM RN C stated she was trained regularly on recognizing and reporting abuse and neglect. She stated she was to report any suspicion of abuse or neglect to ADM.During an interview on 09/11/25 at 01:57 PM LVN D stated she was trained regularly on recognizing and reporting abuse and neglect. She stated she was to report any suspicion of abuse or neglect to ADM.During an interview on 09/11/25 at 02:23 PM DON stated she was not in the building on 09/10/25 when Resident #3 had a hand saw and it was not reported to her.During an interview on 09/11/25 at 02:35 PM ADON stated on 09/10/25 around 4 or 5 PM Resident #3 had a hand saw. She stated she did not see him with the saw she just heard about him having it. She stated she received a phone call from LVN J on 09/10/25. LVN J told ADON it was reported to her (LVN J) Resident #3 had a hand saw that afternoon.During an interview on 09/11/25 at 02:43 PM ADM stated she was in the building on 09/10/25 when Resident #3 had a hand saw. She stated she did not see him with the hand saw but CNA A and CNA B told her about taking the saw from Resident #3. During an interview on 09/11/25 at 04:23 PM LVN G stated Resident #3 had a hand saw and was cutting on the top, front bar of Resident #2's walker and making fun with everyone who was in the common area that he could saw through the walker. She stated she went to his side and asked him to put the saw down because it was not his. LVN G stated she was trained regularly on recognizing and reporting abuse and neglect. She stated she was to report any suspicion of abuse or neglect to ADM.During an observation on 09/11/25 at 05:04 PM Resident #3 was wheeling himself into the front door after smoking in the courtyard. He had been in the courtyard with ADON but came back into the facility on his own.During an interview on 09/12/25 at 08:16 AM CNA H stated she was trained regularly on recognizing and reporting abuse and neglect. She stated she was to report any suspicion of abuse or neglect to ADM.During an interview on 09/12/25 at 08:40 AM ADON stated she was not sure if the facility was going to report the incident of Resident #3 threatening Resident #2 with a hand saw. During an interview on 09/12/25 10:48 AM ADM stated she was not sure why the incident of Resident #3 having a hand saw needed to be reported. She stated she did not think any contact was made between the saw and Resident #2's walker. She stated if she reported the incident on 09/12/25 it would be late.During an interview on 09/12/25 at 10:57 AM CNA B stated she reported the incident of Resident #3 having a saw and using it to saw on Resident #2's walker to ADM and ADON right after it happened on 09/10/25.During an interview on 09/12/25 at 10:58 AM ADON stated she did not tell ADM about Resident #3 having a hand saw after LVN J called and told her (ADON). She stated she did not know how ADM found out about the incident.During an interview on 09/12/25 at 11:01 AM LVN G stated she could not remember if she reported to ADM, DON, or ADON Resident #3 had a saw and used it to saw on Resident #2's walker.During an interview on 09/12/25 at 12:45 PM CNA B stated after she reported to ADM and ADON on 09/10/25 nothing was done to investigate the incident or ensure residents were safe until this surveyor began asking questions about the incident on 09/11/25 at which point staff were in-serviced. She stated a possible negative outcome of not reporting abuse or neglect was, They (residents) are scared, worried, at risk. They don't know what's gonna happen.On 09/12/25 at 01:00 PM ADM and ADON were notified that an Immediate Jeopardy had been identified, IJ templates were provided, and Plan of Removal was requested.During an observation on 09/12/25 at 02:04 PM Resident #3 was observed wheeling himself out the front door of the facility.During an interview on 09/12/25 at 02:54 PM ADON stated a possible negative outcome of not reporting/investigating the incident of Resident #3 threatening Resident #2 according to facility policy was, Somebody could have been hurt. During an interview on 09/12/25 at 02:57 PM DON stated a possible negative outcome of not reporting/investigation the incident of Resident #3 threatening Resident #2 according to facility policy was, It could occur with another resident.The facility's Plan of Removal (as follows) was accepted on 09/12/25 at 08:12 PM.Plan of Removal Tag F 607Problem: There is a need for immediate action due to the break in the facilities policy to ensure residents are free from abuse and neglect. Specifically, the facility staff will need to address corrective action to prevent future incidents of resident to resident abuse from occurring in the facility, especially when residents are exhibiting signs and symptoms of aggressive behavior. All residents who are high risk for elopement are at risk of the alleged defected deficiency.Resident obtained the hand saw due to the maintenance office being locked [sic]. The facility was neglectful in leaving the door unlocked. This has been addressed for the future by installing a self-locking door knob. This will ensure that no one can get into the maintenance office unauthorized again and removes the potential for future neglect or harm.All staff were re-educated on the facility's policies and procedures related to abuse & neglect.Staff directly involved in the incident received targeted retraining focused on compliance, resident rights, and recognition/prevention of neglect and abuse. Interventions:The administrator notified the medical director of Immediate Jeopardy 9/12/25 & anAd HOC completed on 9/12/2025.Physician and family were notified on 9/12/2025.Facility reported the incident to state on 9/12/2025.Copies of the abuse policy are now posted in staff areas for quick reference.Resident was placed on Q 15-minute checks for 72 hours and will re-evaluate for continued of need of 15 minutes checks.The following in-services were provided:All facility staff (all staff/all departments: ADON, licensed nurses, certified nursing assistants, dietary, housekeeping, laundry, activity director, maintenance) have been in-serviced on Reporting Abuse/Neglect Abuse Definitions Behavior interventions Behavior crisis Freedom from abuse Abuse prevention Resident rights Any Resident-to-Resident Near Miss (an incident between two residents that wereverbal and physical in nature but did not cause injury) Any Resident-to-Resident Altercation where physical contact has been made but did notresult in injury will need to be