**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure that all alleged violations involving abuse were reported immediately to the abuse coordinator for immediate intervention and all alleged violations involving abuse were reported no later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or bodily injury, to the administrator of the facility and to other officials, including the State Survey Agency in accordance with State law through established procedures for 3 of 25 residents (Resident #5, #7 and #8) reviewed for abuse. 1. The facility failed ensure ST R reported a witnessed allegation of physical and verbal abuse immediately to the Abuse Coordinator approx. 1.5 weeks prior to 7/1/2025. ST R witnessed CNA M tell Resident #5 to sit you ass down multiple times and then forcefully push Resident #5 into a chair approx. 1.5 weeks prior to 7/1/2025. The Abuse Coordinator became aware of the incident on 7/3/2025 during a facility investigation and staff interviews regarding another abuse allegation of Resident #5. 2. The facility failed to ensure LVN Z reported an allegation of abuse immediately to the Abuse Coordinator on 12/29/24. LVN Z documented on 12/29/24 at 8:16 p.m. that CNA Y observed Resident #7 hit Resident #8. The DON became aware of the incident on 12/30/25 upon review of progress notes and subsequently reported the allegation to the abuse coordinator. 3. The facility failed to ensure LVN XX reported an allegation of abuse immediately to the Abuse Coordinator on 05/18/2025. An Immediate Jeopardy (IJ) was identified on 09/24/2025 at 9:45 a.m. The IJ template was provided to the facility on [DATE] at 11:05 a.m. While the IJ was removed on 09/25/2025, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. The failures could place residents at risk of abuse, physical harm, mental anguish, and emotional distress.Findings included: 1. Record review of Resident #5's face sheet, dated 09/23/2025, indicated a [AGE] year-old male who was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident #5 had diagnoses which included diffuse traumatic brain injury (widespread damage across multiple areas of the brain), hypertension (a condition in which the force of the blood against the artery walls is too high), encephalopathy (group of conditions that cause brain dysfunction, which can manifest as confusion, memory loss, personality changes), dementia (loss of cognitive functioning), lack of coordination, cognitive communication deficit, and major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Record review of Resident #5's quarterly MDS Assessment, dated 5/04/2025, indicated he rarely/never made himself understood and sometimes understood others. He was not assessed for the brief interview for mental status because he is rarely/never understood. He had no behaviors identified within the 7-day look back period. Record review of Resident #5's care plan revision dated 7/03/2025 indicated Resident #5 had an incident of confabulation and had a potential for further episodes of confabulation and confabulation triggered behaviors. Interventions included allow residents to verbalize feelings during episodes of confabulation - gently reorient and maintain safety, orient/re-orient resident daily and PRN, encourage to attend activities of choice, and report to MD/RP as needed and document episodes of confabulation in the clinical record. Record review of the facility's Provider Investigation Report dated 7/01/2025, incident category as abuse signed by the Administrator on 7/11/2025. PIR indicated the incident occurred 7/01/2025 at 7:00 p.m. on the secure unit. PIR indicated during staff interviews ST R said she witnessed CNA M be verbally and physical aggressive with Resident #5 approximately 1.5 weeks ago. CNA M was heard telling Resident #5 to sit you ass down and witnessed forcefully pushing him into the chair and pushing his chair forcefully under the table. LVN X provided head to toe assessment to Resident #5 with no injuries noted. Provider response after the incident included, employee suspended immediately, head to toe assessments on all residents in the secure unit, safe surveys conducted, employee statements collected, abuse and neglect in-services initiated, care plan updated, psych NP notified, MD notified, no family to notify, and local police contacted. Resident abuse confirmed. Employee terminated. During an interview on 09/24/2025 at 2:00 p.m., ST R said she had witnessed CNA M physically and verbally abuse Resident #5 sometime in late June 2025 when she heard CNA M tell Resident #5 to sit you ass down multiple times and then forcefully push Resident #5 into a chair and push him up to the table. ST R said she reported this incident late, when she was being interviewed regarding another incident with Resident #5. She said at the time it happened she felt uneasy about the incident and would not want her family treated that way. She said that she reported the incident to clear her consciousness and knew it should have been reported when she first witnessed the incident. She said she was suspended and received disciplinary actions regarding not reporting the abuse allegation immediately and re-educated prior to returning to work. She said moving forward that any abuse allegations witnessed or reported to her she would report it immediately to the administrator. During an interview on 9/23/2025 at 1:30 p.m., LVN X said she recalled the assessed Resident #5 after the incident and did not identify any injuries. She said that if she was notified of an abuse allegation, she would make sure the resident is safe and then immediately report to the Administrator/Abuse Coordinator. She said if she witnessed a resident being abused that she would intervene and remove the abuser and keep the resident safe, notify the AC and/or send the staff member home and if resident to resident keep separated for safety. During an interview on 09/24/2025 at 8:30 a.m., the Administrator said she was made aware of the witnessed abuse allegation of Resident #5 when she was taking statements from employees on 07/03/2025 during an ongoing investigation with abuse allegation of Resident #5. She said ST R told her on 07/03/2025 that she had witnessed CNA M be verbally and physically abusive to Resident #5 approx. 1.5 weeks prior. She said ST R stated she did not report the allegation at the time because she was confused about the situation, did not want to get anyone in trouble or cause drama. She said ST R was suspended for not reporting the incident immediately. She said she did not report the new abuse allegation to the state but did investigate the allegation while she was investigating the current abuse allegation of Resident #5. She said she included the information in the PIR submitted and did not realize the new allegation should have been reported separately. Record review of ST R's personnel record indicated she was trained on abuse and reporting abuse on 06/29/2025. 2. Resident #7Record review of Resident #7's face sheet dated 09/24/2025 indicated she was a [AGE] year old female, admitted on [DATE], and her diagnoses included hemiplegia (one-sided paralysis or weakness) and hemiparesis (partial one-sided weakness) following cerebral infarction (stroke) affecting left non-dominant side, aphasia (communication disorder), schizoaffective disorder (mental health condition), major depressive disorder (mood disorder), and (intense, persistent worry and fear about everyday situations). Record review of Resident #7's quarterly MDS assessment dated [DATE] indicated she was sometimes able to make herself understood and usually understood others. She was cognitively intact (BIMS-14). There were no behaviors noted. Record review of Resident #7's care plan dated 08/11/2025 indicated Resident #7 had the potential for physical aggression related to a diagnosis of schizoaffective disorder. Interventions included psychiatric consult as indicated and when the resident becomes agitated-intervene before agitation escalates, guide away from source of distress. Resident #8Record review of Resident #8's face sheet dated 09/24/2025 indicated he was a [AGE] year old male, admitted on [DATE], and his diagnoses included unspecified convulsions (involuntary contractions and spasms that do not have a specific diagnoses), HTN (high blood pressure), HDL (high levels of fats), acute hepatitis (inflammation of liver), COPD (chronic lung disease), depression (mood disorder) psychoactive substance abuse (harmful or hazardous use of substances that affect mental processes), schizoaffective disorder (mental health condition), hallucinations (hear, see, smell, taste or feel things that are not present), and suicide ideation (thoughts of suicide). Record review of Resident #8's quarterly MDS assessment dated [DATE] indicated he was able to make himself understood and understood others. He had moderate cognitive impairment (BIMS-12). Record review of Resident #8's care plan dated 10/27/2024 indicated he was at risk of mani episodes and increased behavior related to a diagnosis of schizophrenia. Interventions included administering medications as ordered, monitor for delusions and hallucinations, monitor for increased aggression, psych consult as needed, and remove resident for increased stimuli during behavioral episodes. Record review of Resident #8's nurse note dated 12/29/2024 at 2:00 p.m., completed by LVN Z, indicated she was notified by CNA Y of Resident #7 and Resident #8 were involved in a physical altercation. Resident #7 was hitting Resident #8. CNA Y directed Resident #7 to stop hitting Resident #8. Resident #7 stopped hitting Resident #8. Resident #8 stated he was OK. He said, I'm not worried about that b****. That b**** crazy. I am not worried about her. She better go on. Resident #7 continued to roll up to Resident #8 and tried to hit him again. LVN Z told them to stop and do not hit each other. LVN Z told them that this type of behavior was unacceptable. Further review revealed LVN Z did not document notification of the alleged abuse to the Administrator or the DON. Record review of LVN Z's undated statement indicated she was notified by CNA Y that Resident #7 had an altercation with resident #8. Resident #7 was around Resident #8 and hit him with her hand. Resident #8 said he was OK. CNA Y said she told Resident #7 to stop, and she did. CNA Y said the altercation was because Resident #8 owed Resident #7 $20. LVN Z said she was not around during the incident. Resident #7 was in her room resting. LVN Z was in the hall pulling medications and asked Resident #8 what happened, and he said he was not worried about that bitch. She was crazy. Resident #7 came back towards Resident #8, and she told him to move away. Resident #7 was monitored for the rest of the night for behaviors. Record review of CNA Y's statement dated 12/30/2024 indicated on 12/29/24 around 1:15 p.m., a resident came down the hall and pushed a barrel into Resident #7. Resident #8 tried to stop her by pulling on the handle of the chair. She turned around and started hitting him with a bag of food. Resident #7's son came around the corner and tried to diffuse the problem, but she kept going on. When Resident #8 said he did not owe her $20 she picked up the wet floor sign and tried to hit him and when she could not hit him with the wet floor sign, she raised her leg to kick him. During an interview on 09/23/2025 at 10:00 a.m. the DON said she became aware of the alleged abuse between Resident #7 and Resident #8 that occurred on 12/29/24, when she reviewed the incident written by LVN Z, on 12/30/24. She said Resident #7 was placed on 1 to 1 immediately until cleared by psych on 12/30/24. She said Resident #7 and Resident #8 were assessed with no injuries. She said LVN Z was trained upon hire to report abuse and allegations of abuse immediately to the Administrator. She said LVN Z was terminated due to not reporting immediately. During an interview on 09/24/2025 at 12:27 p.m., previous Administrator U said he did not confirm the incident on 12/29/24 as abuse. He said he recalled Resident #7 swung a shopping bag at Resident #8 because Resident #8 had grabbed the back of her wheelchair. He said LVN Z did not report the incident immediately to him on 12/2920/24 as required and they were terminated. During an interview on 09/25/2025 at 9:28 a.m., LVN Z said she did not see the abuse between Resident #7 and Resident #8 and the reason she did not report it to Administrator U. She said CNA Y reported the alleged abuse to her on 12/29/2024. She said she was called in to the facility on [DATE] and gave her statement. She said she could not recall being trained to report abuse immediately to the administrator. 3. Resident #2Record review of Resident #2's face sheet, dated 09/23/2025, indicated a [AGE] year-old female who was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident #2 had diagnoses which included schizophrenia (a chronic mental disorder characterized by symptoms such as hallucinations, delusions, and cognitive challenges), Alzheimer's Disease (progressive disease that destroys memory and other important mental functions), manic episodes, intellectual disabilities, diabetes type 1 (chronic condition in which the pancreas produces little or no insulin), dementia (loss of cognitive functioning), and major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Record review of Resident #2's quarterly MDS Assessment, dated 4/05/2025, indicated she was able to make herself understood and understood others. She was intact cognitively, identified with a BIMS score of 13. She had an active diagnosis of anxiety disorder, depression, bipolar disorder, and schizophrenia in the last 7 days. She had no behaviors identified within the 7 days look back period. Record review of Resident #2's care plan revision dated 1/16/2024 indicated Resident #2 had inappropriate behaviors. Interventions included to activities, explain procedures using terms gestures residents can understand, monitor and chart behaviors every shift and report progress to MD, observe for early warning signs of behavior - approach in a calm manner, call by name, remove from unwanted stimuli, give medications per order - monitor labs - report results to MD, and consult psychiatric/ psychogeriatric as indicated. Record review of Resident #2's care plan dated 5/19/2025 indicated Resident #2 had physical aggression from another resident. Interventions included analyzing times of day, places, circumstances, triggers, and what de-escalates behavior and document, assessing and addressing for contributing sensory deficits, monitor/document/report as needed any s/s of resident posing danger to self and others, when the resident becomes agitated: intervene before agitation escalates; guide away from source of distress; engage calmly in conversation; if response is aggressive, staff to walk calmly away, and approach later and administer medications as ordered, monitor/document for side effects and effectiveness, and psychiatric/psychogeriatric consult as indicated. Resident #3Record review of Resident #3's face sheet, dated 09/23/2025, indicated a [AGE] year-old female who was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident #3 had diagnoses which included vascular dementia (changes in thinking and memory that occur when there isn't enough blood flow to part of the brain), diabetes (a chronic condition that affects the way the body processes blood sugar), stroke, dementia (loss of cognitive functioning), and major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Record review of Resident #3's quarterly MDS Assessment, dated 3/14/2025, indicated she was sometimes able to make herself understood and sometimes understood others. She was moderately impaired cognitively, identified with a BIMS score of 11. She had an active diagnosis of depression in the last 7 days. She had no behaviors identified within the 7 days look back period. Record review of a progress notes/incident report for physical aggression, dated 05/18/2025, authored by LVN XX indicated an incident was reported that included Resident #2 and Resident #3 sitting in dining room yelling at each other. Residents separated. No injuries were identified. Record review of the facility's Provider Investigation Report, dated 05/18/2025, incident category as resident-to-resident abuse signed by the Administrator on 05/23/2025. The PIR indicated the incident occurred on 05/17/2025 at 6:30 a.m. The PIR indicated Resident #3 scratched and pulled Resident #2's hair, who was trying to prevent her from getting coffee. LVN YY performed a head-to-toe assessment on both residents, Resident #2 received scratch to left forearm. Provider response after the incident included, residents separated, head-to-toe assessments on all involved residents, incident/accident report completed, employee statements, safe surveys conducted, care plans updated, abuse and neglect in-services initiated, psych referral completed, and MD/family notified. Resident abuse confirmed. An attempted telephone interview on 09/24/2025 at 7:45 a.m. with LVN XX was unsuccessful. During an interview and record review of provider investigation report on 09/24/2025 at 8:45 a.m., the Administrator clarified that the incident between Resident #2 and Resident #3 occurred on 5/18/2025 at 8:00 a.m. but she was not made aware of the allegation until she arrived at work on Monday 05/19/2025. She said Resident #2 notified her on 05/19/2025 of the incident and showed her the scratch that she received during the incident. She said she began investigating at that time and reported the allegation to the state once the incident was confirmed. She said that the allegation was reported late, and she is aware that all abuse allegations are to be reported to the state agencies within 2 hours of the incident and the delayed reporting could be other residents at risk for harm or abuse. Record review of the facility's Abuse and Neglect policy dated June 2023 indicated . All allegations and/or suspicions of abuse must be reported to the Administrator immediately. If the Administrator is not present, the report must be made to the Administrator's Designee. All allegations of abuse will be reported to DADS immediately after the initial allegation is received. An Immediate Jeopardy/Immediate Threat was identified on 09/24/2025 at 9:45 a.m. The Administrator was notified of the Immediate Jeopardy on 09/24/2025 at 11:00 a.m. The IJ template was provided to the facility on [DATE] at 11:05 a.m. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The facility's Plan of Removal for Immediate Jeopardy was accepted on 9/25/25 at 10:45 am. and reflected the following: Actions for Resident Involved: Resident #7 / Resident #8: Resident #7 struck Resident #8 with shopping bag; risk of physical harm. Resident #5: Subjected to verbal and physical abuse by CNA M. Resident #3 / Resident #2: Resident #3 scratched Resident #2; delay in reporting placed Resident #2 at risk of further harm. All residents in facility: Placed at risk due to systemic failure to report abuse allegations immediately. Immediate Actions Completed (as of 9/24/2025): Residents assessed for injuries; psychosocial evaluations completed on 12/30/2024 by the Director of Nursing, Skin assessment completed by Treatment Nurse. Resident #7 placed on 1:1 monitoring on 12/30/2024LVN Z terminated for failure to report abuse-1/3/2025. Resident #5CNA M was terminated for abusive behavior on 7/7/2025.ST R suspended and re-educated on 7/3/2025. Facility-wide in-service provided to staff on abuse/neglect reporting policy, including immediate reporting to Abuse Coordinator and State Agency. 12/30/2024-by the DON; 1/15/2025-by the DON; 7/1/2025-by the Administrator; 7/7/2025-by the DON; 7/9/2025-by the DON; 7/22/2025-by the Administrator. Systemic Actions to Prevent Recurrence: Start date: 9/24/25 Completion date: 9/24/25 Responsible: Administrator / Designee DON (Director of Nursing) and Administrator will be educated by CNO (Chief Nurse Officer) and VP of Operations on Abuse, neglect and exploitation, reporting guidelines. All staff will receive mandatory re-education with verbal discussion and signing of in-service sign-in sheet. A post-quiz will be used to determine understanding of timely reporting of any types of abuse and neglect to the Abuse coordinator and or designee along with the appropriate departmental supervisor. 9/24/2025 Abuse reporting flowchart posted in nurse stations, break rooms, med rooms. 9/24/2025 Abuse allegations are logged and reviewed weekly by Admin/DON/designee. Ongoing competency checks added to new hire orientation and annual training. Progressive discipline reinforced for any failure to report. Monitoring/Accountability: Review of 24-hour reports, progress notes, incident reports and any grievances to identify any possible abuse, neglect, or exploitation that may have occurred and on Monday for the weekend. By the Administrator/Designee and DON. Random weekly staff interviews for four weeks or as needed to verify knowledge of reporting procedures Random safe surveys with residents for four weeks or as needed to be completed by Admin/SW/Designee QA Committee will review abuse investigations in the daily standup meetings, and the Governing Body will review monthly. Responsible Staff:Administrator / designee will ensure immediate investigations and reports to HHSC Administrator/ DON will ensure compliance, staff training, and monitoring audits. QA Committee will have oversight of systemic compliance and sustainability.Physician Notified of Immediate Jeopardy 9/24/2025 Section 3 - Timeliness Immediate protective actions completed as of 9/24/2025 Terminations, suspensions, and staff in-servicing completed as of 9/24/2025. Policy revisions and abuse reporting flowchart completed by 9/24/2025. Audits and monitoring began 9/24/2025 and will continue ongoing. Sustainability will be measured monthly in the QAPI meeting by the QAAC and if any changes are needed within the system, it will be performed immediately. Review of the IJ monitoring for the facility's plan of removal reflected the following: Record review of CNA M employee termination form dated 07/07/2025 indicated CNA M was terminated for violation of company policy and a substantiated abuse allegation. Record review of ST R personnel file the disciplinary action form indicated ST R was suspended from 07/03/2025 to 07/07/2025 for failure to report abuse allegation timely and was reeducated on abuse, neglect and reporting process prior to her returning to duty. Record review of in-service dated 09/24/2025 completed by VP of Clinical Reimbursement, [NAME] President of operations and Corporate Nurse indicated the Administrator and Director of Nursing was trained on abuse, neglect, including types of abuse with examples, steps to prevent abuse (screening, training, prevention, identification, investigation, protection and reporting/response), reportable allegations and abuse allegation reporting time frames. Record review of in-services dated 09/24/2025 completed by the DON, indicated staff were trained on abuse and neglect recognition, types, reporting, examples, reporting abuse allegations immediately, flow chart on reportable allegations, resident to resident altercation prevention, protocol following abuse allegations, caring for residents with aggressive behaviors, supervision, and monitoring. Interviews conducted on 09/25/2025 from 12:00 p.m. through 5:30 p.m. representing staff from various shifts (6 a.m.-2p.m., 2p.m.-10p.m., and 10p.m.-6a.m.) and departments included LVN A, RN B, LVN C, MA G, AD H, HSK J, CNA K, CNA L, LVN S, ST R, CNA V, CNA W, LVN X, LVN AA, CNA BB, CNA CC, CNA DD, CNA EE, LVN FF, CNA GG, CNA HH, CNA II, MA JJ, CNA KK, LVN LL, CNA MM, CNA NN, MT OO, PTA PP, DOR, HSK QQ, FT RR, DD, DA SS, DA TT, DA UU, COOK VV, COOK WW, ADON, Housekeeping Supervisor, and Maintenance Director all said they were in-serviced on 09/24/2025 or prior to their shift on 09/25/2025 and then given quiz to complete to verify their knowledge. All were able to state that their abuse coordinator was the Administrator, if he were not available, they were to notify the DON. They were all able to give examples of physical, verbal, and emotional abuse. They all expressed the importance of reporting alleged abuse immediately when they first saw or heard it. All knew location of abuse reporting flow sheet to use for guide for reportable events. All knew where the corporate compliance and state hotline number was posted and knew when to contact if needed. During interviews on 09/25/2025 from 3:55 p.m.- 4:20 p.m. with 8 (including Resident #2 and Resident #7) alert and oriented residents indicated they recently had communication with management regarding their satisfaction with living at the facility and they had no concerns about their safety, about the staff who provided their daily care, or the management at the facility. During observation on 09/25/2025 from 12:00 p.m. through 5:30 p.m. observed abuse reporting flowchart posted in nurse stations, break rooms, and med rooms. During an interview on 09/25/2025 at 5:00 p.m., the DON said she was given one-on-one in-service with the corporate nurse, VP of operations, and VP of Clinical Reimbursement regarding reporting alleged abuse allegations to the abuse coordinator immediately (if abuse coordinator was not available or was unreachable, then staff would report to her), the timeliness of reporting alleged abuse to HHSC (within 2 hours of the alleged abuse), keeping residents safe, prevention of abuse, and she was to begin investigating alleged allegations immediately if delegated by the abuse coordinator to do so. She said if abuse was reported to her in the absence of the abuse coordinator that she would report the alleged allegation to HHSC within 2 hours of the alleged incident. She said the alleged perpetrator would be suspended immediately and would not be able to return to work until approval was granted. During an Interview on 09/25/2025 at 5:10 p.m., the Administrator said he was in-serviced one-on-one with the corporate nurse, VP of operations, and VP of Clinical Reimbursement regarding the timeliness of reporting alleged abuse to HHSC (within 2 hours of the alleged abuse), keeping residents safe, prevention of abuse, and that he was to begin investigating alleged allegations immediately and if he was not available, she was to delegate investigation responsibilities to the DON and/or management staff. She said the alleged perpetrator would be suspended immediately and would not be able to return to work until approval was granted. The Administrator said 95% of the active employees had been in-serviced and the remaining employees would be in-serviced before the start of their next shift. The Administrator said all new hires would receive training on abuse, neglect, and timely reporting prior to providing any resident care. The Administrator was informed that the Immediate Jeopardy was removed on 09/25/2025 at 5:33 p.m. The facility remained out of compliance at a severity level of potential for more than minimal 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 that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents had the right to be free from abuse and neglect for 10 of 25 residents (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #9, Resident #11, Resident #14, and Resident #216) reviewed for abuse. 1. The facility failed to ensure Resident #6 was free from sexual abuse when Resident #25 came into Resident #6's room and rubbed her right leg under the covers on 08/21/2025.2. The facility failed to ensure Resident #5 was free from physical and verbal abuse by CNA F when CNA F called Resident #5 retarded, pushed and held him down on the bed during incontinent care, pulled him off the low bed, landing on the floor and held him down by his shoulder trying to put his shirt on and pinned him against the wall and stomped on his feet on 7/01/2025. 3. The facility failed to ensure Resident #5 was free from physical and verbal abuse by CNA M when CNA M told Resident #5 to sit your ass down multiple times and then forcefully push Resident #5 into a chair sometime in June 2025. 4. The facility failed to ensure Resident #5 was free from physical abuse when Resident #12 had a physical altercation with Resident #5 when Resident #5 wandered into his room causing Resident #5 to receive a scratch on his chest and a scratch on his back on 07/03/25.5. The facility failed to ensure Resident #5 was free from physical abuse when Resident #13 hit Resident #5 on his chest on 05/26/2025 with no injury.6. The facility failed to ensure Resident #2 & #3 was free from physical abuse when Resident #1 spit on and scratched Resident #2 and scratched Resident #3 on 3/19/2025. 7. The facility failed to ensure Resident #2 was free from physical abuse when Resident #1 pinched Resident #2 on 9/04/2025.8. The facility failed to ensure Resident #3 was free from physical abuse when Resident #1 grabbed her hand and would not let go resulting in Resident #3 hitting Resident #1 on 7/24/2025.9. The facility failed to ensure Resident #1 & #3 was free from physical abuse when Resident #1 and Resident #3 were hitting each other on 8/13/2025.10. The facility failed to ensure Resident #9 was free from physical abuse when Resident #1 ran over Resident #9's foot with her wheelchair and he responded by punching Resident #1 in the face on 7/11/2025.11. The facility failed to ensure Resident #4 was free from physical abuse when Resident #1 hit Resident #4 on her arm on 9/5/2025. 12. The facility failed to ensure Resident #2 was free from physical abuse when Resident #3 scratched Resident #2 who was trying to prevent her from getting coffee on 5/18/2025. 13. The facility failed to ensure Resident #2 was free from physical abuse when Resident #4 hit Resident #2 when Resident #2 took Resident #4's bingo tokens on 6/11/2025. 14. The facility failed to ensure Resident #2 was free from physical abuse when Resident #15 hit Resident #2 in the face and knocked off her glasses on 7/4/2025.15. The facility failed to ensure Resident #14 was free from physical abuse when Resident #4 hit Resident #14 in the chest and pushed her walker on 6/19/2025. 16. The facility failed to ensure Resident #11 was free from physical abuse when Resident #10 hit Resident #11 on the back of the head on 06/19/2025. 17. The facility failed to ensure Resident #216 was free from physical abuse when Resident #215 slapped Resident #216 on 5/12/2025. An Immediate Jeopardy (IJ) was identified on 09/24/2025 at 9:45 a.m. The IJ template was provided to the facility on [DATE] at 11:05 a.m. While the IJ was removed on 09/25/2025, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. These failures could place residents at risk of emotional distress, fear, decreased quality of life and further abuse. Findings included: Resident #6 Record review of Resident #6's face sheet, dated 09/24/2025, indicated a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted [DATE]. Resident #6 had diagnoses which included cerebral infarction (occurs when blood flow to part of the brain is blacked leading to tissue death), schizophrenia (a chronic mental disorder characterized by symptoms such as hallucinations, delusions, and cognitive challenges) conversion disorder with seizures or convulsions (mental health condition in which individuals experience neurological symptoms without any detectable neurological or medical cause),acquired absence of left leg below the knee (loss of leg below the knee) and hemiplegia (total paralysis or severe loss of muscle function on one side of the body) following cerebral infarction. Record review of Resident #6's quarterly MDS Assessment, dated 06/10/2025, indicated she had a BIMS score of 14 and diagnoses of hemiplegia, cerebral infarct, schizophrenia and seizure disorder. The assessment indicated Resident #6 was dependent for transfer and needed supervision for locomotion in manual wheelchair for 50 feet. Record review of Progress Notes dated 08/22/2025 indicated Resident #6 received 72-hour trauma monitoring by the SW related being touched inappropriately and without consent by Resident #25, no emotional distress indicated. Record review of Progress Notes dated 08/25/2025 indicated Resident #6 received 72-hour trauma monitoring by the SW related being touched inappropriately and without consent by Resident #25, no emotional distress indicated. Record review of Progress Notes dated 08/26/2025 indicated Resident #6 received 72-hour trauma monitoring by the SW related to being touched inappropriately and without consent by Resident #25, no emotional distress indicated. Record review of Resident #6's quarterly MDS Assessment, dated 09/10/2025, indicated she had a BIMS score of 12 and diagnoses of hemiplegia, cerebral infarct, schizophrenia and seizure disorder. The assessment indicated Resident #6 was dependent for assistance of 1 to 2 persons for transfer and dependent for locomotion in manual wheelchair for 50 feet. Record review of Resident #6's care plan with a target date of 11/18/2025 indicated Resident #6 had a diagnosis of schizophrenia and is at risk of increased behaviors. Interventions included intervene and monitor resident for increased agitation, anger, verbal and physical aggression, and document episodes of behavior. Record review of Resident #6 police report dated 08/21/202025 indicated a crime incident of assault, the victim was Resident #6, and she notified the officer that Resident #25 entered her room put his hand under her leg and rubbed his hand on her leg. She said Resident #25 stated, “I'm sorry it just feels so good to feel skin so soft.” Resident #6 indicated she felt it was a sexual nature, and she wished to file a report. The report indicated a non-consent form was signed. Resident #25 Record review of Resident #25's face sheet, dated 09/24/2025, indicated a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted [DATE]. Resident #6 had diagnoses which included hemiplegia following cerebral infarction, morbid obesity (having too much body fat which increases the risk of health problems), cerebral infarction, post- traumatic stress disorder (disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event) and convulsions. Record review of Resident #25's quarterly MDS Assessment, dated 09/19/2025, indicated he was cognitively independent and had no long-term or short-term memory problem. The assessment indicated Resident #25 required dependence of 1 or 2 persons to transfer from bed to chair and independent of locomotion in a motorized scooter. Record review of Resident #25's Change in Condition Evaluation on 08/21/2025 indicated he had behavior symptoms of sexual behaviors with Resident #25 redirected to his room and sent to a behavioral hospital for monitoring. Record review of Resident #25's care plan with a revision date of 08/22/2025 indicated Resident #25 had inappropriate sexual behaviors and was at risk of further episodes and injury. The Care plan indicated Resident #25 had a history of allowing an intellectually challenged resident perform oral sex on him in the dining room and on 08/21/25 was witnessed rubbing on the leg of another resident that was unwanted. Interventions included to redirect during episodes of inappropriate sexual behavior and document in the clinical record, firmly approach the resident that behaviors are not acceptable. The care plan indicated on 08/21/25 Resident #25 was sent out for a psychiatric evaluation, was on 1 on 1 monitoring and psychiatric referral made in house by the nurse practitioner and discharge planning. During an observation and interview on 09/22/2025 at 10:00 a.m., Resident #25 named in the allegation was lying in bed, he denied sexual abuse of Resident #6. He said he brought his friend Resident #6 a cup of coffee and she was on the verge of tears. Resident #25 said Resident #6 told him no one liked her, and he said everyone here likes you and rubbed her lower leg on top of the covers. Resident #25 said he did not sexually touch anyone inappropriately. He said he was comforting his friend. Resident #25 said a nurse came into the room, did not ask any questions and made a