reported to the Administrator. Resident-to-Resident alterationsThe Administrator has been in-serviced on the topic of Abuse, including Abuse Definitions, Abuse Policies and Procedures, Freedom from Abuse, Resident Rights, Behavior Intervention, Behavior Crisis, Abuse Prevention, Injury of Unknown Source, on 2/6/2025 by [NAME] RDO, and [NAME] Regional Nurse Consultant.On 9/12/2025 the Administrator and Director of Nursing were provided education regarding thorough investigations for abuse and neglect, and injury of unknown source by the RDO and Regional Nurse Consultant.On 9/12/2025 the Administrator and Director of Nursing were provided education regarding reporting allegations of abuse and neglect, and injury of unknown source to the state by the RDO and Regional Clinical Nurse Consultant.Resident #3 does not have a history of physical behavior; this was an isolated incident, however on 9/12/2025 the DON added a care plan for aggressive behaviors.On 9/12/2025 that Care plan was updatedDON/designee will conduct random staff interviews weekly x 8 weeks, then monthly x 4 months, asking staff how to identify and report abuse and neglect. Leadership will ensure mandatory annual abuse training is completed by 100% of staff.We identify that all residents residing in the facility have the potential to be affected by this alleged deficient practice.Psychosocial completed on both residents on 9/12/2025. Charge nurse counseled resident to not use the hand on 9/10/2025. Resident verbalizes understanding of the risk of potential harm.Referral obtained for referral for psych evaluation.Order received for anti-anxiety medication which was administered with resident consent.All facility employees are required to report all suspected abuse, injury of unknown source, and any resident-to-resident altercation to the Administrator and/or the DON if either cannot be reached in a timely fashion.Administrator will audit personnel files monthly for evidence of abuse prevention and training.DON/Designee will monitor Daily M-F, and the Weekend RN supervisor on Saturday and Sunday for 60 days the 24-hour reports, incident reports, and behavior monitoring sheets to ensure the facility identifies any type of possible abuse, neglect, or injury of unknown source.The NHA will review the 24-hour report, incident and accident reports daily M-F, and the Weekend RN supervisor on Saturday and Sundays for 60 days to ensure accurate documentation and interventions are put in place to ensure all possible abuse incidents, resident-to-resident altercations are properly identified and reported to ensure the facility properly identifies, investigates, reports, and implements interventions as required.The NHA will report any changes with this Plan of Removal to the QAPI committee as necessary.Inservices [sic] began 9/12/25 and all staff to be inserviced [sic] prior to beginning shift. Monitoring the Plan of Removal (POR) included:On 09/13/25 record review revealed the in-services, Ad HOC meeting (on 09/12/25), physician and family notifications, care plan updates, psychosocial assessments on Residents #2 and #3 (dated 09/12/25 and showing no issues for either resident), order for antianxiety medication for Resident #3 (dated 09/10/25) facility incident report to state (dated 09/12/25), posting of abuse policy, referral for psych services for Resident #3(dated 09/10/25) and starting of Q-15 minute checks on Resident #3 were completed.Interview with ADM, DON, and ADON on 09/13/25 at 11:00 AM revealed all facility staff had received the in-services started on 09/12/25 regarding elopement and accidents/hazards. ADM stated ADON had been calling staff who were not in the building and following the calls by sending an email copy of the in-service. ADM and DON stated they had been trained by their corporate representatives on investigation and reporting of suspected abuse/neglect. Record review of the in-services provided to ADM and DON on 02/06/25 revealed they were trained on the definition of abuse, abuse policies and procedures, freedom from abuse, resident rights, behavior intervention and crisis, abuse prevention, injury of unknown origin, and reporting.Record review of the in-service provided to staff by corporate on 09/12/25 revealed staff were trained on proper reporting and timely report, abuse policies and procedures including abuse definitions, freedom from abuse, resident rights, behavior interventions, behavior crisis, abuse prevention, injury of unknown source, thorough investigations for abuse and neglect and injury of unknown source, reporting of allegations of abuse to state and corporate, and reporting of allegations of abuse, neglect, and injury of unknown source to state. Record review of in-service provided to staff on 09/12/25 by ADON revealed staff were trained on Safe Storage, Random check to ensure maintenance doors are locked, Abuse/Neglect/Exploitation reviewed/posted, Investigating and reporting Incidents/Accidents, Appropriate assessments/interventions, Resident Rights.During an interview on 09/13/25 at 11:14 AM DA stated she was trained yesterday (09/12/25) on abuse and neglect. She stated she was to report any suspicion of abuse or neglect to ADM. She stated she was trained yesterday on recognizing if a resident was attempting to elope and intervening as necessary. DA stated she was trained on keeping hazardous items out of reach of residents and in locked compartments. During an interview on 09/13/25 at 11:16 AM LVN D stated she was trained yesterday (09/12/25) on abuse and neglect. She stated she was to report any suspicion of abuse or neglect to ADM. She stated she was trained on keeping hazardous items locked and out of resident reach and on recognizing residents at risk of elopement.During an interview on 09/13/25 at 11:18 AM CNA I stated she was trained yesterday (09/12/25) on abuse and neglect. She stated she was to report any suspicion of abuse or neglect to ADM. She stated she was trained on keeping hazardous items locked and out of resident reach and on recognizing residents at risk of elopement. CNA I stated she was trained to keep wipes and cleaning solutions locked in the cabinet or in the shower room and she was trained on her part if a resident was missing from the facility to include searching her unit and counting the residents on her unit.During an interview on 09/13/25 at 11:23 AM CNA B stated she was trained yesterday (09/12/25) on abuse and neglect. She stated she was to report any suspicion of abuse or neglect