mountain out of a mole hill. Resident #25 said he was sent to the hospital to be evaluated and had not been to Resident #6's room since the incident. During an observation and interview on 09/22/2025 at 10:20 a.m., Resident #6 named in the allegation, was up in her scooter with a left below the knee amputee, she said she was treated well, received needed care, call lights answered timely, and she denied abuse/ neglect. Resident #6 said she felt safe in the facility and was comfortable reporting concerns to the nurse. She said Resident #25 was not allowed in her room. Resident #6 said the day of the incident (08/21/2025) Resident #25 brought her coffee and that it was fine, but she said he started rubbing her right lower leg under the covers. She said she told him, ”I don't like that, she said she did not say stop.” Resident #6 said a nurse came into the room and Resident #25 stopped and left the room. She said I was very upset when it happened but now felt safe in the facility. During an interview on 09/23/2025 at 4:30 a.m., Resident #6 said Resident #25 said her skin was so soft he could not help himself when he rubbed her leg the day of the incident (08/21/2025). During a phone interview on 9/23/2025 at 4:00 p.m., Hospice RN said on 08/21/2025 she was in Resident #6's room visiting her roommate and heard Resident #25 say “I want to feel your soft skin”, she said Resident #25 had his hand under Resident #6's covers. Hospice RN said Resident #25 saw her, stopped touching Resident #6 and left the room. She immediately reported the incident to LVN X and then wrote her statement. She said she did not say anything to Resident #25. The Hospice RN said she heard LVN X ask Resident #6 if she asked Resident #25 to do that and she said no and cried. During an interview on 09/23/2025 at 12:00 p.m., LVN X said she did not witness the incident on 08/21/2025 with Resident #6 and Resident #25. She said the Hospice RN notified her she witnessed Resident #25 rubbing Resident #6's leg under the covers of her bed. LVN X said Resident #25 said Resident #6 asked me to come into her room. LVN X said Resident #25 said Resident #6 said no one loved her and he touched her leg. LVN X said Resident #25 normally gets up early, goes outside for the morning then back to bed but not normally into other resident rooms. She said there was no reason for him to visit down Resident #6's hall. LVN X said Resident #6 said she did not give Resident #25 consent to touch her. She immediately notified the DON, ADON and Administrator. LVN X placed Resident #25 on 1 on 1 monitoring after the incident. She said that meant constant monitoring, eyes and ears on Resident #25, a CNA sat outside his room and stared at him in his room alone. She completed an assessment on both residents with no injury noted. LVN X said Resident #25 was sent out to the hospital later that night. She said Resident #25 required 2 CNAs to get Resident #25 out of bed and transferred to his scooter. LVN X said Resident #25 was not allowed to go to Resident #6's room. She was in-serviced prior to the incident on abuse/ neglect and sexual abuse prevention. She said after the incident she was in-serviced on abuse/ neglect and sexual abuse prevention. Resident #12 Record review of Resident #12's face sheet, dated 09/24/2025, indicated a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted [DATE]. Resident #12 had diagnoses which included dementia, seizures, bipolar disorder (chronic mental health condition characterized by extreme mood swings between periods of mania {elevated mood} and depression) and abnormalities of gait and mobility (deviations from the normal pattern of walking and movement). Record review of Resident #12's admission MDS Assessment, dated 06/05/2025, indicated he had long and short-term memory loss and was severely impaired of cognition, rarely/ never understood and rarely/never understood understands. The assessment indicated Resident #12 had inattention and disorganized thinking behaviors continuously present. Record review of Resident #12's quarterly MDS Assessment, dated 09/01/2025, indicated he had long and short-term memory loss and was severely impaired of cognition, rarely/ never understood and sometimes understands. He had wandering behaviors that occurred 1 to 3 days within the 7 days look back period. Resident #5 had physical behaviors, verbal behaviors and other behavioral symptoms 1 to 3 days within the 7 days look back period. Record review of Resident #12's care plan dated 07/08/2025 indicated Resident #12 scratched another resident when the other resident wandered into his room. Interventions included intervene as necessary to protect the rights and safety of others, approach/ Speak in a calm manner, divert attention and remove from situation and take to alternate location as needed. Record review of an incident report for physical aggression, dated 07/04/2025, indicated an incident was reported that included Resident #5 and Resident #12 with the allegation of abuse. Record review of the facility's PIR, dated 07/11/2025, incident category as other and other specified as a resident-to-resident incident signed by the Administrator on 07/11/2025. The PIR indicated the incident occurred on 07/03/2025 at 7:05 a.m., on the secure unit. The PIR indicated Resident #5 went into Resident #12's room and rummaged, Resident #12 became physically aggressive in an attempt to remove Resident #5 from his room and Resident #5 received scratches to back and chest. Residents were separated immediately, LVN S performed a head-to-toe assessment on both residents, Resident #12 received no injury. Resident #5 was placed on 1:1 supervision and scratches treated. The physician was contacted and gave orders for Resident #5 to have an emergency room psych evaluation with medication changes. Reeducated staff on abuse and neglect, with no concerns, Social Worker conducted resident safe survey interviews with no concerns and IDT team met and discussed incident and updated care plans. Investigation findings: Confirmed that residents did have a person-to-person interaction with no major injury, Resident #5 received a scratch to his back and chest. Record review of Resident #12's physician orders dated 09/24/2025 indicated he was prescribed sertraline (antidepressant medication) 100 mg daily for major depressive disorder (a mental health condition characterized by persistent feelings of deadness, hopelessness and loss of interest or pleasure in activities) with a start date of 07/09/2025 and Aripiprazole (antipsychotic medication) 15 mg daily for bipolar disorder. During an observation and interview on 09/24/2025 at 1:44 p.m., Resident #12 was sitting in recliner, he denied abuse/ neglect and said he felt safe in the facility. Resident #12 denied anyone came into his room and messed with his stuff and denied allegations of scratching or hitting Resident #5. During an Interview on 09/24/2025 at 1:55 p.m. LVN S said Resident #5 was found on the floor in Resident #12's doorway with Resident #12 yelling to get out and trying to shut his door. She said she separated residents and assessed both residents. LVN S said Resident #5 had a scratch on his back and chest and was placed on 1 on 1 monitoring. She said Resident #12 had no injuries. She said she Notified psychiatric services the ADON, DON, Administrators, responsible parties and physicians. Resident #13 Record review of Resident #13's face sheet, dated 09/24/2025, indicated a [AGE] year-old female who was admitted to the facility on [DATE] and discharged to the hospital on [DATE]. Resident #13 had diagnoses which included cerebral infarction (a condition where blood flow to the brain was interrupted leading to brain cell damage), abnormalities of gait and mobility, compression of brain (increased pressure within the skull that compresses the brain tissue), muscle weakness, lack of coordination and cognitive communication deficit. Record review of Resident #13's admission MDS Assessment, dated 03/19/2025, indicated she had a BIMS score of 9 and was moderately impaired of cognition. The assessment indicated Resident #13 had inattention and disorganized thinking behaviors present that fluctuated (comes and goes and changes in severity). Resident #13's assessment indicated delusions (misconceptions or beliefs that are firmly held, contrary to reality) and verbal behavioral symptoms directed toward others and other behavioral symptoms not directed toward others occurred 1 to 3 days of the 7day look back period. Record review of Resident #13's care plan dated 05/27/2025 indicated Resident #13 was at risk of manic episodes and increased behaviors with interventions of monitor for increased agitation and removed from increased stimuli. Record review of an incident report for physical aggression, dated 05/26/2025, indicated an incident was reported that included Resident #5 and Resident #13 with the allegation of abuse. Resident #13 was sent to the emergency room for a psychological evaluation and neither resident had injuries. Record review of the facility's Provider Investigation Report, dated 06/02/2025, incident category as other and other specified as a resident-to-resident incident signed by the Administrator on 06/02/2025. The PIR indicated the incident occurred on 05/26/2025 at 4:30 p.m. on the secure unit. The PIR indicated Resident #13 hit Resident #5 with a mop handle. LVN S witnessed the incident and separated the two residents and placed Resident #13 on 1 on 1 until she was transferred to the emergency room and did not return to the facility. Investigation Findings: Confirmed that residents did have a person-to-person interaction with no injury, all metal objects and possible safety hazards removed from the unit. Staff in-serviced on abuse/ neglect and safe surveys indicated no patterns of abuse/ neglect on the secured unit. Record review of Resident #13's physician orders dated 09/24/2025 indicated she was prescribed divalproex 125 mg daily for mood disorder (a mental and behavioral disorder) with a start date of 05/09/2025. During an observation and interview on 09/24/2025 at 1:40 p.m., Resident #5 was sitting in a chair, he denied anyone hit him or hurt him and he denied hitting anyone. Resident #5 was confused and unable to answer more than a few questions. During an interview on 09/24/2025 at 1:55 p.m., LVN S said she witnessed the Resident #13 and Resident #5 incident on 05/26/2025. LVN S said Resident #13 barely bumped Resident #5 in the chest with a broom. She said there was no redness or injury on either resident nor were they upset. She separated the residents, put Resident #13 on 1 on 1 monitoring and sent her to the emergency room. LVN S said she notified the responsible parties for both residents, physicians, DON and Administrator. Resident #5 Record review of Resident #5's face sheet, dated 09/23/2025, indicated a [AGE] year-old male who was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident #5 had diagnoses which included diffuse traumatic brain injury (widespread damage across multiple areas of the brain), hypertension (a condition in which the force of the blood against the artery walls is too high), encephalopathy (group of conditions that cause brain dysfunction, which can manifest as confusion, memory loss, personality changes), dementia (loss of cognitive functioning), lack of coordination, cognitive communication deficit, and major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Record review of Resident #5's quarterly MDS Assessment, dated 5/04/2025, indicated he rarely/never made himself understood and sometimes understood others. He was not assessed for the brief interview for mental status because he is rarely/never understood. He had no behaviors identified within the 7-day look back period. Record review of Resident #5's quarterly MDS Assessment, dated 08/04/2025, indicated he had long and short-term memory loss and was severely impaired of cognition, rarely/ never understood and sometimes understands. He had wandering behaviors that occurred 1 to 3 days within the 7 days look back period. Resident #5 had physical behaviors, verbal behaviors and other behavioral symptoms 1 to 3 days within the 7 days look back period. Record review of Resident #5's care plan revision dated 7/03/2025 indicated Resident #5 had an incident of confabulation and had a potential for further episodes of confabulation and confabulation triggered behaviors. Interventions included allow residents to verbalize feelings during episodes of confabulation - gently reorient and maintain safety, orient/re-orient resident daily and PRN, encourage to attend activities of choice, and report to MD/RP as needed and document episodes of confabulation in the clinical record. Record review of Resident #5's care plan dated 08/22/2025 indicated Resident #5 had inappropriate behaviors. Interventions included monitor and chart behaviors every shift and report progress to the physician, observe for early warning signs of behavior, approach in a calm manner, call Resident #5 by name and remove from unwanted stimuli. Record review of the facility's Provider Investigation Report (PIR) dated 7/01/2025, incident category as abuse signed by the Administrator on 7/11/2025. PIR indicated the incident occurred 7/01/2025 at 7:00 p.m. on the secure unit. PIR indicated CNA D witnessed CNA F be verbally and physical aggressive with Resident #5. On 7/01/2025, CNA D witnessed CNA F hit Resident #5's head against the wall and pinch him. CNA F was heard calling Resident #5 retarded” and making statements “if these cameras were not here, I would do what I really wanted to do.” LVN X provided head to toe assessment to Resident #5 with no injuries noted. Provider response after the incident included, employee suspended immediately, head to toe assessments on all residents in the secure unit, safe surveys conducted, employee statements collected, abuse and neglect in-services initiated, care plan updated, psych NP notified, MD notified, no family to notify, and local police contacted. Resident abuse confirmed. Employee terminated. During an observation on 9/23/2025 at 11:00 a.m., Resident #5 was well groomed, and appropriately dressed. Resident #5 was ambulating independently in the secure unit hallways and in the outdoor secure area. Resident #5 with no signs of abuse or fear of staff identified. During an interview on 9/23/2025 at 12:53 p.m., CNA D said on 7/01/2025 CNA F had asked her to assist with incontinent care on Resident #5, she said during assisting with care she witnessed CNA F push and held Resident #5 down on the bed during incontinent care. CNA D said CNA F held Resident #5's arm down with her knee when Resident #5 slapped her on the arm. CNA D said CNA F told Resident #5 she would sit on him if he hit her again and then she pinched him. CNA D said CNA F roughly pull Resident #5 off the low bed, landing on the floor and holding him down by his shoulder trying to put his shirt on. CNA D said CNA F pin Resident #5 against the wall and stomped on his feet in the attempt to get him dressed. CNA D said she was a new employee at the time of the incident and was shocked at what she witnessed, she said she reported the incident to the administrator. CNA D said she should have stopped the abuse at the time of the incident but was so shocked by the event she was reluctant to say anything to the seasoned staff member. An attempted telephone interview on 09/23/2025 at 1:15 p.m. with CNA F, the alleged perpetrator was unsuccessful. Record review of CNA F employee statement dated 07/01/2025 indicated “changing patient on bed, laid him down to change him, he was kicking, told him to stop put diaper on him had to use a little force because he was scratch and kicking me.” Record review of CNA F employee termination form dated 07/07/2025 indicated CNA F was terminated for violation of company policy and a substantiated abuse allegation. During an interview on 9/23/2025 at 1:30 p.m., LVN X said she recalled she assessed Resident #5 after the incident and did not identify any injuries but does not recall how she became aware of the incident. She said if she was notified of an abuse allegation, she would make sure the resident was safe and then immediately report to the Administrator/Abuse Coordinator. She said if she witnessed a resident being abused that she would intervene and remove the abuser and keep the resident safe, notify the AC and/or send the staff member home and if resident to resident keep separated for safety. Record review of the facility's PIR dated 7/01/2025, incident category as abuse signed by the Administrator on 7/11/2025. PIR indicated the incident occurred 7/01/2025 at 7:00 p.m. on the secure unit. PIR indicated during staff interviews ST R said she witnessed CNA M be verbally and physical aggressive with Resident #5 approximately 1.5 weeks ago. CNA M was heard telling Resident #5 to “sit you ass down” and witnessed forcefully pushing him into the chair and pushing his chair forcefully under the table. LVN X provided head to toe assessment to Resident #5 with no injuries noted. Provider response after the incident included, employee suspended immediately, head to toe assessments on all residents in the secure unit, safe surveys conducted, employee statements collected, abuse and neglect in-services initiated, care plan updated, psych NP notified, MD notified, no family to notify, and local police contacted. Resident abuse confirmed. Employee terminated. During an interview on 09/24/2025 at 2:00 p.m., ST R said she had witnessed CNA M physically and verbally abuse Resident #5 sometime in late June 2025 when she heard CNA M tell Resident #5 to sit you ass down multiple times and then forcefully push Resident #5 into a chair and push him up to the table. ST R said she reported this incident late, when she was being interviewed regarding another incident with Resident #5. She said at the time it happened she felt uneasy about the incident and would not want her family treated that way. She said she reported the incident to clear her consciousness and knew it should have been reported when she first witnessed the incident. She said she was suspended and received disciplinary actions regarding not reporting the abuse allegation immediately and re-educated prior to returning to work. She said moving forward that any abuse allegations witnessed or reported to her she would report it immediately to the administrator. An attempted telephone interview on 09/23/2025 at 1:17 p.m. with CNA M, the alleged perpetrator was unsuccessful. Record review of CNA M employee statement dated 07/03/2025 indicated “Resident #5 was ambulated to chair, sat him down and scooted his chair up to the table, so he would be able to eat his lunch tray. If this happened a week ago why it just now being reported on 07/03/2025, the abuse coordinator number is all over the building.” Record review of CNA M employee termination form dated 07/07/2025 indicated CNA M was terminated for violation of company policy and a substantiated abuse allegation. During an interview on 9/23/2025 at 1:30 p.m., LVN X said she recalled assessing Resident #5 after the incident and did not identify any injuries but does not recall how she became aware of the incident. She said if she was notified of an abuse allegation, she would make sure the resident was safe and then immediately report to the Administrator/Abuse Coordinator. She said if she witnessed a resident being abused that she would intervene and remove the abuser and keep the resident safe, notify the AC and/or send the staff member home and if resident to resident keep separated for safety. Resident #1 Record review of Resident #1's face sheet, dated 09/23/2025, indicated a [AGE] year-old female who was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1 had diagnoses which included cerebral palsy (congenital disorder of movement, muscle tone, or posture due to abnormal brain development), aphasia (disorder that affects language after a stroke), dysphagia (difficulty swallowing after a stroke), and major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Record review of Resident #1's quarterly MDS Assessment, dated 8/08/2025, indicated she was sometimes able to make herself understood and usually understood others. She had severe cognitive impairment, identified with a BIMS score of 3. She had an active diagnosis of psychotic disorder and depression in the last 7 days. She had no behaviors identified within the 7 days look back period. Record review of Resident #1's care plan revision dated 11/11/2024 indicated Resident #1 had physical aggression. Interventions included to Intervene before agitation escalates; guide away from source of distress; Engage calmly in conversation; if response is aggressive, staff to walk calmly away, and approach later, administer medications as order and document side effects and effectiveness, assess and address for contributing sensory deficits and monitor/document/report as needed any s/s of resident posing danger to self and others, and consult psychiatric/psychogeriatric as indicated. Record review of Resident #1's care plan dated 7/12/2025 indicated Resident #1 had impulse control. Interventions included assessing coping skills and support system, analyzing key times, places, circumstances, triggers, and what de-escalates, and assessing and anticipating resident's needs: food, thirst. toileting needs, comfort level, body positioning, pain etc. Record review of Resident #1's care plan revision dated 8/13/2025 indicated Resident #1 had physical aggression. Interventions included to place on 1:1 monitoring for 2 hours and separate from another resident, intervene before agitation escalates; guide away from source of distress; Engage calmly in conversation; if response is aggressive, staff to walk calmly away, and approach later, administer medications as order and document side effects and effectiveness, assess and address for contributing sensory deficits and monitor/document/report as needed any s/s of resident posing danger to self and others, and consult psychiatric/psychog

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 7 of 25 residents (Resident's #1,2,3,4,5, 6, 25) reviewed for care plans. 1. The facility failed to develop and implement interventions in Resident #25's the care plan revised 08/22/2025 to prevent Resident #25's inappropriate and unwanted touching of Resident #6 on 08/21/25. 2. The facility failed to ensure Resident #1's care plan was updated to indicate Resident #1 had an incident of resident-to-resident aggression on 03/19/2025, 07/24/2025 and 09/05/2025. 3. The facility failed to ensure Resident #2's care plan was updated to indicate Resident #2 had received aggression during a resident-to-resident incident on 03/19/2025. 4. The facility failed to ensure Resident #3's care plan was updated to indicate Resident #3 had received aggression during a resident-to-resident incident on 03/19/2025 and 07/24/2025. 5. The facility failed to ensure Resident #4's care plan was updated to indicate Resident #4 had received aggression during a resident-to-resident incident on 09/05/2025. An Immediate Jeopardy (IJ) was identified on 09/24/2025 at 9:45 a.m. The IJ template was provided to the facility on [DATE] at 11:05 a.m. While the IJ was removed on 09/25/2025 at 5:33 p.m., the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that was not immediate jeopardy due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure could place residents at risk of accidents, injuries, and death due to lack of appropriate interventions in place.Findings included: 1. Record review of Resident #6's face sheet, dated 09/24/2025, indicated a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted [DATE]. Resident #6 had diagnoses which included cerebral infarction (occurs when blood flow to part of the brain is blacked leading to tissue death), schizophrenia (a chronic mental disorder characterized by symptoms such as hallucinations, delusions, and cognitive challenges) conversion disorder with seizures or convulsions (mental health condition in which individuals experience neurological symptoms without any detectable neurological or medical cause),acquired absence of left leg below the knee (loss of leg below the knee) and hemiplegia (total paralysis or severe loss of muscle function on one side of the body) following cerebral infarction . Record review of Resident #6's quarterly MDS Assessment, dated 06/10/2025, indicated she had a BIMS score of 14 and diagnoses of hemiplegia, cerebral infarct, schizophrenia and seizure disorder. The assessment indicated Resident #6 was dependent for transfer and needed supervision for locomotion in manual wheelchair for 50 feet. Record review of Resident #6's quarterly MDS Assessment, dated 09/10/2025, indicated she had a BIMS score of 12 and diagnoses of hemiplegia, cerebral infarct, schizophrenia and seizure disorder. The assessment indicated Resident #6 was dependent for assistance of 1 to 2 people for transfer and dependent locomotion in manual wheelchair for 50 feet. Record review of Resident #6's care plan with a target date of 11/18/2025 indicated Resident #6 had a diagnosis of schizophrenia and was at risk of increased behaviors. Interventions included intervene and monitor resident for increased agitation, anger, verbal and physical aggression, and document episodes of behavior. Record review of Resident #6 police report dated 08/21/25 indicated a crime incident of assault, the victim was Resident #6, and she notified the officer that Resident #25 entered her room put his hand under her leg and rubbed his hand on her leg. She said Resident #25 stated, “I'm sorry it just feels so good to feel skin so soft.” Resident #6 indicated she felt it was a sexual nature, and she wished to file a report. The report indicated a non-consent form was signed. Record review of Resident #25's face sheet, dated 09/24/2025, indicated a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted [DATE]. Resident #6 had diagnoses which included hemiplegia following cerebral infarction, morbid obesity (having too much body fat which increases the risk of health problems), cerebral infarction, post- traumatic stress disorder (disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event) and convulsions. Record review of Resident #25's quarterly MDS Assessment, dated 02/13/2025, indicated he had a BIMS score of 15 indicating cognitively intact. The assessment indicated Resident #25 required dependence (helper does all the effort) of 1 or 2 persons to transfer from bed to chair and independent of locomotion in a motorized scooter. Record review of Resident #25's quarterly MDS Assessment, dated 09/19/2025, indicated he was cognitively independent and had no long-term or short-term memory problem. The assessment indicated Resident #25 required dependence of 1 or 2 persons to transfer from bed to chair and independent of locomotion in a motorized scooter. Record review of Resident #25's care plan with a revision date of 08/22/2025 indicated Resident #25 had inappropriate sexual behaviors and was at risk of further episodes and injury. The Care plan indicated Resident #25 had a history of allowing an intellectually challenged resident perform oral sex on him in the dining room and on 08/21/25 was witnessed rubbing on the leg of another resident that was unwanted. Interventions included to redirect during episodes of inappropriate sexual behavior and document in the clinical record, firmly approach the resident that behaviors are not acceptable. The care plan indicated on 08/21/25 Resident #25 was sent out for a psychiatric evaluation, was on 1 on 1 monitoring and psychiatric referral made in house by the nurse practitioner and discharge planning. Resident #25's care plan did not include interventions to prevent further sexual abuse episodes on other residents by Resident #25. Record review of a Resident-to-Resident incident report, dated 08/21/2025 indicated an incident was reported that included Resident #25 and Resident #6 with the allegation of abuse and the police were notified. Record review of the facility's Provider Investigation Report, dated 08/28/2025, incident category as other and other specified as a resident-to-resident incident signed by the Administrator on 08/28/2025. The PIR indicated the incident occurred on 08/21/2025 at 10:00 a.m. PIR indicated Resident #6 stated Resident #25 rubbed on her leg and she did not want the touching on her leg. The incident was witnessed by Hospice RN, Residents were separated immediately, and Resident #25 was placed on 1:1 supervision. The physician was contacted and gave orders for Resident #25 to be transferred to the emergency room. Psychiatric service was contacted and performed an evaluation on Resident #25. Reeducated staff on abuse and neglect and increased rounding. The SW conducted psychosocial evaluations with no concerns, social worker conducted safe surveys with no concerns and the IDT team met and discussed the incident and updated care plans. Investigation findings were confirmed. Record review of an email from the Administrator on 08/22/25 to the MDS Contractor indicated,” Please update the following Care Plans: Resident #6 made sexual abuse allegations on 08/21/25, against Resident #25. Resident #25 was witnessed rubbing on the leg of patient and was unwanted. Resident #25 was sent out for psych eval and on 1on 1 monitoring. Psych Referral made in-house to NP. …” During an observation and interview on 09/22/25 at 10:00 a.m., Resident #25 named in the allegation was lying in bed, he denied sexual abuse of Resident #6. He said he brought his friend Resident #6 a cup of coffee and she was on the verge of tears. Resident #25 said Resident #6 told him no one liked her and he said everyone here likes you and rubbed her lower leg on top of the covers. Resident #25 said he did not sexually touch anyone inappropriately. He said he was comforting his friend. Resident #25 said a nurse came into the room, did not ask any questions and made a mountain out of a mole hill. Resident #25 said he was sent to the hospital to be evaluated and had not been to Resident #6's room since the incident. During an observation and interview on 09/22/25 at 10:20 a.m., Resident #6 named in the allegation, was up in her scooter with a left, below knee amputee, she said she was treated well, received needed care, call lights answered timely, and she denied abuse/ neglect. Resident #6 said she felt safe in the facility and was comfortable reporting concerns to the nurse. She said Resident #25 was not allowed in her room. Resident #6 said the day of the incident (08/21/25) Resident #25 brought her coffee and that it was fine, but she said he started rubbing her right lower leg under the covers. She said she told him, ”I don't like that, she said she did not say stop.” Resident #6 said a nurse came into the room and Resident #25 stopped and left the room. She said I was very upset when it happened but now felt safe in the facility. During an interview on 09/23/25 at 4:30 a.m., Resident #6 said Resident #25 said her skin was so soft he could not help himself when he rubbed her leg the day of the incident (08/21/25). During an interview on 09/23/25 at 12:00 p.m., LVN X said she did not witness the incident on 08/21/25 with Resident #6 and Resident #25. She said the Hospice RN notified her she witnessed Resident #25 rubbing Resident #6's leg under the covers of her bed. LVN X said Resident #25 said Resident #6 asked me to come into her room. LVN X said Resident #25 said Resident #6 said no one loved her and he touched her leg. LVN X said Resident #25 normally gets up early, goes outside for the morning then back to bed but not normally into other resident rooms. She said there was no reason for him to visit down Resident #6's hall. LVN X said Resident #6 said she did not give Resident #25 consent to touch her. She immediately notified the DON, ADON and Administrator. LVN X placed Resident #25 on 1 on 1 monitoring after the incident. She said that meant constant monitoring, eyes and ears on Resident #25, a CNA sat outside his room and stared at him in his room alone. She completed an assessment on both residents with no injury noted. LVN X said Resident #25 was sent out to the hospital later that night. She said Resident #25 required 2 CNAs to get Resident #25 out of bed and transferred to his scooter. LVN X said Resident #25 was not allowed to go to Resident #6's room. She was in-serviced prior to the incident on abuse/ neglect and sexual abuse prevention. She said after the incident she was in-serviced on abuse/ neglect and sexual abuse prevention. During a phone interview on 9/23/25 at 4:00 p.m., the Hospice RN said on 08/21/25 she was in Resident #6's room visiting her roommate and heard Resident #25 say “I want to feel your soft skin”, she said Resident #25 had his hand under Resident #6's covers. The Hospice RN said Resident #25 saw her, stopped touching Resident #6 and left the room. She immediately reported the incident to LVN X and then wrote her statement. She said she did not say anything to Resident #25. The Hospice RN said she heard LVN X ask Resident #6 if she asked Resident #25 to do that and she said no and cried. 