to ADM. She stated she was trained on her part if a resident eloped from the facility as well as on keeping hazardous items out of reach of residents. During an interview on 09/13/25 at 11:24 AM RN SUP stated she was trained today (09/13/25) on abuse and neglect. She stated she was to report any suspicion of abuse or neglect to ADM. She stated she was trained on her part if an elopement took place and on keeping hazardous items out of reach of residents. RN SUP stated she has been trained on her responsibilities regarding reviewing incident accident reports and 24-hour report on the weekends.During an interview on 09/13/25 at 11:27 AM [NAME] stated she was trained today (09/13/25) on abuse and neglect. She stated she was to report any suspicion of abuse or neglect to ADM. She stated she was trained on recognizing if a resident was trying to elope and on how to intervene. [NAME] stated she was trained on keeping hazardous items out of reach of residents. During an interview on 09/13/25 at 11:29 AM CNA H stated she was trained yesterday (09/12/25) on abuse and neglect. She stated she was to report any suspicion of abuse or neglect to ADM. She stated she was trained on keeping hazardous items out of reach of residents and locked in appropriate cabinets or rooms and on her part if a resident attempted or succeeded in eloping.During an interview on 09/13/25 at 11:32 AM CNA F stated she was trained yesterday (09/12/25) on abuse and neglect. She stated she was to report any suspicion of abuse or neglect to ADM. She stated she was trained on keeping dangerous items locked up and out of reach of residents. She stated she was trained on her part if an elopement occurred.During an interview on 09/13/25 at 11:35 AM RN C stated she was trained yesterday (09/12/25) and today (09/13/25) on abuse and neglect. She stated she was to report any suspicion of abuse or neglect to ADM. RN C stated she was trained on her part if a resident attempted or succeeded in eloping and she was trained on keeping hazardous items locked up and out of reach of residents. During an observation on 09/13/25 at 11:40 AM ADM demonstrated the new self-locking doorknob on the maintenance office by unlocking it with a key and closing the door again. It was locked. The new doorknob was smooth on the inside of the door with no locking or unlocking mechanism aside from the keyhole on the outside of the door.Record review on 09/13/25 of Resident #3's revised care plan revealed a note regarding the incident on 09/10/25 with the handsaw. Interventions included Q 15-minute checks as indicated and documenting any signs or symptoms of resident posing a danger to himself or others. Staff were to ensure the maintenance office door was locked at all times.Record review of facility policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program and dated April 2021 revealed the following: .The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: 1. Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to: a. facility staff; b. other residents; c. consultants; d. volunteers; e. staff from other agencies; f. family members; g. legal representatives; h. friends; i. visitors; and/or j. any other individual. 2. Develop and implement policies and protocols to prevent and identify: a. abuse or mistreatment of residents; b. neglect of residents; and/or c. theft, exploitation or misappropriation of resident property. Establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral, cognitive or emotional problems. 8. Identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property. 9. Investigate and report any allegations within timeframes required by federal requirements. 10. Protect residents from any further harm during investigations.Record review of facility policy titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating and dated April 2021 revealed the following: . All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Reporting Allegations to the Administrator and Authorities 1. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. 2. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility; b. The local/state ombudsman; c. The resident's representative; d. Adult protective services (where state law provides jurisdiction in long-term care); e. Law enforcement officials; f. The resident's attending physician; and g. The facility medical director. 3. Immediately is defined as: a. within two hours of an allegation involving abuse or result in serious bodily injury; or b. within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. Upon receiving any allegations of abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source, the administrator is responsible for detem1ining what actions (if any) are needed for the protection of residents. Investigating Allegations 1. All allegations are thoroughly investigated. The administrator initiates investigations. 2. Investigations may be assigned to an individual trained in reviewing, investigating and reporting such allegations. 3. The administrator provides supporting documents and evidence related to the alleged incident to the individual in charge of the investigation. a. Any evidence that may be needed for a criminal investigation is sealed, labeled and protected from tampering or destruction. 4. The administrator is responsible for keeping the resident and his/her representative (sponsor) informed of the progress of the investigation. 5. The administrator ensures that the resident and the person(s) reporting the suspected violation are protected from retaliation or reprisal by the alleged perpetrator, or by anyone associated with the facility. 