2. Record review of Resident #1's face sheet, dated 09/23/2025, indicated a [AGE] year-old female who was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1 had diagnoses which included cerebral palsy (congenital disorder of movement, muscle tone, or posture due to abnormal brain development), aphasia (disorder that affects language after a stroke), dysphagia (difficulty swallowing after a stroke), diabetes (a chronic condition that affects the way the body processes blood sugar), developmental disorder, and major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Record review of Resident #1's quarterly MDS Assessment, dated 2/09/2025, indicated she was sometimes able to make herself understood and usually understood others. She was not assessed for the brief interview for mental status because she is rarely/never understood. She had an active diagnosis of psychotic disorder and depression in the last 7 days. She had no behaviors identified within the 7 days look back period. Record review of Resident #1's quarterly MDS Assessment, dated 5/08/2025, indicated she was sometimes able to make herself understood and usually understood others. She was unable to complete the brief interview for mental status. She had an active diagnosis of psychotic disorder and depression in the last 7 days. She had no behaviors identified within the 7 days look back period. Record review of Resident #1's quarterly MDS Assessment, dated 8/08/2025, indicated she was sometimes able to make herself understood and usually understood others. She had severe cognitive impairment, identified with a BIMS score of 3. She had an active diagnosis of psychotic disorder and depression in the last 7 days. She had no behaviors identified within the 7 days look back period. Record review of Resident #1's care plan revision dated 11/11/2024 indicated Resident #1 had physical aggression. Interventions included to Intervene before agitation escalates; guide away from source of distress; Engage calmly in conversation; if response is aggressive, staff to walk calmly away, and approach later, administer medications as order and document side effects and effectiveness, assess and address for contributing sensory deficits and monitor/document/report as needed any s/s of resident posing danger to self and others, and consult psychiatric/psychogeriatric as indicated. The care plan did not indicate Resident #1 had an updated or revised care plan for aggressive behaviors during a resident-to-resident aggression with two other residents (Resident #2 and #3) on 03/19/2025. Record review of Resident #1's care plan revision dated 8/13/2025 indicated Resident #1 had physical aggression. Interventions included to place on 1:1 monitoring for 2 hours and separate from another resident, intervene before agitation escalates; guide away from source of distress; Engage calmly in conversation; if response was aggressive, staff to walk calmly away, and approach later, administer medications as order and document side effects and effectiveness, assess and address for contributing sensory deficits and monitor/document/report as needed any s/s of resident posing danger to self and others, and consult psychiatric/psychogeriatric as indicated. The care plan did not indicate Resident #1 had an updated or revised care plan for aggressive behaviors during a resident-to-resident aggression with Resident #2 on 07/24/2025. Record review of Resident #1's care plan dated 9/04/2025 indicated Resident #1 had inappropriate behaviors. Interventions included monitoring and charting behaviors every shift and report progress to MD, observing for early warning signs of behavior - approach in a calm manner, call by name, remove from unwanted stimuli and provide psych consult per order. The care plan did not indicate Resident #1 had an updated or revised care plan for aggressive behaviors during a resident-to-resident aggression with Resident #4 on 09/05/2025. Record review of a progress notes/incident report for physical aggression, dated 03/19/2025, indicated an incident was reported that included Resident #1 had fallen and scratched Resident #2 on the leg during the fall. Resident #1 got herself back in her wheelchair and then she spit on Resident #2 and scratched Resident #3. Resident #1 was placed on 1:1 monitoring immediately and was later released. Resident #2 had a scratch on her right forearm. Resident #3 had a scratch on her left leg and 0.5cm x 0.5cm skin tear to left index finger knuckle area. Psych NP of Resident #1 notified of incident and new medication ordered for agitation and anxiety. Record review of the facility's Provider Investigation Report dated 3/19/2025, incident category as resident-to-resident abuse signed by the Administrator on 03/25/2025. PIR indicated the incident occurred 03/19/2025 at 11:13 a.m. PIR indicated Resident #1 scratched Resident #2 and Resident #3. ADON provided head to toe assessment to Resident #2 and #3 injuries of Resident #2 sustained scratch to forearm and Resident #3 sustained scratch to left leg and hand. Provider response after the incident included, residents separated, Resident #1 placed on 1:1 monitoring, Resident #1 referred to psych, head to toe assessments on all involved residents, incident/accident report completed, safe surveys conducted, Resident #2 and #3 treated in house, behavioral monitoring initiate on Resident #1, abuse and neglect in-services initiated, MD/family notified, ordered labs drawn on Resident #1. Resident abuse confirmed. Record review of Resident #2 skin assessment dated [DATE] indicated Resident #2 had a 17 cm x 1cm skin tear to right forearm. No active bleeding but red in color, no swelling, and no bruising. Record review of Resident #3 skin assessment dated [DATE] indicated Resident #3 had a scratch on her left leg and 0.5cm x 0.5cm skin tear to left index finger knuckle area and bilateral legs had multiple old scarring and multiple scattered areas of discoloration to bilateral arms. During an observation and interview on 09/23/2025 at 1:40 p.m., Resident #2 was sitting in a wheelchair in the dining area, she said that she and Resident #1 had several incidents, she pointed to 2 bruises to left forearm, consistent with being pinched, and said Resident #1 had pinched her causing the bruises. She said that she tries to stay away from Resident #1, so she does not scratch or pinch her. During an observation and interview on 09/23/2025 at 1:45 p.m., Resident #3 was sitting in a wheelchair in the dining area, she denied anyone scratching or hitting her and she denied hitting anyone. Resident #3 was confused and unable to answer more than a few questions. During an interview on 09/24/2025 at 1:50 p.m., LVN A said that Resident #1 and Resident #2, and Resident #3 have a love hate relationship. She said some days they request to sit together and communicate and other days they are mad at each other. LVN A said on the days they are mad or upset that staff try to intervene and separate them to keep residents safe but sometimes the behaviors onset quickly and staff are unable to intervene to prevent incidents. LVN A said that if resident to resident altercations occur that the staff separate the residents, and the aggressor is placed on 1:1 monitoring for 2 hours or until released by psych or transferred to hospital. LVN A said she would assess the involved residents and notify the NP/MD and follow the orders provided. Record review of a progress notes/incident report for physical aggression, dated 07/24/2025, indicated the nurse heard Resident #1 yelling very loudly. Nurses responded to the incident in the dining room. Nurse could see down the hall into the dining room, Resident #1 and Resident #3 were both swing arms at each other. Upon nurses' arrival at the dining room, residents were no longer hitting each other but Resident #3 was holding Resident #1's left hand and would not let go. This resident continued to yell. Resident #3 refused to let go of Resident #1's hand. The nurse was eventually able to ungrasp the other resident's hand and then separate residents. Both residents were evaluated, finding no injuries. Resident #3 placed on 1:1 behavior monitoring for 2 hours. Record review of the facility's Provider Investigation Report, dated 07/24/2025, incident category as resident-to-resident abuse signed by the Administrator on 07/25/2025. The PIR indicated the incident occurred on 07/24/2025 at 7:00 a.m. The PIR indicated Resident #3, and Resident #1 were hitting each other and then Resident #3 grabbed Resident #1's hand and would not let go. LVN A performed a head-to-toe assessment on both residents, no injuries indicated. Provider response after the incident included, residents separated, Resident #3 placed on 1:1 monitoring for 2 hours, head-to-toe assessments on all involved residents, incident/accident report completed, safe surveys conducted, abuse and neglect in-services initiated, Psych NP notified, MD/family/hospice notified. Resident abuse confirmed. Record review of a progress notes/incident report for physical aggression, dated 09/05/2025, indicated LVN A witnessed Resident #1 hit Resident #4 twice in her right arm with closed fist, unprovoked as she was passing by her. Resident #4 did not hit the other resident back. Resident #1 was removed from area and placed on 1:1 monitoring. Resident #4 was able to verbalize that she did not do anything to Resident #1 to provoke her to hit her. Resident #4 denied any pain in her arm at this time. DON, Administrator, NP and Psych NP notified of incident. Resident #1 continued with behaviors during 1:1 monitoring and Psych NP ordered Resident #1 Hydroxyzine 25mg 1 tablet by mouth every 6 hours as needed x 14 days. Record review of the facility's Provider Investigation Report, dated 09/05/2025, incident category as resident-to-resident abuse signed by the Administrator on 09/10/2025. The PIR indicated the incident occurred on 09/05/2025 at 4:00 p.m. The PIR indicated LVN A witnessed Resident #1 hit Resident #4 on the arm. LVN A performed a head-to-toe assessment on both residents, no injuries identified. Provider response after the incident included, residents separated immediately, Resident #1 placed on 1:1 monitoring for 2 hours, head-to-toe assessments on all involved residents, incident/accident report completed, safe surveys conducted, care plans updated, abuse and neglect in-services initiated, Psych NP and MD/family notified. Resident abuse confirmed. During an interview on 09/24/2025 at 12:45 p.m., Resident #4 said that she was hit by Resident #1 on the arm when she was coming down the hall. She said that she was not hurt and did not hit her back. She said that she knows not to hit other residents and to notify nurse if someone hits her. During an interview on 09/24/2025 at 2:10 p.m., LVN A said that Resident #1 and Resident #4 were in the hallway, and she witnessed Resident #1 hit Resident #4 on the arm. She said that Resident #4 did not provoke the incident and did not hit Resident #1 back. She said Resident #1 gets upset when she cannot talk to her sister on the phone or in person, and this day her family member was out of town and unable to be reached and Resident #1 started having behaviors after not being able to talk to her family member. She said that she goes out with her family member and stays with her family member overnight and when those visits are unable to be arranged Resident #1 gets upset and acts out. She said that Resident #1 was monitored 1:1 after the incident. 3. Record review of Resident #2's face sheet, dated 09/23/2025, indicated a [AGE] year-old female who was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident #2 had diagnoses which included schizophrenia (a chronic mental disorder characterized by symptoms such as hallucinations, delusions, and cognitive challenges), Alzheimer's Disease (progressive disease that destroys memory and other important mental functions), manic episodes, intellectual disabilities, diabetes type 1 (chronic condition in which the pancreas produces little or no insulin), dementia (loss of cognitive functioning), and major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Record review of Resident #2's annual MDS Assessment, dated 1/17/2025, indicated she was able to make herself understood and understood others. She was intact cognitively, identified with a BIMS score of 14. She had an active diagnosis of anxiety disorder, depression, bipolar disorder, and schizophrenia in the last 7 days. She had no behaviors identified within the 7 days look back period. Record review of Resident #2's care plan revision dated 1/16/2024 indicated Resident #2 had inappropriate behaviors. Interventions included to activities, explain procedures using terms gestures residents can understand, monitor and chart behaviors every shift and report progress to MD, observe for early warning signs of behavior - approach in a calm manner, call by name, remove from unwanted stimuli, give medications per order - monitor labs - report results to MD, and consult psychiatric/ psychogeriatric as indicated. Record review of Resident #2's care plan dated 5/19/2025 indicated Resident #2 had physical aggression from another resident. Interventions included analyzing times of day, places, circumstances, triggers, and what de-escalates behavior and document, assessing and addressing for contributing sensory deficits, monitor/document/report as needed any s/s of resident posing danger to self and others, when the resident becomes agitated: intervene before agitation escalates; guide away from source of distress; engage calmly in conversation; if response is aggressive, staff to walk calmly away, and approach later and administer medications as ordered, monitor/document for side effects and effectiveness, and psychiatric/psychogeriatric consult as indicated. The care plan did not indicate Resident #2 had an updated or revised care plan for receiving aggressive behavior from another resident during a resident-to-resident aggression on 03/19/2025. 4. Record review of Resident #3's face sheet, dated 09/23/2025, indicated a [AGE] year-old female who was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident #3 had diagnoses which included vascular dementia (changes in thinking and memory that occur when there isn't enough blood flow to part of the brain), diabetes (a chronic condition that affects the way the body processes blood sugar), stroke, dementia (loss of cognitive functioning), and major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Record review of Resident #3's quarterly MDS Assessment, dated 3/14/2025, indicated she was sometimes able to make herself understood and sometimes understood others. She was moderately impaired cognitively, identified with a BIMS score of 11. She had an active diagnosis of depression in the last 7 days. She had no behaviors identified within the 7 days look back period. Record review of Resident #3's quarterly MDS Assessment, dated 6/12/2025, indicated she was sometimes able to make herself understood and sometimes understood others. She was severely impaired cognitively, identified with a BIMS score of 6. She had an active diagnosis of depression in the last 7 days. She had behavioral symptoms not directed toward others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) which occurred 1 to 3 days within the 7-day look back period. The care plan did not indicate Resident #3 had an updated or revised care plan for receiving aggressive behavior from another resident during a resident-to-resident aggression on 03/19/2025 and 07/24/2025. 5. Record review of Resident #4's face sheet, dated 09/23/2025, indicated a [AGE] year-old female who was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident #4 had diagnoses which included psychosis (severe mental condition in which thoughts and emotions are so affected that contact is lost with external reality), diabetes (a chronic condition that affects the way the body processes blood sugar), delirium (confusion that happens when illness, changes in your environment or other factors put too much stress on your brain), and major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Record review of Resident #4's quarterly MDS Assessment, dated 8/30/2025, indicated she was able to make herself understood and understood others. She was moderately impaired cognitively, identified with a BIMS score of 8. She had an active diagnosis of depression and psychotic disorder in the last 7 days. She had no behaviors identified within the 7-day look back period. Record review of Resident #4's care plan revision dated 5/30/2025 indicated Resident #4 has potential to be physically aggressive related to anger, and poor impulse control. Interventions included behavior de-escalation by removing her from the issue as it is happening, analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document, assessing and addressing for contributing sensory deficits, assessing and anticipating resident's needs: food, thirst, toileting needs, comfort level, body positioning, pain etc., give the resident as many choices as possible about care and activities and psychiatric/psychogeriatric consult as indicated. The care plan did not indicate Resident #4 had an updated or revised care plan for receiving aggressive behavior from another resident during a resident-to-resident aggression on 09/05/2025. During an interview on 09/24/2025 at 8:55 a.m., the Administrator said that all incidents and allegations are discussed during morning meetings (including herself, administrator, department heads) and if care plans need to be updated that she emailed the VP of Clinical Reimbursement, a MDS Contractor and the care plans and interventions were updated remotely. She said that it appears that no one was verifying that the emails were received, and the tasks were completed. She said she is unsure why the care plans were not updated as requested and if the care plans were not updated or revised, the care plan would not reflect the current resident's needs. She stated new interventions should be added to the care plan regarding recurrent resident-to-resident altercations. She said the DON should have been assigned the responsibilities of ensuring the care plan was updated when the in-house MDS coordinator left. Record review of an undated facility policy titled, “Policy: Comprehensive Care Planning & IDT Participation” indicated, “…. To ensure that every resident at … has an individualized, comprehensive care plan developed and implemented by the Interdisciplinary Team (IDT) in compliance with federal and Texas state regulations. … 3. Behavioral Care Plans must be initiated and completed by the next business day following identification of behaviors. … Social services and Nursing Department are responsible for updating acute or new care plans identified between quarterly Care Plan Review …” An Immediate Jeopardy (IJ) was identified on 09/24/2025 at 9:45 a.m. The IJ template was provided to the facility on [DATE] at 11:00 a.m. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The following Plan of Removal (POR) submitted by the facility was accepted on 9/25/25 at 10:45 a.m.: Resident-Specific Interventions - 09/24/2025 - Completed by VP of Clinical Reimbursement Resident #1's care plan was updated 09/24/25 psych NP discontinued Buspirone 5 mg with new order for Buspirone 20 mg every evening. Resident #2, #3 and #5 care plans updated 09/24/2025 regarding receiving abuse

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents the right to be free from abuse for 2 of 15 residents (Residents #1 and Resident #2) reviewed for abuse. The facility failed to ensure Resident #1 and Resident #2 were free from sexual abuse. On 6/15/2024 at 2:03 p.m., Resident #1 provided oral sex to Resident #2 in the dining room of the facility. The non-compliance was identified as past non-compliance (PNC). The Immediate Jeopardy began on 06/15/2024 and ended on 10/07/2024. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of abuse, physical harm, mental anguish, and emotional distress. Findings included: 1. Record review of Resident #1's face sheet dated 10/24/2024 indicated Resident #1 was [AGE] years old male, initially admitted to facility on 06/17/2022 and readmitted to facility on 05/06/2024. His diagnoses included moderate intellectual disabilities (chronic condition that affects a person's ability to think and understand), schizoaffective disorder depressive type (mental illness that involves symptoms of both schizophrenia and depression), dysphagia (difficulty swallowing), dysarthria (a motor speech disorder that makes it difficult to speak clearly due to issues with the muscles used for speech), anarthria (a speech disorder that results from a severe motor impairment and causes a complete or partial loss of speech) and cognitive communication deficit (a difficulty with communication caused by disruption to cognition, or brain processes like attention, memory, and problem solving). Record review of Resident #1's quarterly MDS assessment dated [DATE] indicated Resident #1 was rarely/never able to make himself understood and usually understands others. He had a BIMS of 03 (severely impaired cognitively). He exhibited no behaviors over the 7 days look back period. He required supervision or moderate assistance for most ADLS. He was frequently incontinent of bladder and bowel. Record review of Resident #1's care plan with a revision dated 06/17/2024 indicated Resident #1 had inappropriate sexual behaviors and was at risk for further episodes and injury AEB a diagnosis of intellectual disability. Interventions included to firmly approach resident that behaviors are not acceptable, administer medications as ordered, inform direct caregivers on methods to assist them in handling resident's inappropriate sexual behaviors while providing care, provide diversional activities, psych services as needed, and redirect during episodes of inappropriate sexual behavior and document in the clinical record. Record review of Resident #1's incident report authored by LVN A indicated on 06/15/2024 at 1:55 p.m. Resident #1 was observed by Resident #3 performing oral sex to Resident #2 in the dining room. Record review of Resident #1's progress note authored by LVN B indicated on 06/15/2024 at 2:03 p.m., [Resident #1] was separated from [Resident #2] area and placed [Resident #1] on the secure unit for now for safety and continue the 1-hour monitoring. Notified Abuse Administrator and DON of full incident. Record review of Resident #1's progress note authored by LVN A indicated on 06/15/2024 at 2:25 p.m., [Resident #3] was sitting in the dining room in the back and observed Resident #1 performing oral sex on Resident #2. CNA assisted [Resident #1] back to his room. [Resident #1] was unable to tell what happened due to Dx of moderate intellectual disability. [Resident #1] assess for any injuries, none noted. [Resident #1] started grabbing at his crotch area, no bruising or abnormalities noted from this area. Administrator, DON, ADON, MD notified, resident RP telephoned, no answer at this time, will continue to call. Resident placed on every 1-hour monitoring; vital signs B/P 122/67, pulse 74, respiratory rate 18, temperature 97.2. No c/o pain or discomfort observed. Record review of Resident #1's progress note authored by LVN A indicated on 06/15/2024 at 8:00 p.m., [Resident #1] was resting in bed at this time with eyes closed, no s/s of distress. No c/o pain or discomfort voiced. Resident RP telephoned x 4 attempts, wireless caller is unavailable at this time, will not allow to leave voice message. Record Review of Resident #1's behavior monitoring log indicated he was monitored hourly from 06/15/2024 at 2:00 p.m. to 07/22/2024 at 5:00 a.m. 2. Record review of a face sheet dated 10/24/2024 indicated Resident #2 was [AGE] years old male, initially admitted to facility on 06/17/2022 and readmitted to facility on 05/06/2024. His diagnoses included hemiplegia and hemiparesis following a cerebrovascular disease affecting left non-dominant side (a stroke or other cerebrovascular disease has damaged the right side of the brain, resulting in weakness or paralysis on the left side of the body), morbid (severe) obesity due to excess calories, post-traumatic stress disorder (a mental health condition that's triggered by a terrifying event - either experiencing it or witnessing it), Type 2 Diabetes Mellitus (chronic condition that affects the way the body processes blood sugar), depression (mental illness that negatively affects how you feel, the way you think and how you act) and anxiety (persistent and excessive worry that interferes with daily activities). Record review of a quarterly MDS assessment dated [DATE] indicated Resident #2 was understood and understood others. He had a BIMS score of 10 (moderately impaired cognitively). She exhibited no behaviors over the 7 days look back period. He required maximum assistance for most ADLS, requiring supervision for eating and oral hygiene. He was frequently incontinent of bladder and always incontinent of bowel. Record review of Resident #2's care plan with a revision dated 06/17/2024 indicated Resident #2 had inappropriate sexual behaviors and was at risk for further episodes and injury AEB, he allowed an intellectual challenged resident to perform oral sex on him in the dining room and stated the resident was an able body. Interventions included discharge planning (resident on parole), to firmly approach resident that behaviors were not acceptable, administer medications as ordered, inform direct caregivers on methods to assist them in handling resident's inappropriate sexual behaviors while providing care, provide diversional activities, psych services as needed, and redirect during episodes of inappropriate sexual behavior and document in the clinical record. Record review of Resident #2's incident report authored by LVN A indicated on 06/15/2024 at 1:55 p.m. Resident #3 observed Resident #1 performing oral sex to Resident #2 in the dining room. Incident description: Resident #2 stated I did not tell him to do it he just rolled up to me in his wheelchair and started performing sex on me. Resident #2 stated to CN and ADON, that Resident #1 (Dx: moderate intellectual disability) was an able body to suck my D***(penis). Resident #2 stated that he was going to call the police after this CN questioned him about the incident. Resident #2 was asked by the ADON why he did not back up and separate himself from the other resident because he had a power wheelchair, and he could remove himself from the situation. Resident #2 stated that the other resident was an able body. Record review of Resident #2's progress note authored by LVN A indicated on 06/15/2024 at 1:55 p.m., [Resident #3] reported that while she was sitting in the dining room in the back, she observed [Resident #1] performing oral sex on [Resident #2]. [Resident #2] stated that [Resident #1] asked the resident if it was good to him. CN interviewed the resident. [Resident #2] stated I did not tell him to do it he just rolled up to me in his w/c and started performing sex on me. [Resident #2] stated to CN and ADON, that [Resident #1] was an able body to suck my d***(penis), [Resident #2] stated that he was going to call the police after this CN questioned him about the incident. The administrator, DON, ADON, MD and local police were notified of the incident. Local police officer here, statement taken from [Resident #3] and [Resident #2]. Police Officer exit the building, case number given to ADON and administrator. RP notified (resident RP stated that she is not the resident RP the state of Texas is due to the resident being on parole). [Resident #2] remains up in motorized w/c going in and out of other resident's room. [Resident #2] was asked to go to his room, resident attempted to argue with staff. [Resident #2] stated f*** all of you, you have to do a lot of paperwork to get me out of here. You guys allowed this shit to happen. Record review of Resident #2's progress note authored by LVN B indicated on 06/15/2024 at 2:03 p.m., This ADON was called to facility to help with incident between two residents, when entering the facility and reporting to Nurses station, seen local Police Department officer there and getting statements from residents. [Resident #3] and [Resident #2] were in electric wheelchairs sitting there listening to conversations going on, I then asked both residents if I could speak to staff and officer to find out information of incident. [Resident #3] stated ok and moved away as asked, [Resident #2] remained for a while, and stated he would find out what was happening, then asked staff to take Resident #1 to separate him from area and place him on unit for now for safety and continue the 1-hour monitoring. Notified Abuse Administrator and DON of full incident. Record review of Resident #2's progress note authored by LVN B indicated on 06/15/2024 at 2:30 p.m., This nurse continued conversation with local police officer and was told that he will have to contact Special Victims and put this incident in their hands and someone would contact us to investigate further, he gave a paper with names of residents with case number of #2024-011832. He believed [Resident #2] was the one who initiated the incident but could not arrest him because of [Resident #1] had a Dx of Intellectual disabilities and he was unable to give a detailed description of incident, so it was being transferred to the proper unit and detective. [Resident#2] continues to come up to nurse station to listen what is being said and arguing with staff, after police left, I asked Resident #2 to go to his room so I could speak with staff, He then stated, call police or whatever, ya'll allowed this shit to happen. Record review of Resident #2's progress note authored by LVN B indicated on 06/15/2024 at 3:20 p.m., I spoke with Medical Director related to incident and he felt the fact Resident #2 was on parole and posed a threat to other residents that we needed to discharge resident immediately, The police officer stated he could not just take him without proper investigation and charges, also if needed we could also send out Resident #1 if needed if resident started to get upset or seemed to be traumatized from the incident. Record review of Resident #2's progress note authored by LVN B indicated on 06/15/2024 at 3:38 p.m., Resident #2 is aware we, both MD and facility are discussing immediate discharge and speaking to family on phone after police interviews and statements given. Resident #2 stating I won't be going anywhere soon to someone on the phone, and they have no idea how much paperwork they will have to do, in front of staff and residents, resident continues to cuss and become belligerent with staff. Record review of Resident #2's progress note authored by LVN B indicated on 06/15/2024 at 4:25 p.m., This nurse continues to move forward after family of Resident #2 stated they are not his RP and not responsible for him in any way, he is responsibility of the state of Texas, attempted to contact parole board as advised by family, Contacted local police department, that gave me a number to [local] Parole Board and spoke with representative who looked up residents name and stated she would have Resident #2's assigned parole officer to call back. Record review of Resident #2's progress note authored by LVN B indicated on 06/15/2024 at 4:30 p.m., This nurse received call back from assigned parole officer, who was trying to find out information to move forward with discharge and awaiting decision and investigation from local police department, he then asked for case number and stated he would see what he could do as soon as able. Record review of Resident #2's psychiatric evaluation authored by NP AA indicated on 06/25/2024, assessment details, Resident #2 was asked about incident that occurred on 06/15/2024 in dining hall with other resident, as per patients own words I was sitting in the dining room waiting for coffee and (Resident #1) came on my left side which is my blind side, he pulled up front of me, pulls my pants down and put his face in my crotch, he started giving me oral. I pushed him off and was looking to my right for nursing staff, I turned around and he jumped back on it. Treatment plan: utilize behavioral interventions to manage episodical behaviors, redirect as needed and provide support and encouragement to increase positive interactions and socialization, and follow up in 4 weeks or as needed. Record Review of Resident #2's behavior monitoring log indicated he was monitored hourly from 06/15/2024 at 2:00 p.m. to 07/23/2024 at 5:00 a.m. Record review of Provider Investigation report dated 06/15/2024 indicated Description of allegation: Resident #3 observed non-verbal Resident #1, alert x 1, performing oral sex to Resident #2, alert x 4, in the dining room. Assessments: Resident #1 was assessed for injuries with none noted. Provider Response: Resident #1 was immediately move to his room, assessed for injuries, none noted, Administrator, DON, ADON, Physician, and Responsible Party called. Resident #1 placed on Q 1 hour monitoring. After several attempts to get Resident #2 from the area to prevent further abuse, he complied and asked to go lay in his bed. Investigation Summary: Resident #2 was observed pulling Resident #1 head to his genitals and Resident #1 performed oral sex in the dining room. Resident #3, that observed the incident, reported it to the nurses. Resident #2 alert x 4 ambulates in a motorized wheelchair stated to the nurse He was an able body to suck by d k(penis) I did not tell him to do it, he just rolled up to me in his wheelchair and started performing sex on me. Resident #1 is alert x 1 ambulates in wheelchair and is nonverbal with intellectual disabilities. Parties notified: Physician, Administrator, Responsible Parties, DON, ombudsman, and ADON. Facility investigation finding confirmed. Provider action taken post-investigation: Local Police Department was called by Resident #2, referred ADON to contact special victims. Resident #2 is on parole, was issued an Immediate discharge, [NAME] Parole Board staff is assisting with discharges. Resident #2 was seen by LCSW with Psychological Services on 6-16-24. Resident #2 was monitoring every hour until discharged from facility. Resident #1 placed on every 1-hour monitoring, notified local LIDDA. Resident #1 with no behaviors noted, continue to call Responsible Party call goes to voicemail. During an observation and attempted interview on 10/24/2024 at 9:40 a.m., Resident #1 was sitting in his wheelchair in the hallway of the secure unit. He was appropriately dressed and well-groomed. He was unable to answer questions about the incident and just continued to reach out to touch or shake hands or hand/give a teddy bear. Resident #1 non-verbal. No indicators of abuse, neglect or distress observed. During an observation and interview on 10/24/2024 at 10:00 a.m., Resident #2 was lying in his bed in his room. He was lying in bed with no shirt on and well-groomed. He said that he gets warm easily, so he did not wear a shirt while in his room. Resident #2 was asked about incident that occurred on 06/15/2024 in dining hall with the other resident, as per patients own words I was sitting in the dining room waiting for coffee and (Resident #1) came on my left side, which is my blind side, he pulled up front of me, pulls my pants down and pulls out by penis and started giving me oral sex. I pushed him off and was looking to my right for nursing staff, I turned around and he jumped back on it. He said it lasted maybe 40 seconds, and I moved away as soon as I could. I didn't make him do that, called the police because he wanted it to be on record. Resident #2 said police officer visited with him and took his statement and report filed. Attempted to contact Resident #1's RP on 10/24/2024 at 5:30 p.m. and 10/25/2024 at 11:00 a.m. with no answer and unable to leave voice mail. During an interview on 10/23/2024 at 4:00 p.m., LVN A said that Resident #3 had reported to her that she observed Resident #1 giving oral sex to Resident #2 in the facility dining room. LVN A said that she went to the dining area but did not observe the sexual act. LVN A said she had CNA take Resident #1 to his room and she went to his room and did a head-to-toe assessment with no injuries noted. LVN A said she notified the MD, ADON, and the administrator and attempted to notify the RP but did not contact her. LVN A said that Resident #1 was placed on every hour monitoring and did not exhibit any s/s of distress from the incident during her shift. LVN A said that Resident #1 was placed in the secure unit briefly after the incident for his safety because Resident #2 was up in his electric wheelchair and refusing to go to his room and lie down, so placed Resident #1 in the secure unit until Resident #2 was placed in bed in his room. Attempted to call LVN B on 10/24/2024 @ 5:10 p.m. and 6:10 p.m. via telephone for interview, unsuccessful with no answer or returned call. Record review of facility census indicated that Resident #3, no longer resided at facility. An attempt was made to call Resident #3 via telephone on 10/24/2024 at 5:15 p.m. and 6:15 p.m The attempts were unsuccessful with no answered or returned phone calls. During an interview on 10/24/2024 at 3:50 p.m., SW said that she was new to the facility but was aware of the incident between Resident #1 and Resident #2. She said that she had reviewed Resident #2's file and ongoing communications with probation officer and continues to work with other facilities for possible transfer or discharge of Resident #2 to another facility. SW said that Resident #1 and Resident #2 were provided behavioral support after the incident. During an interview on 10/24/2024 at 4:00 p.m., the ADON said she was not the acting ADON during the time of the incident between Resident #1 and Resident #2. She said she was aware that would be considered sexual abuse. The ADON said she notifies the Administrator/Abuse Prevention Coordinator immediately by phone/text of any allegation of abuse. The ADON said new protocol for abuse incidents was that staff should immediately remove residents from the situation and stay with the aggressor one-on-one until further instruction from the Abuse Coordinator or MD. ADON said Resident #1 resides in the secure unit and has no contact or communication with Resident #2. During an interview on 10/24/2024 at 4:55 p.m., the Administrator said she was not the active administrator during the incident between Resident #1 and Resident #2, but she had recently (10/05/2024 and 10/06/2024) conducted in-services with all staff addressing the facility abuse/neglect policy and initiating one-on-one monitoring with the aggressor until they were given further instructions on monitoring. She had addressed the different types of abuse and staff had passed a written test. She said she instructed staff on the documentation in behavior monitoring logs. She in-serviced staff on the facility's behavioral management policy which included resident abuse. She said staff were required to pass behavioral management test. She said not keeping the residents free from abuse could place them at risk of abuse, physical harm, mental anguish, and emotional distress. Record review of the undated facility's Abuse and Neglect policy indicated .It is the policy of the facility to administer care and services in an environment that is free from any type of abuse, corporal punishment, misappropriation of property, exploitation, neglect, or mistreatment. The facility follows the federal guidelines dedicated to prevention of abuse and timely and thorough investigations of allegations. These guidelines include compliance with the seven (7) federal components of prevention and investigation. III. Prevention: Have procedures to provide residents, families, and staff information on how and to whom they may report concerns, incidents and grievances without fear of retribution; and provide feedback regarding the concerns that have been expressed. Identify, correct and intervene in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is more likely to occur. Establish a safe environment that supports consensual sexual relationship. Develop and implement policy on abuse, neglect, theft, exploitation, and misappropriation of property. Deployment of sufficient and trained staff to deal with behaviors in the units. Identification, assessment, care planning for intervention, and monitoring of residents with needs and behaviors that might lead to conflicts or neglect. The supervisions of staff to identify inappropriate behaviors .ensuring health and safety of residents .VI. Protect residents from physical and psychosocial harm during investigations. 