6. Any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete. 7. The individual conducting the investigation as a minimum: a. reviews the documentation and evidence; b. reviews the resident's medical record to determine the resident's physical and cognitive status at the time of the incident and since the incident; c. observes the alleged victim, including his or her interactions with staff and other residents; d. interviews the person(s) reporting the incident; e. interviews any witnesses to the incident; f. interviews the resident (as medically appropriate) or the resident's representative; g. interviews the resident's attending physician as needed to determine the resident's condition; h. interviews staff members (on all shifts) who have bad contact with the resident during the period of the alleged incident; i. interviews the resident's roommate, family members, and visitors; j. interviews other residents to whom the accused employee provides care or services; k. reviews all events leading up to the alleged incident; and I. documents the investigation completely and thoroughly.On 09/13/25 at 12:08 PM ADM, DON, and ADON were informed the IJ was removed as of 12:08 PM. An IJ was identified on 09/12/25. The IJ template was provided to the facility on [DATE] at 01:00 PM. While the IJ was removed, the facility remained out of compliance at a level of no actual harm potential for more than minimal harm not immediate jeopardy at a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure the resident environment remains as free of accident hazards as is possible and each resident receives adequate supervision and assistance devices to prevent accidents for 2 (Resident #1 and Resident #3) of 5 residents reviewed for accidents and hazards.1. The facility failed to ensure Resident #1 did not elope on 08/21/25 in his manual wheelchair 8 days after he had cranioplasty surgery .5 of a mile from the facility on his way to the hospital.2. The facility failed to ensure Resident #3 did not have access to a hand saw from the unlocked maintenance office.These failures could place residents at risk of injury or death.An Immediate Jeopardy (IJ) was identified on 09/12/25 at 01:00 PM. Although the IJ was removed on 09/13/25 at 12:08 PM the facility remained out of compliance at a severity level of actual harm that was not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems. Plan of Removal of IJ will be included in findings.Findings Included:1. Record review of Resident #1's admission record dated 09/11/25 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it, stroke), aphasia (a disorder that affects the ability to communicate, read, write, and understand language caused by damage or injury to the specific area of the brain responsible for language), hemiplegia and hemiparesis following cerebral infarction (partial paralysis following stroke) affecting right dominant side, muscle wasting and atrophy, muscle weakness, and other lack of coordination.Record review of Resident #1's quarterly MDS completed on 08/08/25 revealed a BIMS score of 12 which indicated moderately impaired cognition. Section GG Functional Abilities revealed he had impairment on one side to both upper and lower extremities and utilized a manual wheelchair. He was noted to require substantial/maximal assistance with toileting, bathing, personal hygiene, and dressing. He was noted to be independent wheeling himself once he was seated in his wheelchair. Section J Health Conditions revealed Resident #1 received scheduled pain medication and PRN pain medications. His pain was noted to be occasional, severe, and rarely interfered with sleep and day-to-day activities.Record review of Resident #1's care plan completed on 08/08/25 revealed he was a wanderer r/t confusion. The goal was, The resident's safety will be maintained through the review date. Interventions included distracting him by offering diversions and identifying if his wandering had a pattern. Resident #1 was noted to have impaired cognitive function r/t CVA. Interventions included asking him yes/no questions to determine his needs and The resident needs supervision with all decision making. He was noted to have a communication problem r/t Aphasia; makes sounds and gestures to communicate. Resident #1 was noted to have poor balance, impaired though process and to be very mobile in wheelchair and require supervision. One of the interventions for this area of the care plan was to ensure he was wearing appropriate footwear with ambulating or mobilizing in his wheelchair. He was noted to need a safe environment with: even floors . Resident #1 slid out of his wheelchair on 03/02/25 and fell on [DATE] during a self- transfer. He was noted to have hemiplegia/hemiparesis r/t CVA. He was noted to have chronic pain. Staff were to evaluate the effectiveness of pain interventions and notify the physician if interventions were unsuccessful or if current complaint was a significant change from his past experience of pain. Resident #1 was able to answer yes/no by nodding or shaking his head and to gesture thumbs up or thumbs down to assist in pain assessment. He was noted to have bladder incontinence.Record review of Resident #1's order summary report dated 09/11/25 revealed the following orders with corresponding order start dates:02/27/25 Gabapentin Oral Capsule (Gabapentin) Give 300 mg by mouth two times a day for pain - Moderate11/17/24 [Brand name of Acetaminophen] Oral Tablet 325 MG (Acetaminophen) Give 2 tablet by mouth every 6 hours as needed for PainRecord review of Resident #1's MAR for June 2025 revealed he received Gabapentin as ordered all 30 days of the month. He received 650 mg of acetaminophen on the following dates with corresponding pain levels and the medication was effective: 06/01/25 level 10, 06/04/25 level 9, 06/05/25 level 9, 06/24/25 level 9, 06/25/25 level 3.Record review of Resident #1's MAR for July 2025 revealed his Gabapentin was on hold by the physician from 07/22/25 through 08/01/25. Resident #1 received Gabapentin as ordered from 07/01/25 through the morning dose on 07/22/25. He received 650 mg of acetaminophen on the following dates with corresponding pain levels and the medication was effective: 07/04/25 level 2, 07/05/25 level 7, 07/13/25 level 9, 07/15/25 level 3, 07/16/25 level 3, 07/18/25 level 8, 07/19/25 level 7, 07/19/25 level 3, 07/20/25 level 5, 07/20/25 level 2, 07/21/25 level 3, 07/23/25 level 3, 07/24/25 level 4, 07/26/25 level 3, 07/27/25 level 2, 07/28/25 level 4, 07/29/25 level 3, 07/31/25 level 4, 07/31/25 level 3. Record review of Resident #1's MAR for August 2025 revealed his Gabapentin was on hold by the physician from 08/01/25 through 08/06/25. Resident #1 received Gabapentin as ordered from 08/06/25 evening dose through 08/12/25. He was in the hospital from [DATE] to 08/16/25. He received Gabapentin as ordered from the evening dose on 08/16/25 through 08/20/25. Resident #1 received 650 mg of acetaminophen on the following dates with corresponding pain levels and the medication was effective: 08/02/25 level 3, 08/03/25 level 3, 08/04/25 level 4, 08/04/25 level 4, 08/05/25 level 5, 08/05/25 level 3, 08/06/25 level 3, 08/07/25 level 7, 08/08/25 level 3, 08/09/25 level 7, 08/09/25 level 3, 08/10/25 level 4, 08/10/25 level 3, 08/11/25 level 5, 08/11/25 level 3, 08/12/25 level 3, 08/16/25 level 3, 08/17/25 level 3, 08/18/25 