1. If the allegation of abuse involves 2 or more residents, they will all be immediately separated for the protection of all residents involved and those potentially affected by the abuse. 2. Affected residents will be assessed for injury. 3. Attending physician will be notified. a. This includes but not limited to full assessment of physical and psychosocial well-being; sending resident to hospital if needed; depending on circumstance, keep resident on 1:1, assign a female/male depending on the accusation/allegation. Record review of facility incident/accident reports indicated no other incidents of inappropriate sexual behaviors. Record review of quiz results, dated 10/05/24 and 10/06/24, indicated all staff passed the quiz regarding abuse, neglect, reporting, behavioral monitoring and one-on-one monitoring. Record review of a list of all facility staff used for tracking the required in-service training on abuse/neglect, behavioral monitoring, and behavioral management indicated all facility staff had received the in-service training in person or by phone on 10/05/2024 or 10/06/2024. During interviews on 10/24/24 from 3:30 p.m. though 5:30 p.m. and 10/25/2024 from 8:00 a.m. though 10:30 a.m., 4 LVNs (LVN A, LVN C, LVN D, LVN E ), 2 MAs ( MA P and MA Q), 10 CNA's (CNA F, CNA G, CNA H, CNA I, CNA J, and CNA K), 1 Activity Director, 1 Social Worker, 1 Dietary staff (Dietary Manager S), 3 Housekeeping staff (Housekeeper T, U, V) and 1 Maintenance (Maintenance W) were able to identify the Abuse Coordinator as the administrator. Staff indicated they were to report allegations of abuse and neglect immediately to the Administrator and were able to give examples of physical, verbal, sexual abuse and immediate intervention procedures. They were able to state immediate actions to take when an allegation was made and/or identified, such as immediately removing residents from the situation and stay with the aggressor one-on-one until further instruction from the Abuse Coordinator. They verbalized proper documentation of behavior monitoring logs. The non-compliance was identified as past non-compliance (PNC). The Immediate Jeopardy began on 06/15/2024 and ended on 10/07/2024. The facility had corrected the noncompliance before the survey began.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents the right to be free from abuse for 2 of 6 residents (Residents #Unnamed & Resident #4) reviewed for abuse. 1. On 08/02/24 Resident #1 was grabbing Resident #Unnamed breasts. 2. On 08/25/24 Resident #1 touched Resident #4's breast. On 10/05/24 at 4:40 p.m. an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 10/06/24, the facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of the Plan of Removal. These failures could place residents at risk of abuse, physical harm, mental anguish, and emotional distress. Findings included: 1. Record review of a face sheet dated 09/23/24 indicated Resident #1 was [AGE] years old, initially admitted to facility on 03/07/24 and readmitted to facility on 09/09/24. His diagnoses included dementia (loss of cognitive functioning), delusional disorder (a mental health condition that causes unshakable beliefs in something that's untrue), hypertension (condition in which the force of the blood against the artery walls is too high), dysphagia (difficulty swallowing) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). Record review of Resident #1's care plan with revision dated 04/24/24 indicated Resident #1 had inappropriate sexual behaviors; resident seeks to satisfy his sexual desires. Interventions included to firmly approach resident that behaviors are not acceptable and document conversations and actions of resident; inform direct caregivers on methods to assist them in handling resident behaviors while providing care; monitor whereabouts of resident and keep distance from others; provide diversional activities and redirect when behaviors happen and document. Record review of a quarterly MDS assessment dated [DATE] indicated Resident #1 was usually able to make himself understood and usually understands others. He had a BIMS of 08 (moderately impaired cognitively). He exhibited no behaviors over the 7 days look back period. He required supervision or moderate assistance for most ADLS. He was frequently incontinent of bladder and bowel. Record review of Resident #1's progress note authored by previous DON R indicated on 08/02/24 at 8:42 a.m., Resident #1 was in the dining room this morning grabbing other resident's breast when nurse tried to redirect him, he stated let me see your pussy. Nurse informed him that this kind of behavior would not be accepted. Nurse phoned MD and made him aware of situation. Received one time order for lorazepam 1 milligram IM for agitation. Record review of an unsigned 24-hour report indicated: 08/02/24 08:42 a.m. - Behavior Note Resident #1 was in the dining room this morning grabbing other resident breasts. When SN tried to redirect him, he stated, Let me see your pussy. SN informed him that this kind of behavior would not be accepted. SN phoned MD and made him aware of the situation. Received on time order for Lorazepam 1 mg IM for agitation. 08/02/24 10:21 a.m. - Social Services SSD sent referral over to behavioral unit at local hospital per DON who said to refer Resident #1 due to behavior displayed. Spoke with rep who said that he would need to be transported to the ER to be assessed. SSD said she would speak to the ADON/DON on how to proceed. 08/02/24 11:29 a.m. - Behavior Note Resident has been extremely inappropriate to staff and other residents sexually. Speaking graphically lewd and grabbing resident's breasts, then laughing and leering. Unable to redirect. DON notified. 08/02/24 12:32 a.m. - Nurses Note Resident #1 sent to hospital ER for psych evaluation due to inappropriate sexual behavior. Record Review of Resident #1's behavior monitoring log indicated on 08/02/24 Resident #1 was monitored hourly from 9:00 a.m. until 12:30 p.m. Record review of Resident #1's progress note authored by LVN Q on 08/05/24 at 12:55 p.m., indicated the behavioral hospital called to inform facility that Resident #1 did not meet criteria for extended stay and the unit was full. Resident #1 would be transferred back to the facility (on 08/05/24). Record review of Resident #1's psychiatric assessment note dated 08/05/24 and completed by NP AA indicated Resident #1 was seen for a hospital follow up visit for exhibiting anxiety symptoms and hypersexual behaviors toward female peers and staff. Psych treatment plan included to start Resident #1 on Rivastigmine (used for the treatment of mild to moderate Alzheimer's disease) 1.5 mg daily for inappropriate sexual behaviors in dementia, utilize behavioral interventions to manage episodic behaviors, redirect as needed and provide support and encouragement to increase positive interactions and socialization, and follow up in 4 weeks or as needed. Record review of Resident #1's progress note authored by LVN Q on 08/07/24 at 7:10 a.m. indicated Resident #1 continued to speak sexually inappropriately to staff. Resident #1 appeared exhausted, and shower was given to calm resident. Record review of Resident #1's behavior monitoring log did not indicate Resident #1 had any increased monitoring after discharge from behavioral hospital on [DATE]. During an observation and interview on 09/30/24 at 11:45 a.m., Resident #1 was sitting up in wheelchair in secure unit dining room. He said he did not recall the incident involving him inappropriately touching other residents that happened on 08/02/24. Resident #1 said that he knew that he was not supposed to touch or hit other residents or staff. Resident #1 was observed trying to stand up without assistance and staff intervened and redirect him by providing activities. Resident #1 was one of 6 residents in the dining room. During an interview on 09/30/24 at 1:00 p.m., the Administrator said there was no incident report for Resident #1's sexually inappropriate behaviors on 08/02/24. During an interview on 09/30/24 at 2:48 p.m., LVN Q said she was the CN on duty on 08/02/24 and vaguely recalled the incident with Resident #1 touching another female resident's breast. She said she recalled that the incident was in the dining room of the secure unit, and he touched the female's breast and was laughing and leering. He was unable to be redirected, and when removed from the area by staff he was talking sexually to staff and grabbing at their breast. She said that she notified the DON and MD. She said Resident #1 was monitored until he was transferred to a local hospital for evaluation for placement into their behavioral unit. She said she did not recall the female's name that he touched inappropriately. She said that she was in the unit covering for the CNA when the incident occurred, and it was not witnessed by other staff. During an interview on 09/30/24 at 3:30 p.m., the previous DON R said she was the active DON at the facility on 08/02/24. She recalled the incident with Resident #1 touching another female resident's breast. She said she was called to the secure unit that morning after breakfast and the CN reported that Resident #1 had touched another female resident's breast and was laughing and leering and was unable to be redirected and when removed from the area by staff he was talking sexually to staff and grabbing at their breast. She said she told the CN to keep Resident #1 on one-to-one monitoring and that she requested the SW to contact a local behavioral hospital for a transfer due to the behavior. She said that she notified all department heads (including the Administrator) during the 9:00 am morning meeting that day. She said Resident #1 was monitored until he was transferred to a local hospital for evaluation for placement into their behavioral unit. She said she did not recall the female resident's name that Resident #1 touched inappropriately. During an interview on 09/30/24 at 3:55 p.m., previous the Administrator S she said she was the active Administrator on 08/02/24. She said she was not notified of Resident #1 touching another female resident's breast on 08/02/24. She said that was considered sexual abuse. During an interview on 09/30/24 at 4:00 p.m., the ADON said she did not recall the incident with Resident #1 touching another female resident's breast on 08/02/24. She said she was aware that would be considered sexual abuse. The ADON said she notifies the Administrator/Abuse Prevention Coordinator immediately by phone/text of any allegation of abuse. The ADON said residents with behaviors were monitored and incidents were reported to the MD/NP. If MD ordered, resident would be transferred behavioral hospital for evaluation and treatment. During an interview on 10/05/24 at 9:41 a.m., CNA E said she had never observed Resident #1 touch any residents or staff inappropriately. She said she was never told he needed to be monitored closely due to inappropriate sexual touching. She said she knew he talked inappropriately to staff, and he had said many lewd comments to her. During an interview on 10/05/24 at 9:44 a.m., CNA CC said Resident #1 always talked sexually to staff and he had said some vulgar things to her, but she was never told he had sexually/inappropriately touched another resident. 2. Record review of a face sheet dated 10/05/24 indicated Resident #4 [AGE] years old, initially admitted to the facility 03/13/24 and readmitted on [DATE]. Her diagnosis included dementia (loss of cognitive functioning), cognitive communication deficit (a difficulty with communication caused by disruption to cognition, or brain processes like attention, memory, and Problem solving), and major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Record review of a quarterly MDS assessment dated [DATE] indicated Resident #4 was usually understood and sometimes understands others. She had a BIMS of 08 (moderately impaired cognitively). She exhibited no behaviors over the 7 days look back period. She required moderate assistance for most ADLS. She was always incontinent of bladder and frequently incontinent of bowel. Record review of a care plan last revised 07/19/24 for Resident #4 did not indicate she had been touched inappropriately on 08/25/24. Record review of an incident report dated 08/25/24 at 7:45 a.m. and signed by RN U indicated CNA heard Resident #4 yell, let go of my titty. CNA saw Resident #1 grabbing Resident #4's breast and reported the incident to her. Record review of an incident report dated 08/25/24 at 11:18 a.m. and signed by RN U indicated CNA reported to her that she saw Resident #1 touch a female resident on her breast. Residents were separated. Calls placed to notify ADON, NP, and RN T (previous Abuse Coordinator) and resident's FM UU. Resident #1 was on every 30-minute monitoring. Record review of a behavior monitoring log indicated Resident #1 was monitored hourly from 08/25/24 at 8:00 a.m. to 08/27/24 at 10:00 p.m. There was no documentation of further monitoring. Record review of a progress note dated 08/28/24 at 9:22 a.m. authored by previous MDS Coordinator DD indicated call placed to responsible party of Resident #1 to inform that Resident #1 has been having changes in behavior, both inappropriate sexual behaviors and aggressive behavior. Resident has been accepted to a behavioral hospital. RP said OK, thank you. Record review of a progress note dated 08/28/24 at 10:33 a.m. authored by the ADON indicated Resident #1 left facility with transportation company in route to behavioral hospital. During an interview on 09/25/24 at 10:21 a.m. RN T said she was made aware of the incident between Resident #1 and Resident #4. She said staff reported to her (the acting abuse coordinator) Resident #1 and Resident #4 were sitting at a dining table on the secure unit. Staff reported Resident #4 said Resident #1 grabbed her. Resident #1 denied he grabbed Resident #4's breast. She said both residents had low BIMS scores and there was no willful intent. During an interview on 09/25/24 at 12:15 p.m., CNA BB said she was getting all the residents into the dining room for the breakfast meal. She said it looked like Resident #1 was touching Resident #4's breast and then he reached for the coloring book and crayons that was on the dining table. She said she told Resident #1 he did not need to be so close to the ladies and he moved away. She said she advised RN U of the incident. She said RN U called the abuse coordinator. She said Resident #4 did not say anything. She said Resident #1 said he did not touch Resident #4's breast. He said he was reaching for the crayons. During an interview on 9/27/2024 at 4:00 pm, RN U said that on 8/25/2024 a CNA reported to her that Resident #1 touched a female resident on her breast. RN U said Resident #1 was separated from the female resident, assessed and behavioral monitoring initiated. RN U said she reported the incident to the ADON, NP/MD, AC (RN T) and RP. RN U said that Resident #1 was placed on behavioral monitoring for the incident until the AC (RN T) completed an abuse investigation. RN U said that there were 2 CNAs working the secure unit on 8/25/2024 to provide behavioral monitoring for the incident until the AC (RN T) completed an abuse investigation. RN U said if residents had behaviors that facility staff notify the NP/MD and place the residents on behavioral monitoring, depending on the MD orders and/or severity of the behavior's resident may be sent out to behavioral hospital for evaluation and treatment. She said Resident #1 was monitored q15 minutes. During an observation and interview on 10/05/24 at 9:39 a.m., Resident #4 was sitting in her wheelchair in the dining room of the secure unit. She was appropriately dressed and well-groomed. She was unable to answer questions about the incident and just repeated words spoken to her. During an interview on 10/05/24 at 3:55 p.m., the Administrator said that she was not the active Administrator/Abuse Coordinator at the time of the incidents with Resident #1 touching another female resident's breast on 08/02/24 or on 08/25/24 when Resident #1 touched Resident #4's breast. She said her expectation for incidents involving resident to resident abuse was for the residents to be separated and the aggressor to be placed on one-on-one monitoring for the protection of other residents. She said her expectation was care plans be updated when incidents occur, but the current MDS nurse worked remotely and might not have been aware of the incidents. She said the possible negative outcome of not protecting the residents could be physical, emotional, or psychological harm of the residents. Record review of the undated facility's Abuse and Neglect policy indicated .It is the policy of the facility to administer care and services in an environment that is free from any type of abuse, corporal punishment, misappropriation of property, exploitation, neglect, or mistreatment. The facility follows the federal guidelines dedicated to prevention of abuse and timely and thorough investigations of allegations. These guidelines include compliance with the seven (7) federal components of prevention and investigation. III. Prevention: Have procedures to: provide residents, families, and staff information on how and to whom they may report concerns, incidents and grievances without fear of retribution; and provide feedback regarding the concerns that have been expressed. Identify, correct and intervene in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is more likely to occur. Establish a safe environment that supports consensual sexual relationship. Develop and implement policy on abuse, neglect, theft, exploitation, and misappropriation of property. Deployment of sufficient and trained staff to deal with behaviors in the units. Identification, assessment, care planning for intervention, and monitoring of residents with needs and behaviors that might lead to conflicts or neglect. The supervisions of staff to identify inappropriate behaviors .ensuring health and safety of residents .VI. Protect residents from physical and psychosocial harm during investigations. 1. If the allegation of abuse involves 2 or more residents, they will all be immediately separated for the protection of all residents involved and those potentially affected by the abuse. 2. Affected residents will be assessed for injury. 3. Attending physician will be notified. a. This includes but not limited to full assessment of physical and psychosocial well-being; sending resident to hospital if needed; depending on circumstance, keep resident on 1:1, assign a female/male depending on the accusation/allegation. This was determined to be an Immediate Jeopardy (IJ) on 10/05/24 at 4:40 p.m. The Administrator was notified. The Administrator was provided the IJ template on 10/05/24 at 4:45 p.m. The Facility's Plan of Removal for Immediate Jeopardy was accepted on 10/06/24 at 1:50 p.m. and reflected the following: Action: On 10/05/24 R1 was immediately placed on q 15-minute checks for close monitoring for further behaviors. R1 will remain on q 15-minute checks until IDT team meets in 30 days and reevaluate his behaviors for medical adjustment and determine if R1 will remain on q 15-minute checks or can be discontinued. If Res #1 has additional behaviors, he will be placed one-on-one until psychiatric services can reevaluate his behaviors. Res #1 was placed on q 15 minutes checks due to the recurrent behaviors that require closer monitoring. Charge nurse/nurse managers Immediately assessed R2 and the rest of the residents in the secure unit for possible mental, physical, or sexual abuse, no additional mental health needs were identified, nor any suspected physical abuse found at this time. 0 out of 10 residents were affected. Administrator/abuse coordinator Immediately reeducated all staff 100% completion on Abuse & Neglect policy for types of abuse (physical, sexual, mental, verbal, neglect, exploitation, and misappropriation) through verbal in-service and written test. Staff were also reeducated for the identification, and intervention in a situation in which abuse, neglect, exploitation and/or misappropriation of resident property is more likely to occur. This education included protecting and/or removing the resident from the situation, as well as who the abuse coordinator is, when to report, and how to report abuse. Staff were reeducated to stay with the aggressor one-on-one until further instruction from the abuse coordinator and/or until the evaluation or further intervention. on 10/05/24 the Administrator, reeducated 100% of staff on behavioral management policy which included resident to resident abuse in regard to residents exhibiting sexual behaviors towards other and steps to do and approach the situation. Reeducation was provided for the staff with instructions for proper documentation for the behavior monitoring log through verbal in-service with monitoring log attached. Staff were reeducated through verbal in-servicing, tests, and questionnaires. On 10/05/24 MDS nurse immediately reviewed and updated care plan to reflect sexually inappropriate behaviors. The MDS nurse will review all incident reports related to sexual behaviors to make sure interventions were in place, for the floor staff to be able to see in electronic health record (EHC). Administrator/and or designee will reeducate floor staff to review [NAME] in PCC (EHC) for updated interventions for each resident. On 10/06/24 at 11:48 a.m., the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: During interviews conducted on 10/06/24 from 11:05 a.m. though 3:48 p.m. included LVN EE 6:00 a.m. - 6:00 p.m. weekends, LVN FF (6:00 a.m. to 6:00 p.m.) weekends, LVN B (6:00 a.m. 2:00 p.m.), LVN GG (2:00 p.m. to 10:00 p.m.), LVN HH (10:00 p.m. to 6:00 a.m.), LVN X (10:00 p.m. to 6:00 a.m.), MA J (6:00 a.m. to 2:00 p.m & 2:00 p.m. to 10:00 p.m., CNA CC (6:00 a.m. to 2:00 p.m.), CNA E (6:00 a.m. to 2:00 p.m.), CNA JJ (6:00 a.m. to 2:00 p.m.), CNA KK (6:00 a.m. to 2:00 p.m.), CNA LL (6:00 a.m. to 2:00 p.m.), CNA D (2:00 p.m. to 10:00 p.m.), CNA MM (2:00 p.m. to 10:00 p.m.), CNA NN (10:00 p.m. to 6:00 a.m.), and CNA OO (10:00 p.m. to 6:00 a.m.), CNA PP (10:00 p.m. to 6:00 a.m.), Dietary Aide QQ, Housekeeper RR, Occupational Therapist SS, Staffing LVN TT and ADON who worked all shifts. Staff were able to identify the Abuse Coordinator as the administrator. Staff indicated they were to report allegations of abuse and neglect immediately to the Administrator and were able to give examples of physical, verbal, sexual abuse and immediate intervention procedures. They were able to state immediate actions to take when an allegation was made and/or identified, such as immediately removing residents from the situation and stay with the aggressor one-on one until further instruction from the Abuse Coordinator. They verbalized proper documentation of behavior monitoring logs. CNA CC and CNA E said they were now aware of Resident #1's sexual behaviors and the resident was to be monitored q15 minutes. They said they documented every 15 minutes on Resident #1's behavior monitoring log. CNA CC and CNA E said they were in-serviced on abuse/neglect and gave examples of physical, verbal, and sexual abuse. They said the Administrator was the Abuse Coordinator and they would immediately report any abuse/neglect allegations to the Administrator. CNA CC and CNA E gave examples of immediate interventions they would take when an allegation or made incuding removing residents from the situation and staying with the aggressor one on one until the Administrator was notifed and gave further instruction. During an interview on 10/06/24 at 3:55 p.m., the Administrator said she had conducted in-services with all staff addressing the facility abuse/neglect policy and initiating one-on-one monitoring with the aggressor until they were given further instructions on monitoring. She had addressed the different types of abuse and staff had passed a written test. She said she instructed staff on documentation in behavior monitoring logs. She in-serviced staff on the facility's behavioral management policy which included resident abuse. She said staff were required to pass behavioral management test. She said Resident #1's care plan had been updated and a q15 minute monitoring was required by staff until the IDT meeting in 30 days to re-evaluate his behaviors. During an observation and interview on 10/06/24 at 1:15 p.m., Resident #1 was in the TV room with CNA E with no sexual behaviors noted. CNA E said she was assigned to monitor Resident #1 because he was being monitored q15 minutes for sexual behaviors and she was observed documenting the checks on his behavioral monitoring log. Record review of behavioral monitoring logs for Resident #1 indicated he was being monitored by staff every 15 minutes beginning on 10/05/24 at 6:00 p.m. to monitor for sexually inappropriate behaviors. Record review of a check off list of secured unit residents indicated all residents on the secure unit were assessed by charge nurses and the ADON. Record review of nursing assessments completed by the ADON and charge nurses for Resident #4 and all other secure unit residents indicated all residents were assessed for physical and psychosocial changes on 10/05/24. There was no evidence of sexual abuse noted on the assessments. Record review of Resident #1's care plan indicated it was updated on 10/05/24 and included he exhibiting unwanted sexual behaviors with interventions of referral to psychiatric services and increased monitoring for behaviors and changes in mental status. Record review of Resident #4's care plan indicated it was updated on 10/05/24. Record review of facility incident/accident reports indicated no other incidents of inappropriate sexual behaviors. Record review of quiz results, dated 10/05/24 and 10/06/24, indicated all staff passed the quiz regarding abuse, neglect, reporting, and one-on-one monitoring. Record review of a list of all facility staff used for tracking the required in-service training on abuse/neglect, behavioral monitoring, and behavioral management indicated all facility staff had received the in-service training in person or by phone. The Administrator was informed the IJ was removed on 10/06/24 at 3:58 p.m. The facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put in place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review 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 of 6 residents (Resident #4 and Resident #Unnamed) reviewed for abuse and neglect. 1. The facility failed to implement their written policies and procedures to prevent sexual abuse and potential further sexual abuse by Resident #1 when Resident #1 grabbed Resident #Unnamed's breast. 2. The facility failed to implement their written policies and procedures to prevent sexual abuse and potential further sexual abuse by Resident #1 when Resident #1 touched Resident #4's breast. On 10/05/24 at 4:40 p.m. an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 10/06/24, the facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of the Plan of Removal. These failures could place residents at risk of abuse, physical harm, mental anguish, and emotional distress. Findings include: 1. Record review of a face sheet dated 09/23/24 indicated Resident #1 was [AGE] years old, initially admitted to facility on 03/07/24 and readmitted to facility on 09/09/24. His diagnoses included dementia (loss of cognitive functioning), delusional disorder (a mental health condition that causes unshakable beliefs in something that's untrue), hypertension (condition in which the force of the blood against the artery walls is too high), dysphagia (difficulty swallowing) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). Record review of Resident #1's care plan with revision dated 04/24/24 indicated Resident #1 had inappropriate sexual behaviors; resident seeks to satisfy his sexual desires. Interventions included to firmly approach resident that behaviors are not acceptable and document conversations and actions of resident; inform direct caregivers on methods to assist them in handling resident behaviors while providing care; monitor whereabouts of resident and keep distance from others; provide diversional activities and redirect when behaviors happen and document. Record review of a quarterly MDS assessment dated [DATE] indicated Resident #1 was usually able to make himself understood and usually understands others. He had a BIMS of 08 (moderately impaired cognitively). He exhibited no behaviors over the 7 days look back period. He required supervision or moderate assistance for most ADLS. He was frequently incontinent of bladder and bowel. Record review of Resident #1's progress note authored by previous DON R indicated on 08/02/24 at 8:42 a.m., Resident #1 was in the dining room this morning grabbing other resident's breast when nurse tried to redirect him, he stated let me see your P---. Nurse informed him that this kind of behavior would not be accepted. Nurse phoned MD and made him aware of situation. Received one time order for lorazepam 1 milligram IM for agitation. Record review of an unsigned 24-hour report indicated: 08/02/24 08:42 a.m. - Behavior Note Resident #1 was in the dining room this morning grabbing other resident breasts. When SN tried to redirect him, he stated, Let me see your pussy. SN informed him that this kind of behavior would not be accepted. SN phoned MD and made him aware of the situation. Received on time order for Lorazepam 1 mg IM for agitation. 08/02/24 10:21 a.m. - Social Services SSD sent referral over to behavioral unit at local hospital per DON who said to refer Resident #1 due to behavior displayed. Spoke with rep who said that he would need to be transported to the ER to be assessed. SSD said she would speak to the ADON/DON on how to proceed. 08/02/24 11:29 a.m. - Behavior Note Resident has been extremely inappropriate to staff and other residents sexually. Speaking graphically lewd and grabbing resident's breasts, then laughing and leering. Unable to redirect. DON notified. 08/02/24 12:32 a.m. - Nurses Note Resident #1 sent to hospital ER for psych evaluation due to inappropriate sexual behavior. Record Review of Resident #1's behavior monitoring log indicated on 08/02/24 Resident #1 was monitored hourly from 9:00 a.m. until 12:30 p.m. Record review of Resident #1's progress note authored by LVN Q on 08/05/24 at 12:55 p.m., indicated the behavioral hospital called to inform facility that Resident #1 did not meet criteria for extended stay and the unit was full. Resident #1 would be transferred back to the facility (on 08/05/24). Record review of Resident #1's behavior monitoring log did not indicate Resident #1 had any increased monitoring after discharge from behavioral hospital on [DATE]. During an observation and interview on 09/30/24 at 11:45 a.m., Resident #1 was sitting up in wheelchair in secure unit dining room. He said he did not recall the incident involving him inappropriately touching other residents that happened on 08/02/24. Resident #1 said that he knew that he was not supposed to touch or hit other residents or staff. Resident #1 was observed trying to stand up without assistance and staff intervened and redirect him by providing activities. Resident #1 was one of 6 residents in the dining room. During an interview on 09/30/24 at 2:48 p.m., LVN Q said she was the CN on duty on 08/02/24 and vaguely recalled the incident with Resident #1 touching another female resident's breast. She said she recalled that the incident was in the dining room of the secure unit, and he touched the female's breast and was laughing and leering. He was unable to be redirected, and when removed from the area by staff he was talking sexually to staff and grabbing at their breast. She said that she notified the DON and MD. She said Resident #1 was monitored until he was transferred to a local hospital for evaluation for placement into their behavioral unit. She said she did not recall the female's name that he touched inappropriately. She said that she was in the unit covering for the CNA when the incident occurred, and it was not witnessed by other staff. During an interview on 09/30/24 at 3:30 p.m., the previous DON R said she was the active DON at the facility on 08/02/24. She recalled the incident with Resident #1 touching another female resident's breast. She said she was called to the secure unit that morning after breakfast and the CN reported that Resident #1 had touched another female resident's breast and was laughing and leering and was unable to be redirected and when removed from the area by staff he was talking sexually to staff and grabbing at their breast. She said she told the CN to keep Resident #1 on one-on-one monitoring and that she requested the SW to contact a local behavioral hospital for a transfer due to the behavior. She said that she notified all department heads (including the Administrator) during the 9:00 am morning meeting that day. She said Resident #1 was monitored until he was transferred to a local hospital for evaluation for placement into their behavioral unit. She said she did not recall the female resident's name that Resident #1 touched inappropriately. During an observation on 10/05/24 at 9:35 a.m., Resident #1 was in his wheelchair alone in the hallway of the secure unit. During an observation and interview on 10/05/24 at 9:41 a.m., CNA E was in the dining room of the secure unit with 5 residents. She said she had never observed Resident #1 touch any residents or staff inappropriately. She said she was never told he needed to be monitored closely due to inappropriate sexual touching. During an observation and interview on 10/05/24 at 9:44 a.m., CNA CC was in the dining room of the secure unit with 5 residents. She said Resident #1 always talked sexually to staff and he had said some vulgar things to her, but she was never told he had sexually/inappropriately touched another resident or to monitor him closely. 