level 5, 08/18/25 level 5, 08/18/25 level 4, 08/19/25 level 6, 08/19/25 level 7, 08/19/25 level 2, 08/19/25 level 6, 08/20/25 level 5, 08/20/25 level 5. On 08/21/25 he received acetaminophen as ordered at 05:51 AM and it was unknown if it was effective due to his elopement.Record review of Resident #1's elopement risk assessments dated 10/12/24, 04/05/25 and 06/06/25 revealed he was a low risk for elopement with no previous attempts at eloping.Record review of Resident #1's progress notes from 03/11/25 to 08/21/25 revealed his hernia was mentioned 4 times.On 05/07/25 at 13:11 (01:11 PM) he complained of pain to his inguinal area due to hernia. Acetaminophen 650 mg was administered and effective.On 07/03/25 at 08:26 AM the urologist's office called to inform facility staff a referral had been sent to a general surgeon for Resident #1's hernia. Office of surgeon will reach out with appointment time and date.On 08/21/25 at 07:47 AM LVN D documented the following: THIS NURSE DISCOVERED RESIDENT LEFT FACILITY THIS MORNING FROM DINING ROOM AREA WHILE WAITING FOR PARAMEDICS TO ARRIVE TO TRANSPORT RESIDENT TO [name of hospital] HOSPITAL DUE TO NCREASED PAIN FROM EXISTING HERNIA TO LEFT AREA ON TESTICLES. SAW RESIDENT AT ABOUT 7 IN THE MORNING WHILE WALKING THROUGH DINING ROOM TO ASSIST ANOTHER RESIDENT WITH A FINGERSTICK. ALERTED ALL STAFF IN THE BUILDING OF MISSING RESIDENT. ALL STAFF PROCEEDED TO LOOK FOR RESIDENT IN THE BUILDING, OUTSIDE ON FOOT, AND A NURSING AIDE GOT IN HER CARTO [sic] GO LOOK FOR HIM, WHILE THIS NURSE INFORMED [name of ADM] THE ADMINISTRATOR, [name of ADON] ADON. NURSING AIDE IN CAR WENT TO [name of hospital] HOSPITAL AND DISCOVERED RESIDENT WAS THERE. [name of ADM] ADMINISTRATOR [name of ADON] ADON, AND [name and relationship of family member] ALLINFORMED [sic] RESIDENT WAS FOUND SAFE AT THE HOSPITAL. [name of FNP] FNP ALSO INFORMED. [name of hospital] INFORMED THIS NURSE RESIDENT IS TO HAVE SURGERY FOR THE HERNIA. PARAMEDICS ARRIVED AT [name of facility] AT 1 PM TO PICK UP THE RESIDENT THEY WER [sic] TOLD THE RESIDENT WAS GONE OUT TO TEH [sic] HOSPITAL.On 08/21/25 at 06:08 AM LVN E documented the following: Was finishing up report with [name of LVN D] LVN, when patient came out of room without clothes on, yelling and gesturing to head and crotch. Pt is aphasic, and keeps pointing to these areas. This SN had given PRN [brand name of acetaminophen] earlier at 0551 (05:51 AM) per pt request, fot [sic] HA, andc/o [sic] of Left hernia pain to existing hernia. Then went back to bed, and wasn't agitated at that time. [name of LVN D] LVN assumed care of patient at this time.Record review of Resident #1's hospital records for his hospital stay 08/21/25 to 08/26/25 revealed the following:On 08/21/25 at 07:22 AM he arrived at the hospital. His means of arrival was noted to be Wheelchair.On 08/21/25 at 07:30 AM HC noted, Chaplain encountered patient while he was in triage. Chaplain remembered this patient from previous visit to have surgery and is aware of communication barriers. Chaplain helped patient communicate with nursing staff as much as possible and remained with patient. Chaplain will continue to follow to provide support.On 08/21/25 at 07:33 AM it was noted, Asked pt if he is having pain and he points to his genital area. Asked pt if he has been able to go to the restroom and pt states ‘no.'On 08/21/25 at 07:44 AM it was noted, [Name of facility] employee arrived to ER stating that they were missing a patient. This employee presented badge and was able to describe the patient. This employee provided this patients paperwork from [name of facility] with demographics available. Pt demographics updated in pt chart.On 08/21/25 at 11:04 AM it was noted, Pt was found in [name of city park across the street from the hospital] by a bio-med employee. He was unable to state his name or DOB. Pt is pointing to his testicles and scrotum. He appears to be c/o pain and swelling. Pt has not been able to pass urine. Hx/ROS are limited. General: He (Resident #1) is in acute distress. Appearance: He is ill-appearing. He is not toxic-appearing . Testes: Left: Tenderness and swelling (redness) present . Mental Status: He is alert and oriented to person, place, and time. Left inguinal hernia (part of fatty tissue or intestines protrudes through a weak spot in abdominal wall in left groin area) with urinary bladder down and testicular area discussed with surgery who will take to the OR.On 08/21/25 at 12:48 PM it was noted, The patient came in the emergency room today. He lives in a nursing home and was having increasing groin and scrotal pain as well as difficulty urinating. He was found to have a large left inguinal hernia with most of his bladder coming out through the hernia and into his scrotum on this side. On physical examination, he has some tenderness and fullness in the left side of his groin and scrotum. CT scan is reviewed which shows the left inguinal hernia with a large portion of his bladder extending down into the scrotum. I discussed plans with the patient. The patient is not able to speak very much . He does appear to understand what you're saying very well. S/p Craniotomy, Decompressive Craniectomy in 2024. S/p cranioplasty with replacement of bone flap 8/13/25.On 08/21/25 at 04:02 PM Resident #1's left inguinal hernia surgery was begun.On 08/26/25 Resident #1 was discharged from the hospital. His discharge summary note read, The patient was admitted through the emergency room with a symptomatic left inguinal hernia with bladder in it. He underwent a complex repair of the inguinal hernia. His postoperative course was uneventful. The patient had previously been in a nursing home and the family wanted to move him to a different facility postop therefore he was in the hospital for a few days awaiting placement. He was discharged in good condition .Record review of Resident #1's Documentation Survey Report for August 2025 dated 09/11/25 revealed no indication of urinary retention in the days prior to his elopement on 08/21/25. On 08/18/25 he urinated at 12:43 AM and 01:06 PM. On 08/19/25 he urinated at 07:34 AM, 10:22 AM, and 11:47 PM. On 08/20/25 he urinated at 09:02 AM, 10:18 AM, 09:40 PM and 10:04 PM.Record review of weather on 08/21/25 at 07:00 AM revealed the temperature was approximately 70 degrees Fahrenheit with a 5-mph wind and 81% humidity.Record review of Resident #1's History and Physical dated 04/09/25 revealed the following: . Patient has been discharged from hospice services. The facility reports [Resident #1's family member] is wanting him to go back and see the surgeon that did his brain surgery. Staff reports she is concerned about his skull being sunken in and is wanting to have this fixed. She also wants him to have a hernia repair but her first concern is the skull.During an interview on 09/11/25 at 09:19 AM RN C stated she worked with Resident #1. She stated he had a communication deficit but he would get his point across with yes and no questions and hand gestures. She stated she was working on 08/21/25 when Resident #1 eloped but she was not his nurse that day. She stated there were a lot of safety issues with Resident #1 wheeling himself to the hospital. She stated, A lot of things could happen, he could get hit.During an interview on 09/11/25 at 09:32 AM Resident #1's family member stated on 08/21/25 at 06:15 AM she got a call from LVN D saying Resident #1 wanted to go to the hospital and the facility was going to call an ambulance. She stated she received another call from LVN D on 08/21/25 at 07:41 AM telling her Resident #1 was not in the facility but he had managed to wheel himself to the ER. Resident #1's family member stated another family member called and told her to call HC. She stated HC knew Resident #1 from his stay in the hospital for his cranioplasty surgery the week before. HC told her Resident #1 was found near the park across the street from the hospital struggling with his wheelchair and a hospital staff person left his car there on the side of the street and pushed Resident #1 the rest of the way to the ER. She stated Resident #1 had a huge scar and stitches and staples from his forehead and back around to his left ear due to the cranioplasty he had on 08/13/25. Resident #1's family member stated the scar made the hospital staff member who stopped to help him think he had escaped from the hospital and was lost. She stated when he eloped Resident #1 was not wearing his glasses or his teeth or shoes. She stated he only had on socks. She stated when he woke up from his hernia surgery the first things he asked for were his glasses and his teeth. Resident #1's family member stated, When you talk to him it is like playing charades because he only knows 3 words and he gestures. She stated on 08/26/25 when she picked up Resident #1's belongings from the facility ADM told her the ambulance showed up to pick up Resident #1 seven hours after it had been called. She stated, He should never have been able to leave! His safety (was at risk)!During an interview on 09/11/25 at 11:06 AM CD stated a 911 call came in on 08/21/25 at 06:17 AM from the facility requesting an ambulance for Resident #1 due to hernia pain. She stated the ambulance arrived at the facility on 0821/25 at 01:19 PM. She stated operations had downgraded the call to non-emergent.During an interview on 09/11/25 at 11:16 AM HC stated she was in the ER on the morning of 08/21/25 and heard nurses speaking about an unidentified person who was brought to the ER from the park across the street. She said she walked by and recognized the person was Resident #1. She stated, I went over there, and he saw me and burst into tears. He was sitting in a w/c . and he grabbed my arm and held onto it and cried and cried and cried. She stated she referred to her notes from his stay on 08/13/25 and called his family member. HC said, We played some charades for a while, and he communicated to me that he had left the nursing home. She stated Resident #1 indicated to her that he was in pain. She stated a hospital employee saw Resident #1 across the street from the hospital near the park. She stated the employee left his car and pushed Resident #1 in his wheelchair the rest of the way to the ER. During an interview on 09/11/25 at 12:00 PM ADM and ADON stated Resident #1 had no history of elopement. During an observation on 09/11/25 at 12:04 PM this surveyor drove the route from the facility to where Resident #1 was found by hospital staff. It was .5 of a mile and had sidewalks for 3/4 of the route. Some portions of the sidewalks were not accessible by wheelchair and there was no bike lane. The 1/4 of the route with no sidewalks did have a bike lane. The first .4 of a mile was flat or downhill. Some portions of the downhill route were rather steep. The last .1 of a mile was uphill. From where Resident #1 was found and assisted by hospital staff the route was all uphill to include a steep drive from the street to the hospital ER entrance. During an interview on 09/11/25 at 01:57 PM LVN D stated on 08/21/25 at around 06:00 AM she and LVN E were exchanging report and Resident #1 came out of his room with no clothes on complaining of pain. She stated she and LVN E dressed Resident #1 and told him it might be good to lie down and get off that hernia. She stated he got mad and said, No, no, no. LVN D stated Resident #1 let her know he wanted to go to the hospital, and she called the ambulance and got his paperwork ready while he sat near her. She stated, The ambulance was taking so long, and he got more agitated. LVN D stated she called the ambulance to find out why it was taking so long and was told it would be a while longer as they had emergencies everywhere. She stated she told the dispatch officer that Resident #1 was in pain. LVN D stated Resident #1 was agitated and she could not calm him down. She stated she did finger sticks on a few residents and when she walked back by where Resident #1 had been sitting in his wheelchair, she noticed he was gone. LVN D stated she sent a CNA to the other unit to see if he was there and when he was not there, she let all staff know he was missing and called ADON and ADM to let them know as well. She stated all staff but 1 CNA on each unit began to search the building and the grounds for Resident #1 and CNA F got in her personal car and drove toward the hospital looking for him. LVN D stated CNA F found Resident #1 at the hospital. LVN D stated Resident #1 had just returned to the facility after surgery for something on his head. She stated, He was going to take care of the hernia first but then he decided to take care of his cranial area first. LVN D stated, regarding Resident #1's elopement, He could have got hurt. Anything could have happened to him.During an interview on 09/11/25 at 02:23 PM DON stated Resident #1 had his hernia on admission. She stated his family decided to put him on hospice in January and the hernia was discussed with hospice and they (hospice) said he could not have any intervention