2. Record review of a face sheet dated 10/05/24 indicated Resident #4 [AGE] years old, initially admitted to the facility 03/13/24 and readmitted on [DATE]. Her diagnosis included dementia (loss of cognitive functioning), cognitive communication deficit (a difficulty with communication caused by disruption to cognition, or brain processes like attention, memory, and Problem solving), and major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Record review of a quarterly MDS assessment dated [DATE] indicated Resident #4 was usually understood and sometimes understands others. She had a BIMS of 08 (moderately impaired cognitively). She exhibited no behaviors over the 7 days look back period. She required moderate assistance for most ADLS. She was always incontinent of bladder and frequently incontinent of bowel. Record review of a care plan last revised 07/19/24 for Resident #4 did not indicate she had been touched inappropriately on 08/25/24. Record review of an incident report dated 08/25/24 at 7:45 a.m. and signed by RN U indicated CNA heard Resident #4 yell, let go of my titty. CNA saw Resident #1 grabbing Resident #4's breast and reported the incident to her. Record review of an incident report dated 08/25/24 at 11:18 a.m. and signed by RN U indicated CNA reported to her that she saw Resident #1 touch a female resident on her breast. Residents were separated. Calls placed to notify ADON, NP, and RN T (previous Abuse Coordinator) and resident's FM UU. Resident #1 was on every 30-minute monitoring. Record review of a behavior monitoring log indicated Resident #1 was monitored hourly from 08/25/24 at 8:00 a.m. to 08/27/24 at 10:00 p.m. There was no documentation of further monitoring. Record review of a progress note dated 08/28/24 at 9:22 a.m. authored by previous MDS Coordinator DD indicated call placed to responsible party of Resident #1 to inform that resident has been having changes in behavior, both inappropriate sexual behaviors and aggressive behavior. Resident has been accepted to a behavioral hospital. Record review of a Behavior Monitor Post an Incident in-service dated 8/28/24 indicated, Immediately after an incident involving resident with physical, verbal, or sexual aggression, the CN will place the resident on monitoring checks, and fill out the from q 1 hr, q 30 min, q 15 min. Call provider and supervisor to notify them of incident. They will continue monitoring checks until the IDT can review the incident and place further interventions. During an interview on 09/25/24 at 10:21 a.m. RN T said she was made aware of the incident between Resident #1 and Resident #4. She said staff reported to her (the acting abuse coordinator) Resident #1 and Resident #4 were sitting at a dining table on the secure unit. Staff reported Resident #4 said Resident #1 grabbed her. Resident #1 denied he grabbed Resident #4's breast. She said both residents had low BIMS scores and there was no willful intent. During an interview on 09/25/24 at 12:15 p.m., CNA BB said she was getting all the residents into the dining room for the breakfast meal. She said it looked like Resident #1 was touching Resident #4's breast and then he reached for the coloring book and crayons that was on the dining table. She said she told Resident #1 he did not need to be so close to the ladies and he moved away. She said she advised RN U of the incident. She said RN U called the abuse coordinator. She said Resident #4 did not say anything. She said Resident #1 said he did not touch Resident #4's breast. He said he was reaching for the crayons. During an interview on 9/27/2024 at 4:00 pm, RN U said that on 8/25/2024 a CNA reported to her that Resident #1 touched a female resident on her breast. RN U said Resident #1 was separated from the female resident, assessed and behavioral monitoring initiated. RN U said she reported the incident to the ADON, NP/MD, AC (RN T) and RP. RN U said that Resident #1 was placed on behavioral monitoring for the incident until the AC (RN T) completed an abuse investigation. RN U said that there were 2 CNAs working the secure unit on 8/25/2024 to provide behavioral monitoring for Resident #1, but one-on-one monitoring was not initiated. She said Resident #1 was monitored q15 minutes. During an observation and interview on 10/05/24 at 9:39 a.m., Resident #4 was sitting in her wheelchair in the dining room of the secure unit. She was appropriately dressed and well-groomed. She was unable to answer questions about the incident and just repeated words spoken to her. During an interview on 10/05/24 at 3:55 p.m., the Administrator said that she was not the active Administrator/Abuse Coordinator at the time of the incidents with Resident #1 touching another female resident's breast on 08/02/24 or on 08/25/24 when Resident #1 touched Resident #4's breast. She said her expectation for incidents involving resident to resident abuse was for the residents to be separated and the aggressor to be placed on one-on-one monitoring for the protection of other residents. She said the facility policy on abuse and neglect addressed protecting residents from harm during the investigation of the incident and placing the resident on one-on-one monitoring. She said the facility abuse policy was not followed for the incidents involving Resident #1. She said the possible negative outcome of not performing one-on-one monitoring of the resident and protecting the other residents could be physical, emotional, or psychological harm of the residents. She said her expectation was care plans be updated when incidents occur, but the current MDS nurse worked remotely and might not have been aware of the incidents. Record review of the undated facility's Abuse and Neglect policy indicated .It is the policy of the facility to administer care and services in an environment that is free from any type of abuse, corporal punishment, misappropriation of property, exploitation, neglect, or mistreatment. The facility follows the federal guidelines dedicated to prevention of abuse and timely and thorough investigations of allegations. These guidelines include compliance with the seven (7) federal components of prevention and investigation. III. Prevention: Have procedures to: provide residents, families, and staff information on how and to whom they may report concerns, incidents and grievances without fear of retribution; and provide feedback regarding the concerns that have been expressed. Identify, correct and intervene in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is more likely to occur. Establish a safe environment that supports consensual sexual relationship. Develop and implement policy on abuse, neglect, theft, exploitation, and misappropriation of property. Deployment of sufficient and trained staff to deal with behaviors in the units. Identification, assessment, care planning for intervention, and monitoring of residents with needs and behaviors that might lead to conflicts or neglect. The supervisions of staff to identify inappropriate behaviors .ensuring health and safety of residents .VI. Protect residents from physical and psychosocial harm during investigations. 1. If the allegation of abuse involves 2 or more residents, they will all be immediately separated for the protection of all residents involved and those potentially affected by the abuse. 2. Affected residents will be assessed for injury. 3. Attending physician will be notified. a. This includes but not limited to full assessment of physical and psychosocial well-being; sending resident to hospital if needed; depending on circumstance, keep resident on 1:1, assign a female/male depending on the accusation/allegation. This was determined to be an Immediate Jeopardy (IJ) on 10/05/24 at 4:40 p.m. The Administrator was notified. The Administrator was provided the IJ template on 10/05/24 at 4:45 p.m. The Facility's Plan of Removal for Immediate Jeopardy was accepted on 10/06/24 at 1:50 p.m. and reflected the following: Action: On 10/05/24 R1 was immediately placed on q 15-minute checks for close monitoring for further behaviors. R1 will remain on q 15-minute checks until IDT team meets in 30 days and reevaluate his behaviors for medical adjustment and determine if R1 will remain on q 15-minute checks or can be discontinued. If Res #1 has additional behaviors, he will be placed one-on-one until psychiatric services can reevaluate his behaviors. Res #1 was placed on q 15 minutes checks due to the recurrent behaviors that require closer monitoring. Charge nurse/nurse managers Immediately assessed R2 and the rest of the residents in the secure unit for possible mental, physical, or sexual abuse, no additional mental health needs were identified, nor any suspected physical abuse found at this time. 0 out of 10 residents were affected. Administrator/abuse coordinator Immediately in-service all staff 100% completion on Abuse & Neglect policy. for types of abuse (physical, sexual, mental, verbal, neglect, exploitation, and misappropriation) through verbal in-service and written test. Staff were also reeducated for the identification, and intervention in a situation in which abuse, neglect, exploitation and/or misappropriation of resident property is more likely to occur. This education included protecting and/or removing the resident from the situation, as well as who the abuse coordinator is, when to report, and how to report abuse. Staff were reeducated to stay with the aggressor until further instruction from the abuse coordinator and/or until the evaluation or further intervention. on 10/05/24 the Administrator, reeducated 100% of staff on behavioral management policy which included resident to resident abuse in regard to residents exhibiting sexual behaviors towards other and steps to do and approach the situation. Reeducation was provided for the staff with instructions for proper documentation for the behavior monitoring log through verbal in-service with monitoring log attached. Staff were reeducated through verbal in-servicing, tests, and questionnaires. On 10/05/24 MDS nurse immediately reviewed and updated care plan to reflect sexually inappropriate behaviors. The MDS nurse will review all incident reports related to sexual behaviors to make sure interventions were in place, for the floor staff to be able to see in electronic health record (EHC). Administrator/and or designee will reeducate floor staff to review [NAME] in PCC (EHC) for updated interventions for each resident. On 10/06/24 at 11:48 a.m., the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: During interviews conducted on 10/06/24 from 11:05 a.m. though 3:48 p.m. included LVN EE 6:00 a.m. - 6:00 p.m. weekends, LVN FF (6:00 a.m. to 6:00 p.m.) weekends, LVN B (6:00 a.m. 2:00 p.m.), LVN GG (2:00 p.m. to 10:00 p.m.), LVN HH (10:00 p.m. to 6:00 a.m.), LVN X (10:00 p.m. to 6:00 a.m.), MA J (6:00 a.m. to 2:00 p.m & 2:00 p.m. to 10:00 p.m., CNA CC (6:00 a.m. to 2:00 p.m.), CNA E (6:00 a.m. to 2:00 p.m.), CNA JJ (6:00 a.m. to 2:00 p.m.), CNA KK (6:00 a.m. to 2:00 p.m.), CNA LL (6:00 a.m. to 2:00 p.m.), CNA D (2:00 p.m. to 10:00 p.m.), CNA MM (2:00 p.m. to 10:00 p.m.), CNA NN (10:00 p.m. to 6:00 a.m.), and CNA OO (10:00 p.m. to 6:00 a.m.), CNA PP (10:00 p.m. to 6:00 a.m.), Dietary Aide QQ, Housekeeper RR, Occupational Therapist SS, Staffing LVN TT and ADON who worked all shifts. Staff were able to identify the Abuse Coordinator as the administrator. Staff indicated they were to report allegations of abuse and neglect immediately to the Administrator and were able to give examples of physical, verbal, sexual abuse and immediate intervention procedures. They were able to state immediate actions to take when an allegation was made and/or identified, such as immediately removing residents from the situation and stay with the aggressor one-on one until further instruction from the Abuse Coordinator. They verbalized proper documentation of behavior monitoring logs. CNA CC and CNA E said they were now aware of Resident #1's sexual behaviors and the resident was to be monitored q15 minutes. They said they documented every 15 minutes on Resident #1's behavior monitoring log. CNA CC and CNA E said they were in-serviced on abuse/neglect and gave examples of physical, verbal, and sexual abuse. They said the Administrator was the Abuse Coordinator and they would immediately report any abuse/neglect allegations to the Administrator. CNA CC and CNA E gave examples of immediate interventions they would take when an allegation or made incuding removing residents from the situation and staying with the aggressor one on one until the Administrator was notifed and gave further instruction. During an interview on 10/06/24 at 3:55 p.m., the Administrator said she had conducted in-services with all staff addressing the facility abuse/neglect policy and initiating one-on-one monitoring with the aggressor until they were given further instructions on monitoring. She had addressed the different types of abuse and staff had passed a written test. She said she instructed staff on documentation in behavior monitoring logs. She in-serviced staff on the facility's behavioral management policy which included resident abuse. She said staff were required to pass behavioral management test. She said Resident #1's care plan had been updated and a q15 minute monitoring was required by staff until the IDT meeting in 30 days to re-evaluate his behaviors. During an observation and interview on 10/06/24 at 1:15 p.m., Resident #1 was in the TV room with CNA E with no sexual behaviors noted. CNA E said she was assigned to monitor Resident #1 because he was being monitored q15 minutes for sexual behaviors and she was observed documenting the checks on his behavioral monitoring log. Record review of behavioral monitoring logs for Resident #1 indicated he was being monitored by staff every 15 minutes beginning on 10/05/24 at 6:00 p.m. to monitor for sexually inappropriate behaviors. Record review of a check off list of secured unit residents indicated all residents on the secure unit were assessed by charge nurses and the ADON. Record review of nursing assessments completed by the ADON and charge nurses for Resident #4 and all other secure unit residents indicated all residents were assessed for physical and psychosocial changes on 10/05/24. There was no evidence of sexual abuse noted on the assessments. Record review of Resident #1's care plan indicated it was updated on 10/05/24 and included he exhibiting unwanted sexual behaviors with interventions of referral to psychiatric services and increased monitoring for behaviors and changes in mental status. Record review of Resident #4's care plan indicated it was updated on 10/05/24. Record review of facility incident/accident reports indicated no other incidents of inappropriate sexual behaviors. Record review of quiz results, dated 10/05/24 and 10/06/24, indicated all staff passed the quiz regarding abuse, neglect, reporting, and one-on-one monitoring. Record review of a list of all facility staff used for tracking the required in-service training on abuse/neglect, behavioral monitoring, and behavioral management indicated all facility staff had received the in-service training in person or by phone. The Administrator was informed the IJ was removed on 10/06/24 at 3:58 p.m. The facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put in place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to immediately consult with the resident's physician, and notify, consistent with his or her authority, the resident representative when there was a significant change in the resident's physical, mental or psychosocial status for 2 of 7 residents (Resident #1 & #2) reviewed for resident rights. The facility failed to ensure Resident #1's physician and responsible party were immediately notified on 04/19/24 after Resident #1 placed a pillow over Resident #2's face and said she tried to kill her. The facility failed to ensure Resident #2's physician was immediately notified on 04/19/24 after she reported Resident #1 had put a pillow over her face while she was sleeping and tried to kill her. On 04/22/24 at 11:03 a.m., an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 04/23/24, the facility remained out of compliance at a severity level with potential for more than minimal harm and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. These failures could place residents at risk of a delay in medical intervention and decline in health or possible worsening of symptoms. Findings included: 1. Record review of Resident #1's face sheet, dated 04/20/24, indicated she was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included schizophrenia (a serious mental condition involving breakdown in the relation between thought, emotion, and behavior, leading to faulty perception, inappropriate actions and feelings, withdrawal from reality and personal relationships into fantasy and delusion), persistent mood [affective] disorder (marked disruptions in emotions {severe lows called depression or highs called hypomania or mania]), and anxiety disorder (intense, excessive, and persistent worry and fear about everyday situations). Record review of Resident #1's care plan, dated 10/25/23, indicated Resident #1 had a diagnosis of schizophrenia and was at risk for manic episodes and increased behaviors. Interventions included monitor for delusions and hallucinations and monitor for increased agitation, anger, verbal, and physical aggression and document in clinical record. Resident #1 was taking psychotropic medication and was at risk for adverse reactions and depression, anxiety, and/or psychosis driven behaviors. Interventions included monitor for anxiety driven behaviors and report any noted behaviors to MD for further orders. Record review of Resident #1's quarterly MDS assessment, dated 04/08/24, indicated Resident #1 was able to make herself understood and usually understood others, and had moderate cognitive impairment indicated by a BIMS score of 11. She had had no hallucinations, delusions, or physical or verbal behaviors. She required partial to moderate assistance with most ADLs. Record review of Resident #1's clinical file revealed there were no care plans available for review related to homicidal ideations. Record review of a clinical note dated 04/20/24 at 09:59 a.m., and completed by the DON, indicated she spoke with behavioral hospital to initiate referral process due to Resident #1's aggressive behaviors towards other residents. Spoke over the phone with Resident #1's POA to inform of behaviors and sending resident to a behavioral hospital. Verbal consent given by POA. NP for physician also in agreement. Record review of a late entry clinical note dated 04/20/24, at 10:30 a.m., and completed by LVN A, indicated LVN A was notified by CNA B that Resident #2 was yelling for help as Resident #1 had placed a pillow over Resident #2's face and held it over her face. Resident #2 came out of her room yelling for help. Residents were separated and assessed with no bruising to Resident #2's face or complaints of shortness of breath. Resident #1 stated, don't send me to jail please send me to a mental institution. Resident #2 was moved to another room for her protection and safety. Paged on call physician and awaiting response. 2. Record review of Resident #2's face sheet, dated 04/20/24, indicated she was a [AGE] year-old female who was admitted to the facility 12/05/23. Resident #2 had diagnosis which included dementia (a condition characterized by progressive or persistent loss of intellectual functioning) with agitation, major depressive disorder (a metal health disorder characterized by persistently depressed mood causing significant impairment in daily life), and schizophrenia. Record review of Resident #2's quarterly MDS dated [DATE] indicated Resident #2 was able to make herself understood and understood others, and had severe cognitive impairment indicated by a BIMS score of 6. She had feelings of being down, depressed, and hopeless 2-6 (several) days and had no behaviors. Record review of Resident #2's care plan, dated 07/31/23 indicated Resident #2 had an altered thought process and was at risk for further decline and injury as evidenced by dementia and short- and long-term memory deficit. Interventions included keep resident and others safe and monitor for mental status changes. During a telephone interview on 04/20/24 at 08:40 a.m., the Administrator said she received a text from LVN A on 04/19/24 at approximately 06:00 a.m., when she woke up reporting that Resident #1 had placed a pillow over Resident #2's face and Resident #1 was requesting to go to a mental institution. She said her immediate action had been to request an additional CNA from her corporate office and she had just received approval for the CNA this morning but had not hired a new CNA yet. The Administrator said LVN A's text indicated she had called the MD but had not received a response. The Administrator said she was not sure if the MD or Resident #1's RP had been notified about the incident. During an observation and interview on 04/20/24 at 09:10 a.m., Resident #1 was alone in her room on the secure unit resting in bed. She said yesterday (04/19/24) her roommate (Resident #2) was trying to put spells on her, and she had to stop her. She said she tried to hurt Resident #2. Resident #1 would not say how she tried to hurt Resident #2. During an observation and interview on 04/20/24 at 09:15 a.m., Resident #2 was alone in her room on the secure unit lying in bed. She said she had to be moved to a new room because her previous roommate had put a pillow over her face and tried to kill her while she was sleeping. She said she felt as safe as she could in her present surroundings. During an interview on 04/20/24 at 09:35 a.m., the DON said she was not at the facility on 04/19/24 because she had to work the night shift last night. She said she was notified on 04/19/24 that Resident #1 put a pillow over Resident #2's face, but she was now looking back on what was done after the incident. She said LVN A reported the incident, but there was no documentation in the clinical notes that she notified the MD or Resident #1's RP. The DON said Resident #2 was her own RP. The DON said notifications should have been made immediately after the incident, but she was notifying the physician and Resident #1's RP now. During a telephone interview on 04/20/24 at 9:55 a.m., LVN A said on 04/19/24 at 03:30 a.m., CNA B called her and reported that Resident # 1 had placed a pillow over Resident #2's face and tried to smother her. She said CNA B had separated the residents when she arrived on the secure unit. She said she assessed Resident #2 who had no visible injuries, but she kept repeating she tried to kill me. LVN A said Resident #1 admitted she tried to kill Resident #2. LVN A said she did not notify Resident #1's RP about the incident. LVN A said she paged the MD twice but did not receive a response. She said she gave report to LVN C about the incident and that she had not received a return call from the MD. LVN A said she assumed LVN C would notify the MD. LVN A said she had not documented her attempts to notify the MD. During an interview on 04/20/24 at 10:05 a.m., LVN C said he received report from LVN A on 04/19/24 at 06:00 a.m. about the incident between Resident #1 and Resident #2. He said LVN A reported to him she had paged the MD twice and not received a response. He said he did not try to notify the MD or Resident #1's RP about the incident on 04/19/24. During an interview on 04/20/24 at 10:51 a.m., the DON said she notified the NP of the incident that occurred on 04/19/24 to the NP and Resident #1's RP on 04/20/24 at approximately 10:00 a.m. She said she had completed the referral to the behavioral hospital for Resident #1 and was awaiting her transfer. She said the NP gave no new orders for Resident #2. During an interview on 04/20/24 at 02:30 p.m., the DON said she expected all resident changes of condition to be reported immediately to the MD and the resident's RP. She said not reporting these changes could result in harm to the resident or a further decline in the resident's physical or emotional health. During a telephone interview on 04/20/24 at 3:25 p.m., the MD said he did not receive any pages on 04/19/24 and the incident of Resident #1 putting a pillow over the face of Resident #2 had not been reported to him. The MD said if the incident had been reported to him, he would have given orders to transfer Resident #1 to a behavioral hospital. During an observation and interview on 04/20/24 at 02:59 p.m., Resident #1 was walking with ambulance attendants and the DON to an awaiting ambulance. The DON said Resident #1 was being transferred to a behavioral hospital. During a telephone interview on 04/22/24 at 11:15 a.m., the NP said she was notified on 04/20/24 at 09:57 a.m. by the DON of the incident that happened on 04/19/24 when Resident #1 had put a pillow over the face of Resident #2 and admitted to trying to kill her. NP said she gave an order to the DON to transfer Resident #1 to a behavioral hospital. During a telephone interview on 04/22/24 at 11:23 a.m., Resident #1's RP said he was notified of Resident #1 putting a pillow over Resident #2's face by the DON the morning of 04/20/24 and gave the DON his permission to send Resident #1 to a behavioral hospital. Record review of the facility's undated Change in Resident's Condition or Status policy, Indicated Our facility shall promptly notify the resident, his or her attending physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (for example, changes in level of care, billing/payments, resident rights, et cetera). This was determined to be an Immediate Jeopardy (IJ) on 04/22/24 at 08:40 a.m. The Administrator was notified. The Administrator was provided with the IJ template on 04/22/24 at 11:03 a.m. The following Plan of Removal submitted by the facility was accepted on 04/23/24 at 08:08 a.m. Immediate Action: -On 4-20-24 Director of Nursing called Responsible party and the Physician to notify him of the incident involving R1 and R2 on 4-19-24. New orders received to send R1 to inpatient psychiatric hospital. -On 4-22-24 ADON re-educated all nurses on notification policy and what steps to take if the incident occurs as outlined in the change of condition policy. 100% compliance was completed. -On 4-22-24 ADON and Administrator reviewed all new physician orders incident reports and progress notes to make sure any changes in conditions physician were notified. 3 residents were identified as having a change in condition and the physician and responsible party was notified immediately, new orders to be sent to Behavior hospital on all. In-Services All licensed nursing staff were in-serviced on immediate notification of the MD, the RP, the Administrator, and the DON of any mental or physical change in a resident's condition. The ADON completed in-service on the facility's Change in a Resident's Condition or Status policy on 04/22/24. Monitoring On 04/22/24 the Administrator and the ADON reviewed all new physician orders, incident reports, and progress notes to ensure the physician was notified of any change in resident condition. Monitoring of the POR included the following: During interviews on 04/22/24 from 4:00 p.m. through 6:00 p.m. and 04/23/24 from 9:15 a.m. through 10:15 a.m. with LVN A 10 p.m. - 6 a.m., LVN C (6:00 a.m. to 2:00 p.m.), LVN D (6:00 a.m. -2:00 p.m.), LVN E (6:00 a.m. to 2:00 p.m. and 2:00 p.m. to 10:00 p.m.), LVN F (10:00 p.m. to 6:00 a.m.), LVN G (10 p.m. to 10 p.m.), LVN H (2:00 p.m. to 10:00 p.m., LVN I (2:00 a.m. to 10 p.m.), RN J (weekend shifts), and LVN K (6:00 a.m. to 2:00 p.m. and 2:00 p.m. to 10:00 p.m.) and the ADON indicated staff were able to identify the Abuse Coordinator as the administrator. Licensed staff all indicated they were educated on reporting any change of resident condition immediately to the Administrator, DON, MD, and RP. All staff verbalized knowledge of examples of changes in resident condition such as an accident or incident involving the resident, injury of an unknown source, change in the resident's physical/emotional/mental condition, or adverse reactions to medications. The ADON indicated all licensed staff had received in-service training either in person, by email, or be text. During an interview on 04/23/24 at 10:20 a.m., the Administrator said she was in-serviced on 09/22/24 by the Regional Director of Clinical Operations (RCDO). She was able to verbalize the facility change of condition policy and the facility would conduct a thorough investigation of all incidents of resident verbal or physical aggression to others. She said the physician would be notified immediately of any change of condition of any resident. She and the DON would be in-serviced on the change of condition policy upon her return to the facility. She said The DON and ADON would conduct audits daily of any new physician orders, incident reports, progress notes and the 24-hour report to ensure every change in resident condition was reported to the MD and the RP. During an interview on 04/23/24 at 10:25 a.m., the ADON said she was in-serviced on 04/22/24 by the RDCO. She was able to verbalize the facility change of condition policy and the facility would conduct a thorough investigation of all incidents of resident verbal or physical aggression to others. She said the physician would be notified immediately of any change of condition of any resident. She and the DON would be in-serviced on the change of condition policy upon her return to the facility. She said The DON and the ADON would conduct audits daily of any new physician orders, incident reports, progress notes and the 24-hour report to ensure every change in resident condition was reported to the MD and the RP. Record review of all incidents from the previous 90 days indicated there were no additional incidents of resident change of condition not being reported to the MD and the RP. Record review of training records indicated all Licensed staff were in-serviced on 04/22/24 regarding the facility change in resident condition policy, the procedure for reporting any change in resident condition to the resident RP, and physician notification. The Administrator and the ADON were informed the Immediate Jeopardy was removed on 04/23/24 at 10:35 a.m. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm and with a scope identified as isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents the right to be free from abuse for 2 of 7 residents (Residents #2 and #3) reviewed for abuse. 1. On 04/03/24 Resident #3 self-propelled her wheelchair into Resident #1's room and Resident #1 pulled Resident #3 out of her wheelchair onto the floor. 2. On 04/19/24 Resident #1 placed a pillow over the face of Resident #2 and later admitted she was trying to kill Resident #2. On 04/20/24 at 02:29 p.m. an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 04/21/24, the facility remained out of compliance at a severity level with the potential for more than minimal harm and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of thei Plan of Removal. These failures could place residents at risk of abuse, physical harm, mental anguish, and emotional distress. Findings included: 1. Record review of Resident #1's face sheet, dated 04/20/24, indicated she was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included schizophrenia (a serious mental condition involving breakdown in the relation between thought, emotion, and behavior, leading to faulty perception, inappropriate actions and feelings, withdrawal from reality and personal relationships into fantasy and delusion), persistent mood [affective] disorder (marked disruptions in emotions {severe lows called depression or highs called hypomania or mania]), and anxiety disorder (intense, excessive, and persistent worry and fear about everyday situations). Record review of Resident #1's care plan, dated 10/25/23, indicated Resident #1 had a diagnosis of schizophrenia and was at risk for manic episodes and increased behaviors. Interventions included monitor for delusions and hallucinations and monitor for increased agitation, anger, verbal, and physical aggression and document in clinical record. Resident #1 was taking psychotropic medication and was at risk for adverse reactions and depression, anxiety, and/or psychosis driven behaviors. Interventions included monitor for anxiety driven behaviors and report any noted behaviors to MD for further orders. Record review of Resident #1's care plan, dated 10/25/23, indicated Resident #1 was taking psychotropic medication and was at risk for adverse reactions and depression, anxiety, and/or psychosis driven behaviors. Interventions included monitor for anxiety driven behaviors and report any noted behaviors to MD for further orders. Record review of Resident #1's quarterly MDS assessment, dated 04/08/24, indicated Resident #1 was able to make herself understood and usually understand others, and had moderate cognitive impairment indicated by a BIMS score of 11. She had had no hallucinations, delusions, or physical or verbal behaviors. She required partial to moderate assistance with most ADLs. Record review of Resident #1's clinical file revealed there were no care plans available for review related to homicidal ideations. Record review of the incident report dated 04/19/24 at 03:40 a.m., completed by LVN A indicated she was notified by CNA B that Resident #2 was yelling for help because Resident #1 (her roommate) had placed a pillow over Resident #2's face and held it over her face. Resident #2 came out of her room yelling for help. The residents were separated, and Resident #2 was assessed with no bruising on her face and no shortness of breath. Resident #1 admitted she did it and stated, Don't send me to jail please send me to a mental institution. Resident #2 was moved to another room for her protection and safety. MD was paged and LVN A was awaiting response. Administrator was notified. 