while on hospice. DON stated Resident #1 did not have a history of elopement. She stated regarding Resident #1's elopement on 08/21/25, He coulda got run over for one thing. So many things could have happened between here (facility) and there (hospital). DON stated the facility currently had 6-8 residents who were elopement risks.During an interview on 09/11/25 at 02:35 PM ADON stated if Resident #1 had fallen out of his wheelchair during his elopement on 08/21/25 he could have broke something, hit his head, got hit. She stated the facility currently had 8 residents who were elopement risks. ADON stated LVN D called her on 08/21/25 at 07:20 AM to let her know Resident #1 was missing. She stated she was driving to work when CNA F found Resident #1 at the hospital.During an interview on 09/11/25 at 02:43 PM ADM stated Resident #1 did not have a history of elopement. She stated Resident #1 could have been injured during his elopement if he lost his balance and fell out of his wheelchair.During an interview on 09/11/25 at 03:38 PM LVN E stated Resident #1 was real upset when he came out (of his room) during report on 08/21/25. She stated she had not seen him act that agitated during the time she was working with him. LVN E stated Resident #1 did not complain of hernia pain the night of 08/20/25 or overnight into 08/21/25. She stated he did ask for acetaminophen for his joints at bedtime on 08/20/25. She stated he asked for acetaminophen for his joints at bedtime regularly by pointing to his knees arms and she would ask if he was in pain, and he would nod his head. She stated he was not agitated or angry seeming as he was on the morning of 08/21/25.During an interview on 09/11/25 at 04:01 PM CNA F stated she arrived to work on 08/21/25 around 07:30 AM. She stated she saw two CNAs searching around the building for Resident #1. She stated after she clocked in, she got back in her car and drove to the hospital and told them she was looking for a resident. She described Resident #1 to hospital staff, and they took her to him. CNA F said when she saw Resident #1, she asked him why he did not wait for the ambulance, and he shrugged his shoulders at her with his elbows bent and palms facing up and then he touched his left side. She stated Resident #1 seemed normal when she saw him in the hospital. CNA F stated he could have been hurt wheeling himself to the hospital because it is a busy street.During an interview on 09/11/25 at 04:23 PM LVN G stated regarding Resident #1's elopement, He could have got hurt being alone.During an interview on 09/12/25 at 08:16 PM CNA H stated Resident #1 came out of his room on 08/21/25 during morning report complaining of pain and gesturing to his left side. She stated she did not notice any change in his urine output in the days prior to his elopement.During an interview on 09/12/25 at 04:29 PM MD stated an inguinal hernia could go from being fine to becoming a medical emergency and pretty painful pretty quick. He stated regarding Resident #1's elopement, He had mobility issues, he could have fallen out of the chair, hit something, I mean, there was danger.2. Record review of Resident #3's admission record revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Parkinson's disease (chronic and progressive movement disorder that initially causes tremors in one hand and stiffness or slowing of movement) without dyskinesia (abnormality or impairment of voluntary movement), unspecified dementia (a group of thinking and social symptoms that interferes with daily functioning), major depressive disorder (a mental disorder characterized by persistent low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities), anxiety disorder (a group of mental health conditions characterized by excessive and persistent worry, fear, and nervousness that can significantly interfere with daily life), muscle wasting and atrophy, muscle weakness, and other lack of coordination.Record review of Resident #3's quarterly MDS completed 09/05/25 revealed a BIMS score of 12 which indicated moderately impaired cognition. Section E Behavior revealed Resident #3 had no behaviors. Section GG Functional Abilities revealed he was independent across all ADLs. Section M Medications revealed he was receiving antidepressant, antiplatelet, and anticonvulsant medication.Record review of Resident #3's care plan completed on 09/08/25 revealed he was resistive to care r/t impaired cognition and he had potential to be physically aggressive throwing objects r/t behaviors. Resident #3 was noted to have potential to be verbally aggressive very rude and demanding r/t cognitive impairment. He had impaired cognitive function r/t dementia. He had a mood problem r/t MDD and declines to see psych. Interventions included administering medications as ordered, explain all procedures and orders prior to starting and allow time to adjust to changes, discuss inappropriate behaviors with resident when reasonable, monitor behavior episodes and attempt to determine underlying causes, and document behaviors and potential causes. Staff were instructed to give the resident 5-10 minutes when resistive to care before trying again and when he became agitated to intervene before the agitation escalated and guide him away from the source of distress. Staff were instructed to engage him calmly in conversation and if he became aggressive they were to walk calmly away and approach at a later time.Record review of a referral order dated 09/10/25 revealed Resident #3 was being referred for Psychiatric Medication Management and Psychotherapy and Counseling Services.Record review Resident #3's progress notes from 03/11/25 to 09/12/25 revealed no mention of physical or verbal aggression toward another resident.During an interview on 09/11/25 at 08:23 AM a Resident #2 stated a male resident had a saw yesterday and threatened to cut off her feet.During an interview on 09/11/25 at 08:36 AM ADON stated she was just told by Resident #2 about Resident #3 having a saw yesterday.During an interview on 09/11/25 at 08:41 AM ADM stated Resident #3 had a hand saw on 09/10/25. She stated, He took it out of the maintenance room is the only thing we can figure out. ADM stated CNA A and CNA B were working at the time and took the saw away from Resident #3. During an interview on 09/11/25 at 08:50 AM CNA A stated regarding Resident #3 on 09/10/25, I mean he did have a saw but as soon as we seen him, we took it from him. He was rolling with the saw down the hall.During an interview