2. Record review of Resident #2's face sheet, dated 04/20/24, indicated she was a [AGE] year-old female who was admitted to the facility 12/05/23. Resident #2 had diagnosis which included dementia (a condition characterized by progressive or persistent loss of intellectual functioning) with agitation, major depressive disorder (a metal health disorder characterized by persistently depressed mood causing significant impairment in daily life), and schizophrenia. Record review of Resident #2's care plan, dated 07/31/23 indicated Resident #2 had an altered thought process and was at risk for further decline and injury as evidenced by dementia and short- and long-term memory deficit. Interventions included keep resident and others safe and monitor for mental status changes. Record review of Resident #2's quarterly MDS dated [DATE] indicated Resident #2 was able to make herself understood and understood others, and had severe cognitive impairment indicated by a BIMS score of 6. She had feelings of being down, depressed, and hopeless 2-6 (several) days and had no behaviors. During a telephone interview on 04/20/24 at 08:40 a.m., the Administrator said she received a text from LVN A on 04/19/24 at approximately 06:00 a.m. when she woke up reporting Resident #1 had placed a pillow over Resident #2's face and Resident #1 was requesting to go to a mental institution. She said her immediate action had been to request an additional CNA for the secure unit from her corporate office and she had just received approval for the CNA this morning but had not hired a new CNA yet. The Administrator said the secure unit had one dedicated CNA and one nurse that floats between the other rooms and the secure unit. She said Resident #2 had been moved into another room on the secure unit. During an observation and interview on 04/20/24 at 09:05 a.m., CNA L said she was assigned the secure unit today with LVN C who was floating between the secure unit and rooms outside the unit. CNA L was sitting in the TV room with 4 residents and said Residents #1 and #2 were in their rooms alone. During an observation and interview on 04/20/24 at 09:10 a.m., Resident #1 was alone in her room on the secure unit and resting in bed. She said yesterday (04/19/24) her roommate (Resident #2) was trying to put spells on her, and she had to stop her. She said she tried to hurt Resident #2. During an observation and interview on 04/20/24 at 09:15 a.m., Resident #2 was alone in her room on the secure unit lying in bed. She said she had to be moved to a new room because her previous roommate had put a pillow over her face and tried to kill her while she was sleeping. She said she felt as safe as she could in her present surroundings. During an interview on 04/20/24 at 09:35 a.m., the DON said she was not at the facility on 04/19/24 because she had to work the night shift last night. She said was notified on 04/19/24 about Resident #1 putting a pillow over Resident #2's face, but she was now looking back on what was done after the incident. She said LVN A reported the incident, but there was no documentation in the clinical record about the incident or if LVN A notified the police, the physician, or the responsible party. She said notifications should have been made and she was doing the notifications to the MD and RP. She said based on the aggression Resident #1 should have been transferred to a behavioral hospital for evaluation. During a telephone interview on 04/20/24 at 09:55 a.m., LVN A said on 04/19/24 at 03:30 a.m. she received a call from CNA B who reported Resident #1 had placed a pillow over Resident #2's face and tried to smother her. She said CNA B had separated the residents when she arrived on the secure unit. LVN A said she assessed Resident #2 and found no visible injuries, but she kept repeating she tried to kill me. She said Resident #1 admitted she tried to kill Resident #2. LVN A said she paged the MD twice and he did not call by the end of her shift. She said she reported the incident to her Administrator via text and LVN C who was the nurse working the 06:00 a.m. to 02:00 p.m. shift. During an interview on 04/20/24 at 10:05 a.m., LVN C said he received report from LVN A on 04/19/24 at 06:00 a.m. about the incident between Resident #1 and Resident #2. He said LVN A reported to him she had paged the MD twice and not received a response. He said he did not try to notify the MD or Resident #1's RP about the incident on 04/19/24. He said he never noticed if Resident #1 ever came out of her room on his shift and he wasn't sure if Resident #2 was in or out of her room during the day. During a telephone interview on 04/20/24 at 10:21 a.m. CNA B said on 04/19/24 at approximately 03:20 a.m. she was passing by the room Resident #1 and Resident #2 shared when Resident #2 ran out of the room saying Resident #1 put a pillow over her head and tried to kill her. Resident #1 said Resident #2 had been naked during the day and she tried to kill her. Resident #1 then said she wanted to go to a mental hospital in Dallas because that was where her brother sent her whenever she tried to hurt people. CNA B said she separated the residents by bringing Resident #2 into the TV room with her and called LVN A and reported the incident. CNA B said after the incident Resident #1 was pacing up and down the hall talking loudly but not making any sense. She said then Resident #1 went into her room and pulled the mattress off her bed and disrobed and continued pacing around her room. She said Resident #2 said she was afraid to be alone in her room, so CNA B kept Resident #2 with her the rest of the night except when assisting other residents and she took her to sit with LVN A. During an interview on 04/20/24 at 10:51 a.m., the DON said she notified the NP of the incident that occurred on 04/19/24 to the NP and Resident #1's RP on 04/20/24 at approximately 10:00 a.m. She said she had completed the referral to the behavioral hospital for Resident #1 and was awaiting her transfer. She said the NP gave no new orders for Resident #2. During an observation and interview on 04/20/24 at 11:19 a.m., Police Officer M visited Resident #2 in her room. Resident #2 remained alone in her room made a verbal statement to Police Officer M that Resident #1 had tried to kill her by placing a pillow over her face while she was sleeping. She said she wanted to press charges against Resident #1 so she wouldn't try to kill her again. During an observation on 04/20/24 at 11:26 a.m., Resident #1 was sleeping alone in her room. During an interview on 04/20/24 at 03:59 p.m., the DON said she sat with Resident #1 until she was transported by ambulance to a behavioral hospital at approximately 03:30 p.m. 3. Record review of Resident #3's face sheet dated 04/20/24 indicated she was a [AGE] year old female, admitted on [DATE], and her diagnoses included cerebral infarction (stroke), spastic hemiplegia (a common post-stroke condition that causes stiff or rigid muscles) affecting right dominant side, vascular dementia (dementia [a condition characterized by progressive or persistent loss of intellectual functioning] caused by an impaired supply of blood to the brain), mood disorder (marked disruptions in emotions [severe lows called depression or highs called hypomania or mania]), and depression Record review of Resident #3's care plan revised on 06/21/23 indicated Resident #3 was deemed at risk for wandering related to being ambulatory with her wheelchair, diagnosis of dementia, and history of exit seeking. Goals included Resident #3 would be able to wander in a safe environment (secure unit) with no occurrence of injury and dignity would be maintained. Record review of Resident #3's annual MDS dated [DATE] indicated Resident #3 was sometimes able to make herself understood and usually understood others, and had severe cognitive impairment indicated by a staff assessment. She had mood of little interest or pleasure in doing things several (2-6 days) and behaviors directed toward others 1 to 3 days and no wandering behaviors. Record review of Resident #1's clinical note (related to the incident with Resident #3) dated 04/03/24 at 11:30 a.m. and signed by LVN N indicated a CNA B came and informed LVN N that Resident #1 pulled Resident #3 out of her wheelchair onto the floor of Resident #1's room. Resident #1 said I'm not a fucking babysitter, I need help my motherfucking self she needs to keep her ass out of my motherfucking room. On arrival to the secure unit residents were already separated and in different rooms. LVN N educated and redirected Resident #1, she was informed that physical aggression would not be tolerated, and it was not her right to put hands on anyone. LVN A indicated that Resident #1 did not verbalize understanding. During an observation and interview on 04/20/24 at 09:05 a.m., Resident #3 was sitting in the TV room of the secure unit. She was unable to answer question about the incident. She was holding her right arm against her, and it appeared to have contractures at her elbow and wrist. Resident #3 said her arm was not painful. CNA L said Resident #3's arm was paralyzed from a stroke. CNA L said staff tried to keep Resident #3 busy because she wandered into other resident's rooms. She said she was not working the day Resident #3 wandered into Resident #1's room and Resident #1 pulled her out of her wheelchair to the floor, but it had been reported to her by another CNA. During an interview on 04/20/24 at 09:35 a.m. the DON said the only reason Resident #1 had pulled Resident #3 out of her wheelchair on 04/03/24 was because she went into Resident #1's room. She said she had instructed all staff on the secure unit to keep Resident #3 from wandering into other resident's rooms. During a telephone interview on 04/22/24 at 11:35 a.m., LVN N said on 04/03/24 at approximately 11:30 a.m., a CNA reported to her that Resident #3 had self-propelled her wheelchair into Resident #1's room and Resident #1 pulled her out of her wheelchair and onto the floor. LVN N said she assessed Resident #3 who was sitting in the floor of Resident #1's room at the foot of her bed. She had no visible injuries, and she was assisted back into her wheelchair and out of the room. Resident #3 was unable to say how she got onto the floor. LVN N said she notified the ADON, the Administrator, the MD, and the RP of the incident. During a telephone interview on 04/22/24 at 12:16 p.m., Resident #3's RP said she was notified on 04/03/24 by the nurse that Resident #3 had wheeled herself into another resident's room and the other resident had pulled Resident #3 out of her wheelchair and onto the floor. She said Resident #3's right arm had paralysis since her stroke. She said Resident #3 had no bruising or pain after she was pulled from her wheelchair. RP said she visited Resident #3 every day and she had witnessed residents on the secure unit being aggressive to staff and other residents. RP said she could not name the Residents she had seen be aggressive, but she had seen Resident #1 yell and cuss at other residents. She said she had not told the Administration about resident aggression. Record review of the facility's Abuse and Neglect Policy dated June 2023 indicated It is the policy of the facility to administer care and services in an environment that is free of any type of abuse, corporal punishment, misappropriation of property, exploitation, neglect, or mistreatment .The facility follows the federal guidelines dedicated to prevention of abuse and timely and thorough investigations of allegations. These guidelines include compliance with the seven (7) federal guidelines of prevention and investigation .VI. Protect residents from physical and psychosocial harm during investigations. This was determined to be an Immediate Jeopardy (IJ) on 04/20/24 at 02:25 p.m. The Administrator was notified. The Administrator was provided the IJ template on 04/20/24 at 2:29 p.m. The Facility's Plan of Removal for Immediate Jeopardy was accepted on 04/21/24 at 10:37 a.m. and reflected the following: Immediate action: On 4/20/24 Resident #1 was immediately placed on 1 on 1 monitoring until the facility could transfer Resident #1 to psychiatric hospital, waiting on approval from the behavioral hospital to transport. *Charge nurse/ nurse managers Immediately assessed Resident #2 & Resident #3 and the rest of the residents in the secure unit for possible mental or physical abuse, no additional mental health needs were identified, nor any suspected physical abuse found at this time. oAdministrator/abuse coordinator Immediately in-serviced all staff 100% completion on Abuse & Neglect policy. o on 4/20/24 the Director of Nursing, Inservice all 100% of staff on behavioral management policy which included resident to resident abuse regarding residents exhibiting aggressive behaviors towards others, and steps to do, and how to approach the situation. On 4/21/24 the MDS nurse reviewed all residents who have had aggressive behaviors, to make sure interventions were in place, for the floor staff to be able to see in electronic health record (EHR). The facility reviewed the system for abuse identification and reporting. The facility created a plan of improvement to assure residents were free from abuse to address changes including education, daily chart reviews and IDT discussions. The DON and/or Designee will review incident reports and progress notes 5 days weekly to assure that there were no incidents that could meet the qualifications of abuse and discuss any concerns with the abuse coordinator immediately. Resident #1 was placed on one-on-one monitoring until her transfer to a behavioral on 04/20/24. The charge nurses and the nurse managers reviewed all residents on the secure unit on 04/20/24 that were involved in incidents within the last 30 days to ensure all residents had the correct supervision. No additional mental or physical abuse was identified. On 04/20/24 the Administrator completed in-service with all facility staff regarding the behavioral management policy which included resident to resident abuse, residents exhibiting aggressive behaviors, and steps to approach a resident-to-resident situation. On 04/21/23 at 11:48 a.m., the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: During interviews conducted on 04/20/24 from 03:30 p.m. though 06:00 p.m. and 04/21/24 from 08:15 a.m. 11:48 a.m. included LVN A 10 p.m. - 6 a.m., LVN C (6:00 a.m. to 2:00 p.m.), LVN D (6:00 a.m. -2:00 p.m.), LVN E (6:00 a.m. to 2:00 p.m. and 2:00 p.m. to 10:00 p.m.), LVN F (10:00 p.m. to 6:00 a.m.), LVN G (10 p.m. to 10 p.m.), LVN H (2:00 p.m. to 10:00 p.m., LVN I (2:00 a.m. to 10 p.m.),RN j (weekend shifts), and LVN K (6:00 a.m. to 2:00 p.m. and 2:00 p.m. to 10:00 p.m.), CNA B (10:00 p.m. to 6:00 a.m.), CNA L (6:00 a.m. to 2:00 p.m.), CNA O (6:00 a.m. to 2:00 p.m.), CNA P (2:00 p.m. to 10:00 p.m.), CNA Q (2:00 p.m. to 10:00 p.m.), CNA R (10:00 p.m. to 6:00 a.m.), and CNA S (6:00 a.m. to 2:00 p.m.), the Dietary Manager, Dietary Aide T, Dietary Aide U, Housekeeper V, Housekeeper W, MDS Nurse and 1 ADON who worked all shifts. Staff were able to identify the Abuse Coordinator as the administrator. Staff indicated they were to report allegations of abuse and neglect immediately to the charge nurse or administrator and were able to give example of physical, verbal, sexual abuse and immediate intervention procedures. They were able to state immediate actions to take when an allegation was made and/or identified, such as immediately removing the alleged perpetrators from providing care to residents and separating residents. Staff were educated on facility posting related to reporting abuse were able to locate numbers for reporting and alternate methods of reporting abuse such as department supervisors and/ or charge nurses. During an interview on 04/21/24 at 10:20. a.m., the Administrator and the DON indicated the facility 24 Hour Report and Incident Reports would be reviewed in the morning clinical meetings attended by the Administrator and the Director of Nursing to review for any allegations or instances of abuse and/ or neglect. The weekend manager on duty and weekend RN Supervisor would report any incidents or allegations to the DON and administrator immediately. The Administrator was informed the IJ was removed on 04/21/24 at 12:39 a.m. The facility remained out of compliance at potential for more than minimal harm with a scope identified as isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put in place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 of 7 residents (Resident #1) reviewed for accidents and supervision. The facility failed to place Resident #1 on one-on-one supervision or move her to a private room after she pulled Resident #3 out of her wheelchair after Resident #3 self-propelled her wheelchair into Resident #1's room. The facility failed to place Resident #1 on one-on-one supervision after Resident #1 tried to kill Resident #2 (her roommate) by placing a pillow over her face. On 04/20/24 at 02:29 p.m. an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 04/21/24, the facility remained out of compliance at a severity level with the potential for more than minimal harm and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. These failures could place residents at risk of abuse, physical harm, mental anguish, emotional distress, and death. Findings included: 1. Record review of Resident #1's face sheet, dated 04/20/24, indicated she was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included schizophrenia (a serious mental condition involving breakdown in the relation between thought, emotion, and behavior, leading to faulty perception, inappropriate actions and feelings, withdrawal from reality and personal relationships into fantasy and delusion), persistent mood [affective] disorder (marked disruptions in emotions {severe lows called depression or highs called hypomania or mania]), and anxiety disorder (intense, excessive, and persistent worry and fear about everyday situations). Record review of Resident #1's care plan, dated 10/25/23, indicated Resident #1 had a diagnosis of schizophrenia and was at risk for manic episodes and increased behaviors. Interventions included monitor for delusions and hallucinations and monitor for increased agitation, anger, verbal, and physical aggression and document in clinical record. Resident #1 was taking psychotropic medication and was at risk for adverse reactions and depression, anxiety, and/or psychosis driven behaviors. Interventions included monitor for anxiety driven behaviors and report any noted behaviors to MD for further orders. Record review of Resident #1's quarterly MDS assessment, dated 04/08/24, indicated Resident #1 was able to make herself understood and usually understand others, and had moderate cognitive impairment indicated by a BIMS score of 11. She had had no hallucinations, delusions, or physical or verbal behaviors. She required partial to moderate assistance with most ADLs. Record review of Resident #1's clinical file revealed there were no care plans available for review related to homicidal ideations. Record review of Resident #1's clinical note (related to the incident with Resident #3) dated 04/03/24 at 11:30 a.m. and signed by LVN N indicated CNA came and informed LVN N that Resident #1 pulled Resident #3 out of her wheelchair onto the floor of Resident #1's room. Resident #1 said I'm not a fucking babysitter, I need help my motherfucking self she needs to keep her ass out of my motherfucking room. On arrival to the secure unit residents were already separated and in different rooms. LVN N educated and redirected Resident #1, she was informed that physical aggression would not be tolerated, and it was not her right to put hands on anyone. LVN A indicated that Resident #1 did not verbalize understanding. Record review of a psychiatric services visit note completed on 04/17/24 at 11:01 a.m. and signed by the NP indicated Resident #1 was being seen for schizophrenia and anxiety. Goals for treatment included compliance with treatment plan, reduced risk of assaultive or inappropriate behaviors, reduction of psychotic thinking, stabilization of anxious/irritable mood, stabilization of cognitive problems, stabilization of depressed mood, increased interpersonal interactions and reduced withdrawal. Resident #1 had shown mild improvement in response to treatment. Record review of the incident report dated 04/19/24 at 03:40 a.m., Completed by LVN A indicated she was notified by CNA B that Resident #2 was yelling for help because Resident #1 (her roommate) had placed a pillow over Resident #2's face and held it over her face. Resident #2 came out of her room yelling for help. The residents were separated, and Resident #2 was assessed with no bruising on her face and no shortness of breath. Resident #1 admitted she did it and stated, Don't send me to jail please send me to a mental institution. Resident #2 was moved to another room for her protection and safety. MD was paged and LVN A was awaiting response. Administrator was notified. During a telephone interview on 04/20/24 at 08:40 a.m., the Administrator said she received a text from LVN A on 04/19/24 at approximately 06:00 a.m. when she woke up reporting Resident #1 had placed a pillow over Resident #2's face and Resident #1 was requesting to go to a mental institution. She said her immediate action had been to request an additional CNA for the secure unit from her corporate office and she had just received approval for the CNA this morning but had not hired a new CNA yet. The Administrator said the secure unit had one dedicated CNA and one nurse that floats between the other rooms and the secure unit. She said Resident #2 had been moved into another room on the secure unit. She said no other safety measures had been put in place on the secure unit. During an observation and interview on 04/20/24 at 09:05 a.m., CNA L said she was assigned the secure unit today with LVN C who was floating between the secure unit and rooms outside the unit. CNA L was sitting in the TV room with 4 residents and said Residents #1 and #2 were in their rooms alone. During an observation and interview on 04/20/24 at 09:10 a.m., Resident #1 was alone in her room on the secure unit and resting in bed. She said yesterday (04/19/24) her roommate (Resident #2) was trying to put spells on her, and she had to stop her. She said she tried to hurt Resident #2. Resident #1 could not recall trying to hurt any other residents. During an interview on 04/20/24 at 09:35 a.m., the DON said she was not at the facility on 04/19/24 because she had to work the night shift last night. She said was notified on 04/19/24 about Resident #1 putting a pillow over Resident #2's face, but she was now looking back on what was done after the incident. She said LVN A reported the incident, but there was no documentation in the clinical record about the incident or if LVN A notified the police, the physician or the responsible party. She said notifications should have been made and she was doing the notifications to the MD and RP. She said based on the aggression Resident #1 should have been transferred to a behavioral hospital for evaluation. The DON said the only reason Resident #1 had pulled Resident #3 out of her wheelchair on 04/03/24 was because she went into Resident #1's room. She said she had instructed all staff on the secure unit to keep Resident #3 from wandering into other resident's rooms, but no additional safety measures had been put in place. During an interview on 04/20/24 at 10:05 a.m., LVN C said he received report from LVN A on 04/19/24 at 06:00 a.m. about the incident between Resident #1 and Resident #2. He said he was assigned to the secure unit and other rooms outside the secure unit on the 06:00 a.m. to 02:00 p.m. shift on 04/19/24. He said he never noticed if Resident #1 ever came out of her room on his shift and he wasn't sure if Resident #2 was in or out of her room during the day. During an interview on 04/20/24 at 10:51 a.m., the DON said she notified the NP of the incident that occurred on 04/19/24 to the NP and Resident #1's RP on 04/20/24 at approximately 10:00 a.m. She said she had completed the referral to the behavioral hospital for Resident #1 and was awaiting her transfer. She said the NP gave no new orders for Resident #2. During an observation on 04/20/24 at 11:26 a.m., Resident #1 was sleeping alone in her room. Staff were assisting other residents on the secure unit with ADLs. There was no one-on-one monitoring with Resident #1. During an interview on 04/20/24 at 02:30 p.m., the DON said the facility only placed residents on one-on-one monitoring if they were homicidal or suicidal. She said Resident #1 was not placed on one-on one monitoring, but she should have been. The DON said was going to sit with Resident #1 (after surveyor intervention) until she was transported to the behavioral hospital. She said not having her under increased monitoring could result in harm to other residents on the secure unit. During a telephone interview on 04/20/24 at 3:25 p.m., the MD said he did not receive any pages on 04/19/24 and the incident of Resident #1 putting a pillow over the face of Resident #2 had not been reported to him. The MD said if the incident had been reported to him, he would have given orders to transfer Resident #1 to a behavioral hospital. During an interview on 04/20/24 at 03:59 p.m., the DON said she sat with Resident #1 until she was transported by ambulance to a behavioral hospital at approximately 03:30 p.m. 2. Record review of Resident #2's face sheet, dated 04/20/24, indicated she was a [AGE] year-old female who was admitted to the facility 12/05/23. Resident #2 had diagnosis which included dementia (a condition characterized by progressive or persistent loss of intellectual functioning) with agitation, major depressive disorder (a metal health disorder characterized by persistently depressed mood causing significant impairment in daily life), and schizophrenia. Record review of Resident #2's care plan, dated 07/31/23 indicated Resident #2 had an altered thought process and was at risk for further decline and injury as evidenced by dementia and short- and long-term memory deficit. Interventions included keep resident and others safe and monitor for mental status changes. Record review of Resident #2's quarterly MDS dated [DATE] indicated Resident #2 was able to make herself understood and understood others, and had severe cognitive impairment indicated by a BIMS score of 6. She had feelings of being down, depressed, and hopeless 2-6 (several) days and had no behaviors. Record review of a psychiatric visit note completed on 04/17/24 at 11:01 a.m. and signed by the NP indicated Resident #2 was being seen for anxiety, dementia, depression/sadness, schizophrenia, bipolar, and insomnia. Resident #2 was oriented to person, place, month, and situation. Resident #2 exhibited a logical thought process with fair insight and judgement. She had little to no risk of aggression. Record review of Resident #2's clinical note dated 04/19/24 at 03:54 a.m. and signed by LVN A indicated she was notified by CNA that Resident #2 came running out of her room yelling for help and saying her roommate (Resident #1) placed a pillow over her face and held it over her face. The residents were separated, and Resident #2 was assessed with no bruising on her face and no shortness of breath. Resident #2 was moved to another room for her protection and safety. During an observation and interview on 04/20/24 at 09:15 a.m., Resident #2 was alone in her room on the secure unit lying in bed. She said she had to be moved to a new room because her previous roommate had put a pillow over her face and tried to kill her while she was sleeping. She said she felt as safe as she could in her present surroundings. During an observation and interview on 04/20/24 at 11:19 a.m., Police Officer M visited Resident #2 in her room. Resident #2 remained alone in her room and made a verbal statement to Police Officer M that Resident #1 had tried to kill her by placing a pillow over her face while she was sleeping. She said she wanted to press charges against Resident #1 so she wouldn't try to kill her again. During an interview on 04/22/24 at 01:45 p.m., CNA O said she worked the 06:00 a.m. to 02:00 p.m. on 04/19/24 and the incident of Resident #1 putting a pillow over Resident #2's face was reported to her by CNA B. She said Resident #1 was in a happy mood all day going into and out of the TV room listening to the music that was playing in the room. CNA O said Resident #2 said she was afraid to be in her room and stayed close to her or other residents in the TV room. She said Resident #2 kept saying, why is she still here-she tried to kill me. 3. Record review of Resident #3's face sheet dated 04/20/24 indicated she was a [AGE] year old female, admitted on [DATE], and her diagnoses included cerebral infarction (stroke), spastic hemiplegia (a common post-stroke condition that causes stiff or rigid muscles) affecting right dominant side, vascular dementia (dementia [a condition characterized by progressive or persistent loss of intellectual functioning] caused by an impaired supply of blood to the brain), mood disorder (marked disruptions in emotions [severe lows called depression or highs called hypomania or mania]), depression Record review of Resident #3's care plan revised on 06/21/23 indicated Resident #3 was deemed at risk for wandering related to being ambulatory with her wheelchair, diagnosis of dementia, and history of exit seeking. Goals included Resident #3 would be able to wander in a safe environment (secure unit) with no occurrence of injury and dignity would be maintained. Record review of Resident #3's annual MDS dated [DATE] indicated Resident #3 was sometimes able to make herself understood and usually understood others, and had severe cognitive impairment indicated by a staff assessment. She had mood of little interest or pleasure in doing things several (2-6 days) and behaviors directed toward others 1 to 3 days and no wandering behaviors. Record review of a psychiatric services visit note completed 04/10/24 at 11:06 a.m. and signed by the NP indicated Resident #3 was being seen for anxiety, dementia, and depression/sadness. Resident #3 was aphasic (unable to speak, write, or understand speech or writing because of damage to the brain) with no behavioral problems. Goals for treatment included adjustment to need for placement in facility, increased compliance with treatment plan, stabilization of anxious/irritable mood, stabilization of cognitive problems, stabilization of depressed mood, increased interpersonal interactions and reduced withdrawal. Resident had shown mild decline in response to treatment. During an observation and interview on 04/20/24 at 09:05 a.m., Resident #3 was sitting in the TV room of the secure unit. She was unable to answer question about the incident. She was holding her right arm against her, and it appeared to have contractures at her elbow and wrist. CNA L said staff tried to keep Resident #3 busy because she wandered into other resident's rooms. She said she was not working the day Resident #3 wandered into Resident #1's room and Resident #1 pulled her out of her wheelchair to the floor, but it had been reported to her by another CNA. During an interview on 04/20/24 at 09:35 a.m. the DON said the only reason Resident #1 had pulled Resident #3 out of her wheelchair on 04/03/24 was because she went into Resident #1's room. She said she had instructed all staff on the secure unit to keep Resident #3 from wandering into other resident's rooms. During an interview on 04/20/24 at 10:51 a.m., the NP said the facility notified her on 04/03/24 of the incident of Resident #1 pulling Resident #3 out of her wheelchair and onto the floor. During a telephone interview on 04/22/24 at 11:35 a.m., LVN N said on 04/03/34 at approximately 11:30 a.m., a CNA reported to her that Resident #3 had self-propelled her wheelchair into Resident #1's room and Resident #1 pulled her out of her wheelchair and onto the floor. Resident #3 was on the floor in Resident #3's room. LVN N said she assessed Resident #3 who was sitting in the floor of Resident #1's room at the foot of her bed. She had no visible injuries, and she was assisted back into her wheelchair and out of the room. Resident #3 was unable to say how she got onto the floor. LVN N said she notified the ADON, the Administrator, MD, and the RP of the incident. During a telephone interview on 04/22/24 at 12:16 p.m., Resident #3's RP said she was notified on 04/03/24 by the nurse that Resident #3 had wheeled herself into another resident's room and the other resident had pulled Resident #3 out of her wheelchair and onto the floor. RP said she visited Resident #3 every day and she had witnessed residents on the secure unit being aggressive to staff and other residents. Record review of the facility's Abuse and Neglect Policy dated June 2023 indicated VI. Protection: Have procedures to: Protect residents from physical or psychosocial harm during the investigation . 3. Attending physician will be notified. A. This includes but not limited to full assessment of physical and psychosocial well-being; sending resident to hospital if needed; depending on circumstance, keep resident on 1:1, assign a female/male depending on the accusation/allegation. Record review of the facility's undated policy Problematic Behavior Management- Clinical Protocol indicated 2. The staff will identify, document, and inform the Physician about a resident's mental status, behavior, and cognition. This will include details about any problematic behavior such as onset, frequency, and precipitating factors. This was determined to be an Immediate Jeopardy (IJ) on 04/20/24 at 02:25 p.m. The Administrator was notified. The Administrator was provided the IJ template on 04/20/24 at 2:29 p.m. The Facility's Plan of Removal for Immediate Jeopardy was accepted on 04/21/24 at 10:37 a.m. and reflected the following: Action: o On 4/20/24 Resident #1 was immediately placed on 1 on 1 until the facility could transfer Resident #1 to psychiatric hospital, waiting on approval from the behavioral hospital to transport. On 4/20/24 Charge nurse/ nurse managers Immediately reviewed residents in the secure unit that have had recent incidents within the last 30 days involving resident altercation to make sure they had the correct supervision. 0 residents besides Resident #1 were identified. Charge nurse/ nurse managers Immediately assessed Resident #2 & Resident #3 and the rest of the residents in the secure unit for possible mental or physical abuse, no additional mental health needs were identified, nor any suspected physical abuse found at this time. o on 4/20/24 Administrator/ or designee Immediately in-service all staff 100% completion on behavioral management policy which included resident to resident abuse regarding residents exhibiting aggressive behaviors towards others, steps to do and how to approach the situation. o On 4/20/24 the Administrator reviewed schedules and a second CNA was added in the secure unit for extra supervision. If a resident was identified as a repeated aggressor, the facility will immediately add additional support staff in order to keep residents safe. On 4/21/24 Administrator/ DON were Inservice by Regional Director of Clinical Operations if additional staff was needed for immediate safety interventions no approval was needed from corporate to add additional staff for support. After completion of secure unit resident review/assessments on 04/20/24 by charge nurses and nurse mangers, no other residents were found to have additional mental health needs and no other suspected physical abuse was found. The facility reviewed the system for problematic behavior management. The facility created a plan of improvement to assure residents behaviors were monitored, documented, and reported to the MD. The Administrator reviewed schedules and a second CNA was added in the secure unit for extra supervision and if a resident was identified as a repeated aggressor, the facility will immediately add additional support staff in order to keep residents safe. All staff were educated on behavioral management policy which included resident to resident abuse regarding residents exhibiting aggressive behaviors towards others. steps to do and how to approach the situation. Until alternative and/or safe living arrangements were made the resident will be placed on one-on-one supervision with facility staff. Resident care plans will also be updated to include any acts of aggression or being to receiver of aggression. Monitoring of the POR included the following: During interviews conducted on 04/20/24 from 03:30 p.m. though 06:00 p.m. and 04/21/24 from 08:15 a.m. 11:48 a.m. included LVN A (10 p.m. - 6 a.m.), LVN C (6:00 a.m. to 2:00 p.m.), LVN D (6:00 a.m. -2:00 p.m.), LVN E (6:00 a.m. to 2:00 p.m. and 2:00 p.m. to 10:00 p.m.), LVN F (10:00 p.m. to 6:00 a.m.), LVN G (10 p.m. to 10 p.m.), LVN H (2:00 p.m. to 10:00 p.m., LVN I (2:00 a.m. to 10 p.m.),RN j (weekend shifts), LVN K (6:00 a.m. to 2:00 p.m. and 2:00 p.m. to 10:00 p.m.), CNA B (10:00 p.m. to 6:00 a.m.), CNA L (6:00 a.m. to 2:00 p.m.), CNA O (6:00 a.m. to 2:00 p.m.), CNA P (2:00 p.m. to 10:00 p.m.), CNA Q (2:00 p.m. to 10:00 p.m.), CNA R (10:00 p.m. to 6:00 a.m.), CNA S (6:00 a.m. to 2:00 p.m.), the Dietary Manager, Dietary Aide T, Dietary Aide U, Housekeeper V, Housekeeper W, MDS Nurse and 1 ADON who worked all shifts. Staff were able to verbalize procedure of separating residents during an act of aggression, reporting the aggression to a charge nurse, the ADON, the DON, and the Administrator. To maintain one-on one monitoring of the aggressor for the protection of other residents. Licensed staff verbalized aggression incidents should also be reported to the MD, police, and both resident's RPs. Interviews conducted with five alert residents on 04/21/24 from 8:00 a.m. to 10:00 a.m. indicated they would report abuse to the administrator or the DON. They were not afraid of any residents. During an interview on 04/21/24 at 10:20. a.m., the Administrator and the DON indicated the facility 24 Hour Report and Incident Reports would be reviewed in the morning clinical meeting attended by the Administrator and Director of Nursing to review for any allegations or instances physical aggression. The weekend manager on duty and weekend RN Supervisor would report any incidents or allegations to the DON and administrator immediately. Record review of all incidents from the previous 90 days indicated there were no additional incidents of acts of physical aggression as of 04/21/24. Record review of training records indicated all staff (nursing and non-nursing) were in-serviced on 04/20/24 and 04/21/24 regarding the facility abuse and neglect policy and the behavioral management policy, the procedure for reporting incidents and acts of aggression, suspected abuse/neglect, recognizing threats of harm (to self and others), and physician notification. The Administrator was informed the Immediate Jeopardy was removed on 04/21/24 at 12:39 p.m. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm and with a scope identified as isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure basic life support, including cardiopulmonary resuscitation (CPR), was provided to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advance directives for 1 of 2 residents (Resident #1) reviewed for CPR. The facility failed to ensure staff utilized the AED (automated external defibrillator- a medical device that analyzes the heart's rhythm and, if necessary, delivers an electrical shock to the heart in attempt to re-establish an effective rhythm) when Resident #1 was found on [DATE] unresponsive, not breathing, and no pulse. Resident #1 was pronounced deceased on [DATE]. An IJ was identified on [DATE] at 3:57 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place residents at risk of not receiving necessary life-saving measures, decline in health, and death. Findings include: Record review of Resident #1's face sheet dated [DATE] indicated he ws a [AGE] year old male admitted to the facility on [DATE] with diagnoses including type II diabetes (a disease that occurs when blood glucose, also called blood sugar, is too high), cerebral infarction (pathologic process that results in an area of necrotic tissue in the brain), chronic combined systolic and diastolic congestive heart failure (systolic CHF, the ventricles cannot produce enough pressure in the contraction phase to push blood into circulation, diastolic CHF, the ventricles cannot relax, expand, or fill with enough blood-combined CHF is a combination of the two), hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time) with heart failure, acute kidney failure (kidneys are suddenly not able to filter waste products from the blood), hyperlipidemia (also known as high cholesterol, means too many lipids (fats) in the blood), morbid obesity, hypokalemia (low blood potassium levels), respiratory failure with hypoxia (not have enough oxygen in your blood), and angina pectoris (chest pain or discomfort due to coronary heart disease). The face sheet indicated Resident #1 was a full code (if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures would be provided to keep them alive. This process can include chest compressions, artificial ventilation and defibrillation and is referred to as CPR.). Record review of Resident #1's quarterly MDS dated [DATE] indicated he had clear speech, was usually understood and usually understood others, he had moderate impaired cognitive function (BIMS score 11). Record review of Resident #1's care plan dated [DATE] (revised [DATE]) indicated Resident #1's RP requested full code status. Interventions included if Resident #1's heart stops, initiate CPR and call 911 for transfer to the hospital. Record review of Resident #1's physician order dated [DATE] indicated Resident #1 was full code-CPR. Record review of the facility's incident report dated [DATE] at 11:10 p.m. (per LVN A the time was an error) completed by LVN A indicated Resident #1 was noted lying face down on the floor. Resident #1 was unresponsive. His name was called and he was rolled on to his back. Code team was initiated and 911 was called. Staff performed resuscitation efforts until paramedics took over. Physician, RP, and DON notified. Resident #1's breathing was noted as noisy, labored, long period of hyperventilation, ([NAME] Stokes Respiration- respiration is a type of breathing disorder characterized by cyclical episodes of apnea and hyperventilation). He was comatose-(unrousable to verbal or physical stimuli). Record review of the progress note dated [DATE] at 2:50 a.m., completed by LVN A indicated LVN A reassessed Resident #1 post fall. Resident #1 was lying on the floor face down. Resident #1 was not breathing. LVN attempted to get BP, pulse ox (electronic device that measures the saturation of oxygen carried in red blood cells). Resident #1 did not respond to his name or sternum rub. Code team was initiated and 911 was called. After several attempts to resuscitate Resident #1, he was pronounced expired by doctor via EMS. Notified physician. Family notified and present in facility. Record review of the EMS run time provided by SW I indicated EMS received an alarm on [DATE] at 11:28 p.m. EMS left the faciity on [DATE] at 12:29 a.m. Record review of the facility's crash cart check of list dated [DATE] and [DATE] indicated there was no AED device listed. During an interview on [DATE] at 10:43 a.m., LVN A said Resident #1 had a fall at approximately 10:45 p.m. on [DATE]. She said the time indicated on the incident report was an approximate time and not the correct time. She said CNA B assisted to get Resident #1 up and into his wheelchair. She said he was yelling and cussing. When she asked him why he did not push the call light for help, Resident #1 got up from his wheelchair and went to the toilet then got clean clothes and went to bed. She said she assessed Resident #1 and all his vital were WNL . She said he did not hit his head and had clear speech. She said she told Resident #1 she would be back in 15 minutes to complete another set of neurological checks. She said she went to administer medications to two other residents and was returning to Resident #1's room at approximately 11:15 p.m. when CNA B indicated Resident #1 was on the floor. She said Resident #1 was face down on the floor and did not respond to his name or to sternum rub. She said he had no pulse and she could not get a pulse. She said she called for the crash cart and directed a CNA (she could not recall which CNA) to call 911. She said she began CPR because Resident #1 was a full code. She said she continued CPR until EMS arrived and took over. She said she did not call for the AED and did not use the AED during CPR for Resident #1. She said she could not recall why she did not call for the AED or use the AED during CPR. She said she had her CPR training and CPR card. She said she should have used the AED and followed the prompts. She said the AED device was used for giving the heart a shock if it was needed. During an interview on [DATE] at 10:55 a.m., the DON said she received a call on [DATE] at 11:38 p.m. from LVN A. LVN A reported Resident #1 was unresponsive and the paramedics were working on him. She said she arrived in the facility on [DATE] at 11:42 p.m. to cover a shift. Observation on [DATE] at 11:05 a.m. revealed the facility's crash cart was adjacent to the nurse station. The check off list did not include AED inspection. Observation of the AED device indicated it was in a red box with a sign hanging on a wall halfway between the nurse's station and the dining room area. There was no inspection or check off list available for review. During an interview on [DATE] at 11:39 a.m., the DON said she asked LVN A why she did not use the AED during CPR for Resident #1 on [DATE]. She said LVN A said she did not know and that she was probably busy with CPR and did not think about the AED. She said LVN A should have called for the AED and the crash cart. She said the AED device was used for giving the heart a shock if it was needed. She said the only AED was located down the hall from where the crash cart was located (by the nurse station). She said she had scheduled training for 2:00 p.m. today ([DATE]) to re-train staff to remember to use the AED during CPR. The DON said there was no separate check off list for the AED device. She said she checked the device daily and replaced the pads when necessary. During an interview on [DATE] at 3:15 p.m., CNA B said on [DATE] at approximately 11:15 p.m., she was passing Resident #1's door and saw he was lying face down on the floor . She said he did not respond when she called his name. She said she called for LVN A as LVN A was coming up the hall and she went immediately into the room. She said she assisted to roll Resident #1 over on to his back. She said LVN A called Resident #1's name and rubbed his chest and Resident #1 did not respond. She said CNA D arrived and was directed to call 911. She said LVN A began CPR. CNA B said she went to get LVN C from another area of the facility. She said LVN C brought the crash cart. She said CNA D returned to the room and said she called 911. She said she did not recall anyone calling for the AED device. She said she did not think or remember to get the AED device. She said she had her CPR card and knew the AED device was should have been implemented during the CPR for Resident #1. She said the AED device was used for giving the heart a shock if it was needed. The surveyor called, left a voicemail, and sent a text to LVN C on [DATE] at 3:46 p.m. for an interview. The surveyor left her contact information. LVN C did not respond. Record review of LVN A's CPR card was issued on [DATE] and valid until 10/2025. Record review of LVN C's CPR card issued on [DATE] and valid for two years. Record review of the facility's undated Emergency Procedure-Cardiopulmonary Resuscitation indicated Personnel have completed training on the initiation of the cardiopulmonary resuscitation (CPR) and basic life support (BLS), including defibrillation, for victims of sudden cardiac arrest. 4. The chances of surviving SCA may be increased if CPR is initiated immediately upon collapse, 5. Early delivery of a shock with a defibrillator plus CPR within 3 to 5 minutes of collapse can further increase chances of survival. Record review of the facility's undated Automatic External Defibrillator policy indicated The facility has an automatic external defibrillator (AED) equipment available for emergency use. The Administrator was notified on [DATE] at 3:57 p.m. that an Immediate Jeopardy situation was identified due to the above failure. The Administrator was provided the Immediate Jeopardy template and the plan of removal was requested on [DATE] at 4:06 p.m. The facility's Plan of Removal was accepted on [DATE] at 8:14 a.m. and included: Action: Immediately an In-service was conducted with nurses on CPR/ and using AED machine when someone is in cardiac arrest, 100% in-service completion was done by Director of Nursing on [DATE]. Licensed nurses are the only ones to perform CPR and use AED currently at the facility. The Clinical Director of Operations provided the Director Of Nursing (DON) a modified crash cart checklist which included AED machine, DON was in serviced on form to be checked off daily by nurses to ensure AED is operable and ready for usage. Director of Nursing completed services with nurses on [DATE]. AED will be placed with the Crash cart for easy access during CPR. Please review and accept this Plan of Removal. All items above have been completed with completion date and time [DATE], at 8:30 pm. On [DATE] the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Observation on [DATE] at 8:45 a.m. revealed the crash cart was located under the AED (located in a red box under a sign) in the hall between the nurse station and the dining room. The daily check sheet was updated with checks to include the AED and checked off by nursing staff. The green indicator light was flashing on the AED. The DON verified that the AED was functioning as intended. Interviews were conducted on [DATE] from 9:00 a.m. through 10:35 a.m. with the Administrator, the DON, LVN E 6-2, LVN F 6-2, CNA G 6-2 and 2-10, CNA H 6-2, prn other shifts, CNA J 6-2, prn other shifts, RNA K 8-5 Monday-Friday, CMA L 6-2, prn other shifts, CNA M 10-6, LVN A 10-6, and LVN N weekend doubles. They indicated they received an in-service on [DATE] and were aware the AED was supposed to be collected with the crash cart and utilized when staff called for the crash cart/911. They were aware the crash cart was moved from the nurse station and located under the AED on the wall, in the hall between the nurse station and the dining room. The nurses also said that checking the box marked AED meant the AED was above the crash cart and the AED's blinking green indicator light was observed. The nurses said the flashing green indicator light the AED was ready for use. Record review of an in-service dated [DATE] indicated all nursing staff were trained on the CPR policy including the use of AED and daily checks of the crash cart and of the AED to ensure it was working. Record review of the daily check sheet for the crash cart was updated on [DATE] with checks to include the AED. The sheet was checked off on [DATE] by nursing staff. While the IJ was removed on [DATE] at 10:37 a.m., the facility remained out of compliance at no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to immediately consult with the resident's physician of lab results and treatment recommendations for 1 of 8 residents (Resident #1) reviewed for change of condition. The facility did not notify Resident #1's wound care doctor or primary physician of recommendations dated 11/16/22 for antibiotics for possible wound infection of the right foot and a CT or MRI to rule out (osteomyelitis inflammation or swelling that occurs in the bone). Resident #1 had a partial resection of the 5th metatarsal of the right foot and wound and muscle debridement of the left trans-metatarsal stump on 12/15/22. The facility did not notify or consult Resident #1's physician of stat lab dated 11/22/22 results positive for MRSA. An Immediate Jeopardy (IJ) situation was identified on at 01/25/23 at 12:58 p.m. While the IJ was removed on 01/26/23 at 2:40 p.m., the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of not receiving immediate corrective actions necessary for their health and that could cause, or likely continue to cause, serious injury, harm, impairment or death. Findings included: Record review of physician orders dated 01/03/2022 indicated Resident #1 was a [AGE] year-old male re-admitted on [DATE] (originally admitted on [DATE]). His diagnoses included long term use of antibiotics, acute osteomyelitis (inflammation or swelling that occurs in the bone) right ankle and foot, diabetes (a disease that occurs when your blood glucose, also called blood sugar, is too high , cellulitis bacterial skin infection that causes redness, swelling, and pain in the infected area of the skin, gangrene (death of body tissue due to a lack of blood flow or a serious bacterial infection), non-pressure chronic ulcer of left foot, cellulitis of left lower limb and acute osteomyelitis of left foot and ankle. Record review of an MDS dated [DATE] indicated Resident #1 had moderate impaired cognition, was understood by others and usually understood others. He was not able to focus and had disorganized thinking. He had delusions. He required supervision for most ADLS. He utilized a wheelchair for mobility. He was continent of bladder and bowel. Resident #1 had surgical wounds and received surgical wound care. There was no antibiotic use noted. Record review of a care plan dated 11/09/22 indicated Resident #1 had right foot amputation of small toe and was at risk of further skin breakdown, infection, and worsening surgical wound. Interventions included inform MD of progress and perform treatment per order and if no improvement report to MD. Record review of a care plan dated 11/09/2022 indicated Resident #1 had a left foot amputation of toes and was at risk for further skin breakdown, infection and worsening surgical wound. Interventions included inform MD of progress and perform treatment per order and if no improvement report to MD. Record review of a wound evaluation dated 11/16/22, completed by RN B, indicated Resident #1's right lateral toe's surgical wound measured 3.5 cm X 2.0 cm X .3 cm, 25 % slough (necrotic tissue that needs to be removed from the wound), and moderate serous exudate (type of exudate that is clear, thin, and watery in contrast to a purulent exudate that is opaque). There was purulent (discharging) pus present and RN B recommended ABT (Bactrim, Doxycycline) and a CT or MRI to rule out osteomyelitis (inflammation or swelling that occurs in the bone). Record review of Resident #1's clinical record indicated there was no progress note or treatment note available for review from the wound care consult on 11/16/22. Record review of progress note dated 11/21/22 at 12:08 p.m., completed by RN N (previous DON) indicated Resident #1 complained he had drainage to bilateral feet. Scant amount of clear drainage noted with no signs of infection. MD A's office was called and there was no answer and would follow-up. Record review of progress note dated 11/21/22 at 4:57 p.m., completed by ADON D, indicated she contacted MD A's office and received order for wound culture of wounds to bilateral feet. Antibiotic to be ordered once results were received. Record review of STAT lab results dated 11/22/22 indicated Resident #1 was positive for methicillin-resistant Staphylococcus aureus (MRSA) - (staph infection that is difficult to treat because of resistance to some antibiotics). Record review of wound care report dated 12/13/22, competed by DPM C indicated Resident #1 was admitted to hospital for infection of right foot. Record review of a history and physical report (included with the hospital records) dated 12/14/22 indicated Resident #1 had osteomyelitis with gangrene at right metatarsal site. Record review of consult report (included with the hospital records) dated 12/15/22 indicated Resident #1 had a partial resection of the 5th metatarsal of the right foot and wound and muscle debridement of the left trans-metatarsal stump. The wound cultures were growing MRSA. Resident #1 returned to the facility on [DATE]. During an observation and interview on 12/30/23 at 10:50 a.m., Resident #1 was wearing a protective foot device on his right and left foot. He said he had a staph infection on his foot and was in the hospital and received intravenous antibiotics. He said he had to have more amputations because he did not get the antibiotics he was supposed to get. He could not recall who said he should have antibiotics. During an interview on 01/04/23 at 10:07 a.m., TX LVN E said she made wound rounds with RN B (wound care consultant) on 11/16/22. She said it was toward the end of her shift and she asked a nurse to fax the wound care consult with recommendations to Resident #1's wound care doctor (DPM C) and to follow up because she was not returning to the facility. She said 11/16/22 was the last day she worked in the facility. She said she could not recall the name of the nurse she gave the recommendations or directions to notify the physician. She said she did not notify Resident #1's primary physician or DPM C. She said she could not recall if she documented the recommendations in a progress note. During an interview on 01/04/23 at 1:40 p.m., LVN F said she worked on 11/16/22 and did not recall TX LVN E giving her a wound care recommendation for Resident #1 or being directed to fax it to DPM C. During an interview on 01/04/23 at 2:00 p.m., ADON H said she worked on 11/16/22 and did not recall TX LVN E giving her a wound care recommendation for Resident #1 or being directed to fax it to DPM C. During an interview on 01/4/23 at 3:26 p.m., RN L (from the wound care clinic) said they did not have any knowledge and were not informed of RN B's recommendations dated 11/16/22 for Resident #1 that included ABT (Bactrim, Doxycycline) and a CT or MRI to rule out osteomyelitis. During an interview on 01/04/23 at 5:10 p.m., RN B said she was a wound care consultant and was contracted by the facility to observe wound care and train the staff. She said she completed rounds with TX LVN E on 11/16/22 and noted purulent pus and made recommendation for ABT and CT or MRI to rule out osteomyelitis. She said TX LVN E should have informed the primary physician of the assessment and recommendations. She said some primary physicians would direct the facility to forward the recommendations to the wound care physician. She said infection of the wound could get to the blood or get septic (infected with microorganisms, especially harmful bacteria). During an interview on 01/05/23 at 9:43 a.m., ADON D said she did get the order for Resident #1's wound culture on 11/21/22. She said she was new to the position and should probably have followed up on the results. She said she was off sick and then forgot to follow up when she returned to work. During an interview on 01/05/23 at 10:54 a.m., MD A said he did not receive notification of Resident #1's wound culture results dated 11/22/22 regarding positive MRSA results. He said the facility staff should have notified him of RN B's recommendations dated 11/16/22 for Residents #1. He said the delay of notification, treatment, or ABT most likely would not have made any difference because Resident #1 had been on multiple [NAME] and was ABT resistant. He said Resident #1 was non-compliant with wound care and physician orders. MD A said it was also most likely to require additional surgeries and amputations. During an interview on 01/05/23 at 12:06 p.m., ADON H said if they received recommendations from consultants, they would contact the physician. ADON D said lab results were supposed to be called or faxed over to the physician for review. ADON H said the lab results should be noted in the progress notes and also in the 24-hour report. During an interview on 01/05/23 at 12:27 p.m., LVN J said all recommendations for care, tests, or treatments were supposed to be sent to the physician for review. LVN M said lab results were supposed to be called or faxed over to the physician for review. LVN M They said the lab results are supposed to be noted in the progress notes and also in the 24-hour report. During an interview on 01/05/23 at 8:25 a.m., the DON said Resident #1's lab results were not forwarded to MD A. She said the lab results should have been followed up by nursing staff to ensure Resident #1 received treatment. She said the results were in the facility electronic portal but not all staff had access to the portal. She said not informing the physician of recommendations or lab results could result in delay of treatment or further decline of condition. She said she could not attribute the delay of antibiotics to Resident #1 requiring additional amputation surgery because he was noncompliant with care and treatment. She said staff were in-serviced on 12/29/22 to ensure labs were documented and followed up as required. During an interview on 01/05/23 at 8:30 a.m., LD I said Resident #1's lab results were available in the portal. He said the lab results were also faxed to the facility. He said he was not able to say who had access to the portal or who reviewed the labs. The surveyors made three attempts on 01/03/23 and three attempts on 01/04/22 were made to contact DPM C regarding Resident #1 and there was no return call. Record review of the facility's undated Laboratory Services and Reporting policy indicated .7. Promptly notify the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of laboratory results that fall outside the clinical reference range. Record review of the facility policy Change in Condition Communication dated 06/19 indicated physicians and nursing staff to promote optimal patient/resident care, provide nursing staff with guidelines for making decisions regarding appropriate and timely notification of medical staff regarding changes in a patients/ residence condition, enter. Provide guidance for the notification of patients/ residents and their responsible party regarding changes in condition. F. Recent Labs The Administrator and the DON were notified an Immediate Jeopardy (IJ) situation was identified on at 01/25/23 at 12:58 p.m. While the IJ was removed on 01/26/23 at 2:40 p.m., the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. The facility's POR dated 01/26/23 indicated: DON and CNO reviewed 24-hour report for the last 24 hours. Changes in condition noted on the 24-hour report were addressed and documented. On 1.25.23 CNO re-educated facility nurses including nurse managers regarding: Documentation on resident's change(s) in condition to include completion of SBAR assessment when notifying MD and documenting on 24-hour report. During shift nurses were educated and those not scheduled to work will be in-serviced prior to their next scheduled shift. Completion Date 1.26.23 @ 12 pm. ADON/Designee will pull 24-hour report and 24-hour lookback and SBARS for completion of MD notification and that orders were followed through. ADONs will bring 24-hour report book and SBAR to clinical morning meeting to discuss follow-up if needed. DON/Designee will audit 24-hour report and SBARS weekly on Wednesdays looking for MD notification and that orders were carried out and acted upon. On 01/26/23 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Record review of staff training dated 01/25/23 indicated all nursing staff were trained in person or by phone to notify the physician via phone call of lab results and document in the electronic records. If there was no response the nursing staff would notify the Medical Director. If there was no answer nursing staff would send the resident to the hospital if it was a critical lab result. Record review of new hire education indicated the DON incorporated physician notification and the facility policy as part of the onboarding education as of 01/26/23. Record review of the facility monitoring sheets indicated the Administrator would verify the education was done for new hires starting 01/26/23. There were no new hires as of 01/26/23. Record review of the monitoring sheets indicated the Administrator reviewed at the morning meetings on 01/26/23 to verify that a change in condition requiring physician notification was done, physician orders, a follow up if physician deemed it necessary and the order was followed through for 3 residents. Record review dated 01/25/23 indicated the Administrator was educated by Corporate Nurse on how review change of condition at morning meetings. During an interview on 01/26/23 at 2:20 p.m., the Administrator was able to verbalize the monitoring for change of condition procedures. She said the DON and the ADON were designees if she was not able to complete the monitoring during morning meeting. Record review of the facility's chart audit dated 01/25/23 indicated the facility had completed 100% chart audit and notified the physicians of any changes as required. Interviews conducted on 01/26/23 from 1:15 p.m. through 2:30 p.m. with the DON, the 2 ADONs, 1 RN, and 6 LVNS, who worked all shifts, indicated they were able to correctly state the protocols for notification of the physician when there was a change of condition or a need to alter treatment for a resident, reviewing and reporting abnormal labs, clarification of verbal orders, ensuring the physician was made aware of the change or condition, and ensuring the physician received the lab results. An Immediate Jeopardy (IJ) situation was identified on at 01/25/23 at 12:58 p.m. While the IJ was removed on 01/26/23 at 2:40 p.m., the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not immediate jeopardy 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 observation, interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive care plan, and resident choices for 1 of 8 residents (Resident #1) reviewed for treatment and services. The facility failed implement interventions and recommendations for Resident #1 dated 11/16/22 for antibiotics for possible wound infection of the right foot and a CT or MRI to rule out (osteomyelitis inflammation or swelling that occurs in the bone). Resident #1 he was admitted to the hospital on [DATE] had a partial resection of the 5th metatarsal of the right foot and wound and muscle debridement of the left trans-metatarsal stump. The facility failed to address Resident #1's stat lab dated 11/22/22 results positive for MRSA. An Immediate Jeopardy (IJ) situation was identified on at 01/25/23 at 12:58 p.m. While the IJ was removed on 01/26/23 at 2:40 p.m., the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of not receiving care as required and could result in further decline of condition and possible death. Findings included: Record review of physician orders dated 01/03/2022 indicated Resident #1 was a [AGE] year-old male re-admitted on [DATE] (originally admitted on [DATE]). His diagnoses included long term use of antibiotics, acute osteomyelitis (inflammation or swelling that occurs in the bone) right ankle and foot, diabetes (a disease that occurs when your blood glucose, also called blood sugar, is too high , cellulitis bacterial skin infection that causes redness, swelling, and pain in the infected area of the skin, gangrene (death of body tissue due to a lack of blood flow or a serious bacterial infection), non-pressure chronic ulcer of left foot, cellulitis of left lower limb and acute osteomyelitis of left foot and ankle. Record review of an MDS dated [DATE] indicated Resident #1 had moderate impaired cognition, was understood by others and usually understood others. He was not able to focus and had disorganized thinking. He had delusions. He required supervision for most ADLS. He utilized a wheelchair for mobility. He was continent of bladder and bowel. Resident #1 had surgical wounds and received surgical wound care. There was no antibiotic use noted. Record review of a care plan dated 11/09/22 indicated Resident #1 had a left foot amputation of toes and right foot amputation of small toe and was at risk of further skin breakdown, infection, and worsening surgical wound. Interventions included inform MD of progress and perform treatment per order and if no improvement report to MD. Record review of a wound evaluation dated 11/16/22, completed by RN B (wound consultant), indicated Resident #1's right lateral toe's surgical wound measured 3.5 cm X 2.0 cm X .3 cm, 25 % slough (necrotic tissue that needs to be removed from the wound), and moderate serous exudate (type of exudate that is clear, thin, and watery in contrast to a purulent exudate that is opaque). There was purulent (discharging) pus present and RN B recommended ABT (Bactrim, Doxycycline) and a CT or MRI to rule out osteomyelitis (inflammation or swelling that occurs in the bone). Review of Resident #1's clinical records indicated there was no progress note or treatment note available for review from the wound care consult on 11/16/22. Record review of progress note dated 11/21/22 at 12:08 p.m., completed by RN N (previous DON) indicated Resident #1 complained he had drainage to bilateral feet. Scant amount of clear drainage noted with no signs of infection. MD A's office was called and there was no answer and would follow-up. Record review of progress note dated 11/21/22 at 4:57 p.m., completed by ADON D, indicated she contacted MD A's office and received order for wound culture of wounds to bilateral feet. Antibiotic to be ordered once results were received. Record review of STAT lab results dated 11/22/22 indicated Resident #1 was positive for methicillin-resistant Staphylococcus aureus (MRSA) - (staph infection that is difficult to treat because of resistance to some antibiotics). There was no documented evidence the results were reviewed by the physician or NP. Record review of wound care report dated 12/13/22, competed by DPM C indicated Resident #1 was admitted to hospital for infection of right foot. Record review of a history and physical report (included with the hospital records) dated 12/14/22 indicated Resident #1 had osteomyelitis with gangrene at right metatarsal site. Record review of consult report (included with the hospital records) dated 12/15/22 indicated Resident #1 had a partial resection of the 5th metatarsal of the right foot and wound and muscle debridement of the left trans-metatarsal stump. The wound cultures were growing MRSA. Resident #1 returned to the facility on [DATE]. During an observation and interview on 12/30/23 at 10:50 a.m., Resident #1 was wearing a protective foot device on his right and left foot. He said he had a staph infection on his foot and was in the hospital and received intravenous antibiotics. He said he had to have more amputations because he did not get the antibiotics he was supposed to get. He could not recall who said he should have antibiotics. During an interview on 01/04/23 at 10:07 a.m., TX LVN E said she made wound rounds with RN B (wound care consultant) on 11/16/22. She said it was toward the end of her shift and she asked a nurse to fax the wound care consult with recommendations to Resident #1's wound care doctor (DPM C) and to follow up because she was not returning to the facility. She said 11/16/22 was the last day she worked in the facility. She said she could not recall the name of the nurse she gave the recommendations or directions to notify the physician. She said she did not notify Resident #1's primary physician or DPM C. She said she could not recall if she documented the recommendations in a progress note. During an interview on 01/04/23 at 1:40 p.m., LVN F said she worked on 11/16/22 and did not recall TX LVN E giving her a wound care recommendation for Resident #1 or being directed to fax it to DPM C. During an interview on 01/04/23 at 2:00 p.m., ADON H said she worked on 11/16/22 and did not recall TX LVN E giving her a wound care recommendation for Resident #1 or being directed to fax it to DPM C. During an interview on 01/4/23 at 3:26 p.m., RN L (from the wound care clinic) said they did not have any knowledge and were not informed of RN B's recommendations dated 11/16/22 for Resident #1 that included ABT (Bactrim, Doxycycline) and a CT or MRI to rule out osteomyelitis. During an interview on 01/04/23 at 5:10 p.m., RN B said she was a wound care consultant and was contracted by the facility to observe wound care and train the staff. She said she completed rounds with TX LVN E on 11/16/22 and noted purulent pus and made recommendation for ABT and CT or MRI to rule out osteomyelitis. She said TX LVN E should have informed the primary physician of the assessment and recommendations. She said some primary physicians would direct the facility to forward the recommendations to the wound care physician. She said infection of the wound could get to the blood or get septic (infected with microorganisms, especially harmful bacteria). During an interview on 01/05/23 at 9:43 a.m., ADON D said she did get the order for Resident #1's wound culture on 11/21/22. She said she was new to the position and should probably have followed up on the results. She said she was off sick and then forgot to follow up when she returned to work. During an interview on 01/05/23 at 10:54 a.m., MD A said he did not receive notification of Resident #1's wound culture results dated 11/22/22 regarding positive MRSA results. He said the facility staff should have notified him of RN B's recommendations dated 11/16/22 for Residents #1. He said the delay of notification, treatment, or ABT most likely would not have made any difference because Resident #1 had been on multiple [NAME] and was ABT resistant. He said Resident #1 was non-compliant with wound care and physician orders. MD A said it was also most likely to require additional surgeries and amputations. During an interview on 01/05/23 at 12:06 p.m., ADON H said if they received recommendations from consultants, they would contact the physician. ADON D said lab results were supposed to be called or faxed over to the physician for review. ADON H said the lab results should be noted in the progress notes and also in the 24-hour report. During an interview on 01/05/23 at 12:27 p.m., LVN J said all recommendations for care, tests, or treatments were supposed to be sent to the physician for review. LVN M said lab results were supposed to be called or faxed over to the physician for review. LVN M They said the lab results are supposed to be noted in the progress notes and also in the 24-hour report. During an interview on 01/05/23 at 8:25 a.m., the DON said Resident #1's lab results were not forwarded to MD A. She said the lab results should have been followed up by nursing staff to ensure Resident #1 received treatment. She said the results were in the facility electronic portal but not all staff had access to the portal. She said not informing the physician of recommendations or lab results could result in delay of treatment or further decline of condition. She said she could not attribute the delay of antibiotics to Resident #1 requiring additional amputation surgery because he was noncompliant with care and treatment. She said staff were in-serviced on 12/29/22 to ensure labs were documented and followed up as required. During an interview on 01/05/23 at 8:30 a.m., LD I said Resident #1's lab results were available in the portal. He said the lab results were also faxed to the facility. He said he was not able to say who had access to the portal or who reviewed the labs. The surveyors made three attempts on 01/03/23 and three attempts on 01/04/22 were made to contact DPM C regarding Resident #1 and there was no return call. Record review of the facility's undated Laboratory Services and Reporting policy indicated .7. Promptly notify the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of laboratory results that fall outside the clinical reference range. Record review of the facility policy Change in Condition Communication dated 06/19 indicated physicians and nursing staff to promote optimal patient/resident care, provide nursing staff with guidelines for making decisions regarding appropriate and timely notification of medical staff regarding changes in a patients/ residence condition, enter. Provide guidance for the notification of patients/ residents and their responsible party regarding changes in condition. F. Recent Labs An Immediate Jeopardy (IJ) situation was identified on at 01/25/23 at 12:58 p.m. While the IJ was removed on 01/26/23 at 2:40 p.m., the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. The facility's POR indicated: CNO and DON reviewed recommendations from Wound Care Consultant's last visit. Recommendations were addressed with Primary Care Physician and followed through. Nurses at the facility including nursing supervisors were re-educated on 1/25/2023 by CNO that: When a recommendation is made to ask the physician for a decision on the recommendation and follow it through. During shift nurses were educated and those not scheduled to work will be in-serviced prior to their next scheduled shift. Completion Date 1.26.23 @ 12 pm. DON will incorporate this education as part of the onboarding education for any newly hired nurses. Dietary, Wound Care, and Pharmacy Consultants will email recommendations to DON/Administrator once visit is complete. DON will forward recommendations to assigned ADON/Designee for MD notification to obtain approval/denial of recommendation. DON/Designee will audit recommendation(s) on day 4, for completion to include MD notification and that orders were carried out and acted upon. On 01/26/23 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Review of recommendations from Wound Care Consultant's last visit were addressed with Primary Care Physician and followed through as of 01/26/23. Review of nurse training and nursing supervisors indicated they were re-educated on 01/25/23 by the CNO to ask the physician for a decision on recommendations and follow it through. All nurses were educated as of 01/26/23 and those not scheduled to work would be in-serviced prior to their next scheduled shift. The DON will incorporate this education as part of the onboarding education for any newly hired nurses. As of 01/26/23 there were no untrained new hires. Review of email notification sent to contracted consultants including dietary, wound care, and pharmacy, indicated they would ensure their recommendations were emailed to the DON and Administrator once they have completed their assessments. During an interview on 01/26/23 at 2:30 p.m., the DON said she would forward all recommendations to assigned ADON/Designee for MD notification to obtain approval/denial of recommendation. She said she or the Designee would audit recommendation(s) on day 4, for completion to include MD notification and orders were followed. Interviews conducted on 01/26/23 from 1:15 p.m. through 2:40 p.m. with the DON, 2 ADONs, 1 RN, and 6 LVNS, who worked all shifts, indicated they would document all recommendations in resident clinical record, shift report, and 24-hour report for follow-up and implementation of orders. They were able to correctly state the protocols for reviewing and reporting abnormal labs, clarification of verbal orders, ensuring the physician was made aware of the change or condition, and ensuring the physician received the lab results. An Immediate Jeopardy (IJ) situation was identified on at 01/25/23 at 12:58 p.m. While the IJ was removed on 01/26/23 at 2:40 p.m., the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not immediate jeopardy 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 observation, interview and record review the facility failed to ensure that a resident who needed respiratory care, which included tracheostomy care and tracheal suctioning, was provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 13 residents (CR #106) reviewed for respiratory and tracheostomy care. The facility failed to ensure CR #106's ventilator alarm was set appropriately according to the ventilator manufacture manual and/or ventilator company guidelines. CR #106 ventilator was not alarming when she was found lifeless with no pulse, she was transferred to the hospital and expired the following day. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated with actual harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. These failures placed residents who are dependent on ventilators at risk of hypoxemia, hospitalization, and death. Findings include: Record review of CR #106's undated face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] and discharged to the hospital on [DATE]. She had diagnoses which included: acute and chronic respiratory failure (the inability of the respiratory system to meet the oxygenation, ventilation, or metabolic requirements of the patient, chronic obstructive pulmonary disease a group of diseases that cause airflow blockage and breathing-related problems), multiple sclerosis (a chronic disease affecting the central nervous system the brain and spinal cord), and tracheostomy (an opening created at the front of the neck so a tube can be inserted into the windpipe [trachea] to help you breathe). Record review of CR #106's Admit/Readmit screener dated [DATE] revealed she was alert and oriented to person, place, time, and situation. She had equipment upon admission which included tracheostomy and ventilator. Additional information for ventilator noted, AVAP - R - 16 IPAP 10 EPAP 7 tv 350. Further review of equipment revealed she had Respiratory treatment and CPAP (continuous positive airway pressure [CPAP] therapy -a common treatment for obstructive sleep apnea. A CPAP machine used a hose connected to a mask or nosepiece to deliver constant and steady air pressure to help you breathe while you sleep). The comments for the CPAP noted, patient has a CPAP left at hospital CPAP used at night. Record review of CR #106's baseline care plan dated [DATE] revealed she had special treatments of oxygen therapy, suctioning, tracheostomy care and ventilator or respirator. Record review of CR #106's hospital discharge records dated [DATE] revealed she was admitted on [DATE] and her reason for visit was Acute Respiratory Failure with Hypoxia/Hypercapnia (represents a specific condition wherein competing mechanisms are simultaneously acting to increase [hypoxia] and decrease [hypocapnia] brain blood flow, resulting in an adjustment that is ideal for neither the regulation of oxygen delivery nor tissue pH). Further review of the discharge record did not indicate ventilator settings or the residents' condition. Record review of CR #106's progress notes dated [DATE] at 8:38 PM by RT A revealed, Patient transported via EMS via stretcher from hospital at approximately 7:55 PM. Patient hooked up to vent, which settings are AVAPS VT 350 Rate 16 IPAP 10 EPAP 7 3L Bleed-in Oxygen. Patient has intact and clean #4 trach. HR 103 O2SAT 99%. Patient able to communicate. Patient tolerating well. No distress noted. Call light string and remote at patient bedside. Patient asked for water to drink and check on fans she had in room at hospital. Further review of the progress note revealed no mention of ventilator alarm settings. Record review of CR #106's progress notes dated [DATE] at 9:23PM revealed, Patient arrived via EMS in a stretcher around 8 p.m. Patient was placed in bed with the wheels lock, call light in reach. Respiratory came setup patient machine and oxygen. On call Doctor was notified about patient arrival waiting on medication reconciliation. Patient was given a sandwich and some water patient appears to not be in any pain she is laying comfortable in the bed resting with her eyes close. Record review of CR #106's physician orders dated [DATE] revealed vent settings: AVAPS Rate 16 (average volume-assured pressure support is a noninvasive technology developed to ensure delivery of a fixed tidal volume [VT ]; how much air is moving in or out of the lungs with every respiratory cycle, along with the benefits and convenience of pressure support ventilation), IPAP 10 (inspiratory positive airway pressure is pressure delivered by the ventilator while the patient is inhaling), EPAP 7 (Expiratory positive airway pressure is pressure delivered by the ventilator while the patient is exhaling), 3L O2 bleed-in with target VT 350 (Tidal volume is the volume of gas inhaled or exhaled during a breath. The average volume of as entering or leaving the lungs per minute). Further review of the order did not reveal information regarding ventilator alarm settings. Record review of CR #106's Detailed Written Order for Home Invasive Mechanical Ventilator from the Ventilator company dated [DATE] revealed her Trilogy Home Invasive Mechanical Ventilator was ordered to be set to: Mode - S/T (The S/T or Spontaneous/Timed mode offers a combination of machine delivered breaths [set respiratory rate] and spontaneous [patient triggered] assisted breaths), AVAPS on, VT target 350, Rate 16, EPAP 7, IPAP 10, IPAP max 25, O2 LPM (bleed-in) 3. Further review of order did not reveal information regarding ventilator alarm settings. Record review of CR #106's physician orders dated [DATE] revealed she may have (Shiley) Trach #4 cuffed (A cuffed trach tube has a balloon cuff around the lower end of the trach tube. It is often used for people who need to use a ventilator or BiPAP machine. When the balloon is filled, air will not leak around the trach tube). Record review of CR #106's progress notes dated [DATE] at 9:02 AM by RT A, revealed, Was informed patient had been pulling vent circuit off. HR 154 O2SAT 96%. Patient laying there with eyes close. On AVAPs rate 16/35, VT 274, Fio2 30% (Percentage of oxygen in the air mixture that is delivered to the patient), IPAP 10, EPAP 7, PIP 24.0 (the peak inspiratory pressure [PIP ] is the highest pressure measured during the respiratory cycle and is a function of both the resistance of the airways and the compliance of the respiratory system). Slight wheeze scattered. Suctioned small white thick secretions. Patient tolerated well. Record review of CR #106's progress notes dated [DATE] at 11:55AM by RT A revealed Heard vent going off. Entered room, found patient had pulled trach completely out. Patient was turning a grey/blue color. Re-inserted the trach, placed back on vent. Patients HR 97 with O2SAT 94%. Patient is reaching to pull off again, nurse aide, came in to sit with patient while Nurse was going get Xanax. Record review of CR #106's physician order started on [DATE] revealed an order for Alprazolam Tablet (Xanax) 0.5mg give 0.5mg by mouth two times a day for anxiety. Record review of CR #106's [DATE] MAR revealed she received Alprazolam Tablet 0.5mg by mouth two times a day for anxiety at 8:00AM and 5:00PM on [DATE]. Record review of CR #106's late entry progress note entered on [DATE] by the DON, dated to reflect [DATE] at 12:33 PM revealed Physician in to visit - he was made aware that resident had an elevated heart rate - respiration. Is currently on Metoprolol - verbal order given to give one time dose of Metoprolol 12.5 mg now and obtain labs in AM- CBC, CMP, lipid. Medication given per MD verbal order. Record review of CR #106's physician orders dated [DATE], revealed an order for Metoprolol Tartrate Tablet 25 mg give 25 mg by mouth two times a day for hypertension. Record review of CR #106's [DATE] MAR revealed Metoprolol Tartrate Tablet 25 mg was set to be administered at 8:00 AM and 5:00 PM starting on [DATE], further review of the MAR revealed an administration for 8 AM on [DATE] was not entered, the 5 PM dose was mark as administered. Record review of CR #106's physician orders and [DATE] MAR revealed no orders or administrations documented of a one time dose of Metoprolol 12.5mg on [DATE]. Record review of CR #106's physician note dated [DATE] at 2:30 PM revealed in part, . patient currently on the vent on SIMV (Synchronized intermittent mandatory ventilation [SIMV] is a type of volume control mode of ventilation. With this mode, the ventilator will deliver a mandatory [set] number of breaths with a set volume while at the same time allowing spontaneous breaths). Tolerating well and has been put on CPAP (continuous positive airway pressure is a machine that uses mild air pressure to keep breathing airways open while you sleep) from time to time. Patient self is alert and showing that she wants to get off the ventilator . Respiratory therapist claimed no evidence of any fever or chills or any other complications. Patient has a tracheostomy with no complications at this point . Assessment/Plan 1. Dependence on respirator - discussed with respiratory therapist. Will put the patient on trach collar 5 minutes at a time and slowly build up her respiratory reserve and then will start weaning her off the ventilator. Breathing treatments every 6 hours Further review of the physicians note revealed no information regarding alarm ventilator settings. Record review of CR #106's progress notes dated [DATE] at 4:12 PM by RT A revealed Patient resting well, tolerating vent settings. No vent changes. HR 136 O2SAT 99%. Fine rales scattered. RR 16/30, VT 341, FIO2 35%, IPAP 10, EPAP 7, PIP 24.9. Suctioned small white thin secretions. Record review of CR #106's progress notes dated [DATE] at 6:57 PM by LVN B revealed, Resident very agitated and pulling at trachea and disconnecting tubing. Resident encouraged not to pull at tubing unsuccessful as resident is confused. Will continue to monitor. Record review of CR #106's ventilator tracking sheet dated [DATE] - [DATE], revealed CR #106's vent settings were checked approximately every 2 hours. Further review of the vent tracking sheet revealed no area regarding ventilator alarm settings. The ventilator tracking sheet showed starting on [DATE] at 9:02 AM CR #106 had an elevated heart rate of 154, the on [DATE] at 12:00 PM the heart rate was 94, on [DATE] at 2:00 PM the heart rate was 144, on [DATE] at 4:12 PM the heart rate was 136, and starting on [DATE] at 6:12 PM the heart rate went down to 88 and remained in the 80's through the last documented ventilator check on [DATE] at 4:00 AM . Record review of CR #106's progress notes, dated [DATE] at 5:18AM, by LVN C revealed, This nurse entered patient room at 5:00 AM due to patient's ventilator alarm machine sounding. 5:10 AM other nurse on shift notified me that resident was not showing any signs of life. CPR started until 911 EMS arrived and took over. Patient being transferred to hospital. Nurse Practitioner was notified of resident not showing any signs of life and transferred to hospital. RP notified at 5:18 AM. Record review of CR #106's hospital discharge summary from admission dated [DATE] revealed reason for hospitalization was PEA arrest (Pulseless electrical activity [PEA] refers to cardiac arrest in which the electrocardiogram shows a heart rhythm that should produce a pulse but does not). Further review of the discharge summary revealed in part, .presents for cardiac arrest. The patient was discharged about 2 days ago to a nursing home after being admitted for respiratory failure. The patient was seen apparently 5 - 10 minutes prior to 911 being called by EMS. EMS reported they arrived, and the patient was asystole (Asystole is a type of cardiac arrest, which is when your heart stops beating entirely. This usually makes you pass out. It's also likely that you'll stop breathing or that you'll only have gasping breaths. Without immediate CPR or medical care, this condition is deadly within minutes). The gave the patient epi (epinephrine) x 3 as well as epi drip. They report asystole was on the monitor the entire time. When the patient arrived in the emergency department there was no pulses felt however there was PEA on the monitor. We continued ACLS (advanced cardiovascular life support) protocols and continued CPR ROSC (Return of spontaneous circulation is the resumption of a sustained heart rhythm that perfuses the body after cardiac arrest) was achieved at 5:41 AM . So far, no evidence of brain activity . she appears terminal at this point . [DATE] family came and signed the TNDA (Texas Natural Death Act) consent. Patient died several hours later . suspect severe respiratory acidosis (Respiratory acidosis is a state in which there is usually a failure of ventilation and an accumulation of carbon dioxide. This causes body fluids, especially the blood, to become too acidic) to blame for PEA Interview on [DATE] at 4:45 PM, LVN C said she worked the 10PM -6AM shift and she recalled CR #106 repeatedly trying to get out of the bed which caused her ventilator alarm to go off because her trach would disconnect. LVN C said the last time she heard CR #106's ventilator alarm go off was around 5:00 AM on [DATE]. LVN C said she went into the room to check on CR #106 when the alarm went off and the resident was fine. LVN C said the ventilator alarm cut off on its own and said whatever the issue was had resolved itself. LVN C said she left out of CR #106 room and continued with her rounds. LVN C said about 10 minutes later she heard LVN D yell out for her to come because there was a situation in CR #106 room. LVN C said she went into CR #106's room and she was lifeless with no pulse so they started CPR and had the CNA's call 911. LVN C said she did not hear CR #106's ventilator alarm going off before LVN D called her to the room. LVN C said LVN D reported she (LVN D) happened to be walking by CR #106 room and noticed from the hallway CR #106 color looked off. LVN C said LVN D reported CR #106 color being off was the cause of her to going into the room to check on CR #106 and discovered CR #106 with no pulse. LVN C said CR #106 ventilator alarm was not going off when LVN D went into CR #106 room and found her with no pulse. Interview on [DATE] at 5:30 PM, the DON said on [DATE] the nursing staff noticed CR #106 heart rate was high and she had some agitation because she kept pulling her trach out. The DON said the physician was notified of the heart rate and behavior and he came to the facility to assess CR #106. The DON said the physician's NP gave a verbal order to administer a one-time dose of metoprolol 12.5 mg to help with the elevated heart rate. The DON said the medication was given by the 2-10 PM shift nurse (LVN B) and said the order was not put into CR #106 electronic orders, but she (the DON) did chart in her note (the DON's late entry note) the medication was given. The DON said her note was a late entry because she did a look back of CR #106 chart and what had transpired and completed some of the charting late. The DON said in her look back of CR #106's discharge she learned LVN D was doing rounds when she found CR #106 unresponsive and initiated CPR. The DON said they called 911 and CR #106 was taken to the hospital. The DON said the staff monitored CR #106 every 2 hours on her ventilator sheet which showed her medications had worked and her heart rate stabilized. The DON said she did not know of any other changes or issues CR #106 had before she was found unresponsive. Interview on [DATE] at 5:45 PM, CNA E said she worked 2PM - 10PM on [DATE] and described CR #106 as being nervous and shaking a lot. CNA E said CR #106 kept grabbing at her trach and the staff would have to stop her and redirect her to leave it alone. CNA E said either herself, RT A, and LVN B were always in the room with CR #106 to keep her from pulling out her trach. CNA E said she did not know why CR #106 was grabbing at her trach and acted the way she did but said the nurse gave CR #106 some medication and she calmed down and went to sleep around 8:30 PM. CNA E did not know what medications CR #106 was given. Interview on [DATE] at 9:20 AM, CNA F said she worked the night shift with CR #106 on [DATE]. CNA F said she recalled CR #106 was irritated throughout the night and the nurse (LVN C) had to sit in the room with CR #106. CNA F said she could tell CR #106 was irritated because she would move around a lot because she did not want the trach. CNA F said she recalled CR #106's alarm going off a couple of times during her shift and she would see LVN C go into the room to check on CR #106. CNA F said she was doing her final rounds around 5 AM when she last heard CR #106 alarm go off and saw LVN C go into CR #106 room. CNA F said LVN C came out of CR #106 shortly after she went in and did not hear the ventilator alarm sounding anymore. CNA F said she did not hear CR #106 alarm go off again but a few minutes later she heard LVN D yelling out for them to come to CR #106 room. CNA F said CR #106 was unresponsive and the nurse's started CPR while she called 911. CNA F said, CR #106 coding seemed to come out of nowhere. Interview on [DATE] at 9:43 AM, LVN B said she worked 2PM-10PM on [DATE] and said she recalled CR #106 was very agitated throughout the shift. LVN B said CR #106 had a lot of anxiety and pulled at her trach which caused her ventilator alarm to go off repeatedly. LVN B said either her or RT A was constantly running to CR #106's room because the alarm was going off and they found her with her trach pulled out holding it in her hand. LVN B said they would reinsert the cannula and redirect her not to pull it out. LVN B said she recalled the DON told her about CR #106 new order for Metoprolol 12.5 mg one time dose and said she did administer CR #106 the medication. LVN B said she also recalled administering some anxiety medication to CR #106 but could not recall what the medication was. LVN B said they had an aide (CNA G) come sit one on one with CR #106 until she finally calmed down. LVN B said CR #106 had calmed down enough to fall asleep but when she woke up, she would still be agitated and pulled at her trach. LVN B said she could not recall if she entered the Metoprolol 12.5 mg order in the electronic record but said it was a busy shift and patient care came first so she may have forgot to go back and document the order and administration of the medication. Interview on [DATE] at 1:00 PM, CNA G said she worked on [DATE] from 11:30 AM - 7:30 PM and she recalled CR #106 panicking and trying to pull out her trach. CNA G said she was assigned to sit with CR #106 to make sure she would not pull out her trach. CNA G said she had to constantly redirect her and ask her to calm down and not pull at her trach. CNA G said she recalled LVN B came in and gave CR #106 some medication and she calmed down enough to fall asleep shortly after. CNA G said she had to go give showers, so LVN B came in to sit with CR #106 when she left. CNA G said CR #106 could communicate on paper and she wrote to her she did not like the trach and did not want it. CNA G said the nursing staff was aware CR #106 did not want the trach. Interview and observation on [DATE] at 2:30 PM, RT A presented CR #106 ventilator she used in the facility which was a Trilogy Vent 100. RT A was able to present the last few alarms alerted on CR #106's ventilator alarm log which showed the circuit disconnect alarm went off on [DATE] at 8:20 PM, 8:26 PM, 8:30 PM and 11:44 PM, then on [DATE] at 12:17 AM, 12:49 AM, 4:27 AM, 4:27 AM, 4:28 AM, 4:29 AM, and 4:44 AM. The last alarm noted in the log was on [DATE] at 9:50 AM which was AC Power Disconnect. RT A said if a resident was on a vent, and they died/had no pulse it would alarm apnea. RT A said circuit disconnect meant there was a disconnect in the circuit which could mean something was unplugged or disconnected. RT A said when the circuit disconnect alarm went off the staff should check the patient and assess why it was going off by checking all the lines and attachments to make sure they were connected. Observation and interview on [DATE] at 5:12 PM, CR #106's alarm settings were reviewed in her ventilator by RT A and state surveyors which showed the circuit disconnect alarm was set for 5 seconds. The alarm settings showed all other alarms were set to off which included: apnea alarm, low Vte alarm, high Vte alarm, Low minute ventilation alarm, High minute ventilation alarm, low respiratory rate alarm, and high respiratory rate alarm. RT A reiterated the apnea alarm would be the alarm to go off if she had no pulse and if just the circuit disconnect alarm was set the alarm would not go off for no pulse or respiratory distress. RT A said staff would have had to physically observe CR #106 during their checks to know she went into cardiac arrest (Cardiac arrest occurs when the heart suddenly and unexpectedly stops pumping) because the alarm would not have gone off in that situation. Interview on [DATE] at 5:15 PM, an EMS representative said the EMS records showed the facility called 911 on [DATE] at 4:51 AM for CR #106 cardiac arrest and the ambulance arrived at the facility on [DATE] at 4:58 AM. Interview on [DATE] at 5:33 PM, RT A said before residents with ventilators were admitted they coordinated with the ventilator company to deliver the ventilator before the resident admitted to the facility. RT A said the ventilator company got the physician orders for the vent settings and they set up the vent with the settings. RT A said when the ventilator company RT delivered CR #106 vent to the facility, her and the vent company RT reviewed the settings together to ensure they were correct before she accepted the vent. RT A said they did look at the alarm settings and said if she noticed the alarms were off, she should have asked the vent company RT to set the apnea alarm. RT A said alarm settings were typically not specified in the physician orders so the vent company RT or herself would have to make sure the appropriate alarms were set. RT A said she had not noticed the alarms were not set for CR #106. RT A said there was a manual for the ventilator for the to refer to. Interview on [DATE] at 5:54 PM, LVN D said she worked the night of [DATE] but she was not CR #106 assigned nurse. LVN D said she recalled CR #106 ventilator alarm going off a few times over night and she saw LVN C went into the room to check the resident. LVN D said it was close to 5:00 AM on [DATE] when she happened to be walking down the hall and glanced into CR #106 room and noticed she looked pale. LVN D said she went into the room and checked for a pulse and CR #106 did not have a pulse, she called out for help and the CNA's and LVN C ran to the room and assisted with running a code blue (a code to rush to the specific location and begin immediate resuscitative efforts). LVN D said there was no ventilator alarm going off when she found CR #106, and her trach was still attached. LVN D said she could not recall if the alarm went off when she disconnected her from ventilator to perform CPR because she was focused on the patient. According to record review Resident #106's ventilator alarm log the last time CR #106 was disconnected was on [DATE] at 4:44 AM and prior to that, the alarm last went off at 4:29 AM which indicated a 15-minute window from the time she was potentially last checked by LVN C and when she was found lifeless and disconnected to perform CPR by LVN D. Interview on [DATE] at 12:15 PM, the Corporate Nurse provided the AARC Clinical Practice Guideline for Long-term Invasive Mechanical Ventilation in the Home - 2007 Revision and Updated and said the ventilator company reported using those guidelines. Record review of AARC (American Association for Respiratory Care) Clinical Practice Guideline for Long-term Invasive Mechanical Ventilation in the Home - 2007 Revision and Updated provided by the Corporate Nurse on [DATE] at 12:15PM revealed in part, .The patient eligible for invasive long - term mechanical ventilation in the home (HIMV) requires a tracheotomy tube for ventilatory support, but no longer requires intensive medical and monitoring services. This guideline refers to patient ventilated by positive pressure via a tracheostomy tube in the home . The setting is the home, which for the purposes of this guideline may be the patient's home, a foster home, or a group living environment . Contraindications to HIMV include: 5.1 The presence of a physiologically unstable medical condition requiring higher level of care or resources than available in the home. Examples of indicators of a medical condition too unstable for the home and long-term care settings are . 5.1.3 Need for continuous invasive monitoring in adult patients . 10.1.6 Alarms 10.1.6.1 A patient disconnect (eg, low-pressure or low-exhaled-volume) and a high-pressure alarm are essential. 10.1.6.2 If patient disconnection is likely to produce a serious adverse effect, a remote alarm and secondary alarm may be indicated. A secondary alarm may be used on chest-wall impedance and cardiac activity, exhaled volume, end-tidal CO2, or pulse oximetry with alarm capabilities Interview on [DATE] at 4:10 PM, the facility Pulmonologist said he was not familiar with CR #106 and said she discharged before he was able to meet/assess her. The Pulmonologist said in his experience with residents on ventilators in long term care, the apnea alarm was the most important alarm to be on. The Pulmonologist said for his patients he expected the apnea alarm to be on but said ventilator manufacturer should be the ones to set the alarms and the facility staff should not deactivate any alarms. The Pulmonologist said it was unfortunate CR #106's apnea alarm and other alarms were not turned on. Interview on [DATE] at 4:31 PM, the [NAME] President (VP) of the ventilator company said the high volume and circuit disconnect are the two alarms they set on the ventilators per the AARC Clinical Guidelines. The VP said the apnea alarm was moot point (A debatable question, an issue open to argument; also, an irrelevant question, a matter of no importance) and they typically did not use it because it could cause alarm fatigue (occurs when clinicians experience high exposure to medical device alarms, causing alarm desensitization and leading to missed alarms or delayed response). CR #106 alarm settings were reviewed with the VP which revealed only the circuit disconnect alarm was on. The VP said he did not know why the high volume alarm would not be set but said it was usually their standard to set both alarms (circuit disconnect and high volume). The VP said they were required to service the machines the facility rents from them, not the patient, and said the facility should coordinate with them if they or physician want settings changed according to the patient's needs. The VP forwarded a copy of the contract between the ventilator company and the nursing facility that lists facility and ventilator company obligations. Record review of the Rental Contract for Medical Equipment between the ventilator company and nursing facility, provided on [DATE] at 5:12 PM by the ventilator company VP, dated [DATE], revealed in part, . C. Company is engaged in the business of renting and selling durable medical equipment . Lessee will lease from company and company will provide at the request of Lessee, items of durable medical equipment for Lessee's patients on an as-needed basis, as requested by Lessee, and strictly in accordance with any and all care plans approved by the patient's physician and Lessee . Lessee will initiate the equipment rental by furnishing to [NAME] a list of the equipment required for each patient. This list will be furnished by Lessee on a case-by-case basis and will be delivered to [NAME] pursuant to the notice requirements . Lessee is entitled during the period of use of any item of equipment to control, operate, and possess the equipment being lease, subject to the direction and supervision of approved personnel of Lessee Further review of the contract revealed an area circled by the VP titled Miscellaneous Services which revealed in part, .Other than the delivery, retrieval and repair and maintenance obligation, as set forth above, company shall have no service obligations whatsoever to the Lessee, other than as expressly agreed in writing between parties at mutually-agreeable rates. Any Respiratory Therapist services (area was underlined by VP), including without limitation, equipment set-up and routine maintenance, mask fitting, patient education, staff in-servicing, 24/7 on-call service for equipment malfunction or discomfort causing service interruption, 24 hour follow-p calls after set-up, 72 hour 3rd party quality control call, weekly compliance follow-up calls for first month, 31 - day and quarterly visits with compliance downloads and education, 7 day compliance program for patients having difficulty, oral and/or tracheal suction and care, clinical assessment, nebulizer treatments, MDI or inhaler treatment, pulse oximetry checks, arterial blood gas draws, and emergency response assistance, and any and all other miscellaneous services will be the sole responsibility of the Lessee, unless expressly agreed otherwise in writing . All services covered by this agreement must be ordered, evaluated, and supervised by Lessee. A registered Respiratory Therapist employed by Lessee will coordinate the services between Lessee and [NAME] . Lessee will retain professional management of the patient for the purposes of managing the patient's illness and treatment Interview on [DATE] at 9:40 AM, the ventilator company RT said she coordinated with RT A when she brought new ventilators to the facility. The ventilator company RT said she delivered the ventilator with the settings already set according to the physician orders. The vent company RT said upon delivery she did go over the settings with RT A to ensure they were correct. The vent company RT said the facility had access to the machines to make changes and said they were given instruction on how to unlock the screen to change the settings if needed. The vent company RT said she ensured RT A knew how to unlock the settings in the event there was an emergency and settings needed to be changed. The vent company RT said the vent company would not leave ventilator machines in facilities without them knowing how to get into the machine. Interview on [DATE] at 2:51 PM, CR #106 physician said CR #106 was not doing well at all and he knew CR #106 from her previous facility. The physician said he did not see CR#106 getting any better, he said she was aspirating constantly, she had dementia, and her brain was not functioning properly to protect her airway. The physician said before CR #106 came to the facility he had consulted with a case manager about hospice for CR #106 because he did not see her getting better. The physician said the family must have decided against hospice in the hospital because she came to the facility on a ventilator. The physician said he was going to speak with the family again regarding hospice and if they decided to still proceed with her receiving treatment for her to get better, he was going to recommend an LTAC (long-term acute care) or sending CR #106 back to the hospital because she needed a higher level of care of what she could receive at the nursing facility. The physician said CR #106 coded before the con[TRUNCATED]