on 09/11/25 at 08:51 AM CNA B stated Resident #3 had a saw on 09/10/25 and he was using the saw on a female resident's walker. She stated, You can look at her walker. There is proof. CNA B stated Resident #3 got the saw from the maintenance office. During an interview on 09/11/25 at 09:00 AM Resident #3 was lying in bed in his room. He stated he had a saw yesterday (09/10/25) and he got the saw from the shop (here he gestured with his left hand in the direction of the hallway which housed the maintenance office. Resident #3 was asked if he threatened to cut off a female resident's feet with the saw and he answered, Foot. He stated he threatened to cut off her foot. When asked if he used the saw on the female resident's walker, he said he did. During an observation on 09/11/25 at 09:03 AM of Resident #2's top, front walker bar revealed a small, shallow groove approximately 1.5 centimeters in length and 2 millimeters in depth with jagged edges.During an observation and interview on 09/11/25 at 09:06 AM this surveyor opened the door into the maintenance office. As the door opened the first thing visible from waist height to the floor was the side of a desk upon which 4 -6 different types of hand saws were hanging. MA was in the maintenance office and stated any time he leaves the office he locks the door behind him. He stated he was working on 09/10/25 but he was not in the office much that day because he was painting all day. He stated MS was working on 09/10/25.During an interview on 09/11/25 at 02:23 PM DON stated she was not in the building on 09/10/25 when Resident #3 had a hand saw. She stated a possible negative outcome of him having a hand saw was definite injury.During an interview on 09/11/25 at 02:35 PM ADON stated on 09/10/25 around 4 or 5 PM Resident #3 had a hand saw. She stated she did not see him with the saw she just heard about him having it. She stated she received a phone call from LVN J on 09/10/25. LVN J told ADON it was reported to her (LVN J) Resident #3 had a hand saw that afternoon.During an interview on 09/11/25 at 02:43 PM ADM stated she was in the building on 09/10/25 when Resident #3 had a hand saw. She stated she did not see him with the hand saw but CNA A and CNA B told her about taking the saw from Resident #3. She stated a possible negative outcome of a resident having access to a hand saw was, Someone could get cut. During an interview on 09/11/25 at 02:53 PM MS stated he heard about Resident #3 having a hand saw. He stated he did not know how Resident #3 got the hand saw because the maintenance office was locked. MS stated, I always lock the door behind me when I'm going out. If it happens to be I made a mistake-I have so much going on and I am always in a hurry-it is a possibility. But there is no excuse for that, and it will not happen again. MS stated a possible negative outcome of a resident having access to a hand saw was, Somebody gets chopped up. He could hurt someone else or hurt himself.During an interview on 09/11/25 at 04:23 PM LVN G stated Resident #3 was agitated on 09/10/25 and was telling her his doctor had increased his Parkinson's medication. She stated he was upset with her when she told him she could not increase his medication without an order and more upset when she called his doctor's office, and they said it was not to be increased. She stated during this time she left Resident #3 at the nurses' station in his motorized wheelchair and she went to help another resident. LVN G stated when she came back to the nurses' station, she saw him with a hand saw cutting on the top, front bar of a female resident's walker and making fun with everyone who was in the common area that he could saw through the walker. She stated she went to his side and asked him to put the saw down because it was not his. LVN G stated he put the saw on the ground when she asked him to put it down. She stated he was still agitated so she called the doctor for an order for something to calm him down and he was given Vistaril which seemed to help calm him down. LVN G stated, Someone could have been cut due to Resident #3 having access to the hand saw.During an observation on 09/11/25 at 05:04 PM Resident #3 was wheeling himself into the front door after smoking in the courtyard. During an interview on 09/12/25 at 12:42 PM RN C stated she was told on 09/12/25 to keep a closer eye on Resident #3.On 09/12/25 at 01:00 PM ADM and ADON were notified that an Immediate Jeopardy had been identified, IJ templates were provided, and Plan of Removal was requested.The facility's Plan of Removal (as follows) was accepted on 09/12/25 at 08:12 PM.Plan of RemovalProblem: There is a need for immediate action due to the break in the facility's risk management process regarding abuse, neglect, and elopement. Specifically, the facility staff will need to address corrective action to prevent future incidents of elopement from occurring in the facility, especially when residents are exhibiting signs and symptoms of elopement. All residents who are high risk for elopement are at risk of the alleged defected deficiency.Interventions: The administrator notified the medical director of Immediate Jeopardy 9/12/25 & Ad HOC completed on 8/22/2025. The following in-services were provided:o On 8/21/25 DON/ADON provided education to staff on Dementia Care: Mental Decline, elopement policy & exit seeking protocol, and wandering/elopement education prior to their next working shift.o On 8/21/25 DON/ADON provided education to charge nurses on wandering/elopement, dementia care: Mental Decline, elopement policy and exit seeking protocol prior to their next working shift.o All staff will be educated by DON/ADON prior to working their next shift with a completion date of 8/21/25. All NEW staff will be educated prior to working their first shift.o On 8/22/25 Admin and DON/ADON provided education to staff on how to identify residents at risk/high risk. DON/ADON completed audit on 8/21/25 to ensure Elopement Assessments have been completed according to protocol. Charge Nurses will complete an Elopement Risk Assessment quarterly, upon admit, and for exit seeking behaviors. The assessment will provide a score to indicate if they are at risk or high risk for elopement. ADMIN/DON will be responsible for ensuring a resident has 1:1 supervision when required and will monitor that it is being followed. For residents who score at risk/high risk for elopement on the elopement assessment, a shoe emblem will be placed above the name pla