**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, observation, and record reviews, the facility failed to protect residents' rights to be free from verbal abuse, physical abuse, and involuntary seclusion for 7 (Resident #1, 2, 3, 4, 5, 6, and 7) of 12 residents reviewed for abuse and neglect, in that: 1. Residents #2, 5, and 6 were pinched, pulled, and told bad words by CNA A on 01/11/24. 2. CNA A was arguing with Resident #4 in a disrespectful manner on 01/11/24. 3. CNA A was physically aggressive with Resident #7 on 01/11/24 4. Residents #1 and #3 revealed CNA A verbally abused them, undated. The noncompliance was identified as past noncompliance IJ (Immediate Jeopardy). The noncompliance began on 01/11/24 and ended on 01/12/24. The facility had corrected the noncompliance before the investigation began. The facility implemented interventions to prevent further abuse and neglect risks to include educating staff about abuse, neglect, exploitation, performing resident safe surveys to ensure safety of residents, and terminating the alleged perpetrator. This failure could affect all residents at the facility by placing them at risk for physical, mental, and emotional decline, psychosocial harm, and can lead to residents being at risk for harm and injury. The findings included: 1. Record review of Resident #2's face sheet revealed Resident #2 was a female initially admitted to the facility on [DATE] and re-admitted [DATE]. Resident #2 had diagnoses to include major depressive disorder, anxiety disorder, altered mental status, dementia (loss of cognitive functioning that interferes with daily life and activities), and unspecified pain. Record review of Resident #2's BIMS report, completed 10/18/23, revealed resident had a BIMS of 03 out of 15, which signified severe cognitive impairment. Record Review of Resident #2's Nursing progress note, dated 01/11/24 at 05:09 PM, revealed a head-to-toe assessment with a slight discoloration identified on resident's left forearm identified. The MD and RP were notified. Record review of Resident #5's face sheet revealed Resident #5 was a female initially admitted to the facility on [DATE]. Resident #5 had diagnoses to include depression, cognitive communication deficit, anxiety disorder, restlessness and agitation, and mild cognitive impairment. Record review of Resident #5's BIMS report, completed 01/08/24, revealed resident had a BIMS of 03 out of 15, which signified severe cognitive impairment. Record Review of Resident #5's Nursing progress note, dated 01/11/24 at 05:05 PM, revealed a head-to-toe assessment with no skin concerns identified. The MD and RP were notified. Record review of Resident #6's face sheet revealed Resident #6 was a female initially admitted to the facility on [DATE]. Resident #6 had diagnoses to include major depressive disorder, cognitive communication deficit, anxiety disorder, and Alzheimer's disease (brain disorder that causes problems with memory, thinking, and behavior). Record review of Resident #6's BIMS report, completed 12/26/23, revealed resident had a BIMS of 02 out of 15, which signified severe cognitive impairment. Record Review of Resident #6's Nursing progress note, dated 01/11/24 at 05:07 PM, revealed a head-to-toe assessment with no skin concerns identified. The MD and RP were notified. Record Review of Accident/Incident Investigation Witness Statement on 01/11/24, written by NA E in regard to Residents #2, 5, and 6, reflected I report [CNA A] since today she was quite rude and abusive person with the residents, pinching them, pulling them to sit in their place, fighting with them and telling them bad words just because they were not letting her change their briefs. She doesn't let them walk in the hallway and wants to keep them sitting. Since 3:30 pm she took them to the dining room while they were trying to watch a movie. I told her it was too early for food and she got angry. I immediately reported it to my nurse. Attempted interview on 03/06/24 at 10:35-10:40 AM with Resident #2 and #6 with no success due to improper responses. Resident #5 was not in the facility for an interview. 2. Record review of Resident #4's face sheet revealed Resident #4 was a female initially admitted to the facility on [DATE]. Resident #4 had diagnoses to include dementia (loss of cognitive functioning that interferes with daily life and activities), unspecified hip pain, altered mental status, and hearing loss. Record review of Resident #4's BIMS report, completed 12/28/23, revealed resident had a BIMS of 07 out of 15, which signified severe impairment. Record Review of Resident #4's Nursing progress note, dated 01/11/24 at 05:06 PM, revealed a head-to-toe assessment with no skin concerns identified. The MD and RP were notified. Record Review of Accident/Incident Investigation Witness Statement on 01/11/24, written by MA H, reflected I was helping a resident to seat down in the tv room when [CNA A] was arguing in a [disrespectful] manner to the [Resident #4]. I told the CNA to not treat the resident that way. I immediately reported to my nurse. Attempted interview on 03/06/24 at 10:35-10:40 AM with Resident #4 with no success due to improper responses. 3. Record review of Resident #7's face sheet revealed Resident #7 was a female initially admitted to the facility on [DATE]. Resident #4 had diagnoses to include recurrent depressive disorders and unspecified pain. Record review of Resident #7's BIMS report, completed 10/18/23, revealed resident had a BIMS of 02 out of 15, which signified severe impairment. Record Review of Resident #7's Nursing progress note, dated 01/11/24 at 05:07 PM, revealed a head-to-toe assessment with no skin concerns identified. The MD and RP were notified. Record Review of Accident/Incident Investigation Witness Statement on 01/11/24, written by the Activities Director, reflected At 4:30 pm on 1/11 I witnessed [CNA A] aggressively shove a baby doll into [Resident #7] arms and forcefully sit her down. I then reported to ADON. Resident #7 was not in the facility for an interview. 4. Record review of Resident #1's face sheet revealed that Resident #1 was a male initially admitted to the facility on [DATE] and re-admitted [DATE]. Resident #1 had diagnoses to include major depressive disorder, anxiety disorder, and unspecified pain. Record review of Resident #1's BIMS report, completed 01/30/24, revealed resident had a BIMS of 12 out of 15, which signified moderate cognitive impairment. Record review of Resident #3's face sheet revealed that Resident #3 was a male initially admitted to the facility on [DATE] and re-admitted [DATE]. Resident #3 had diagnoses to include depression and anxiety disorder. Record review of Resident #3's BIMS report, completed 02/27/24, revealed resident had a BIMS of 13 out of 15, which signified intact cognition. During an interview on 03/06/24 at 10:42 AM, LVN B revealed CNA A was not physically or verbally abusive towards residents. LVN B mentioned residents would complain about not being able to understand CNA A and CNA A needed to speak more clearly when providing care with residents for them to not be confused and accepting of care. After 01/11/24 incidents of abuse from CNA A, LVN B revealed he reported to ADON prior behaviors he witnessed from other residents to CNA A due to their frustration with the miscommunication and care they would receive from CNA A. He further revealed this may have caused CNA A's inappropriate responses to the residents, which were unacceptable. During an interview on 03/06/24 at 10:57 AM, Resident #1 revealed CNA A was not good and she yelled at him multiple times. Resident #1 revealed he told a nurse (he could not recall their name) and the administrator about CNA A, but they did not do anything about it. He further revealed CNA A yelled at other residents too. During an interview on 03/06/24 at 11:25 AM, MA C revealed CNA A would overwhelm residents due to language barrier and not slowing down to speak with residents. MA C educated CNA A on the job about not overwhelming residents before it would escalate into a problem. MA C further revealed CNA A probably should not have worked in the women's secured unit based on her interactions with CNA A. MA C further revealed she could have written this complaint, had it addressed, and would do this in the future. During an interview on 03/06/24 at 03:22 PM, the ADON revealed 3 residents (2 out of the 3 residents were still at the facility) did not want CNA A to care for them. The ADON further revealed she did not ask why these residents did not want CNA A to be caring for them. The ADON was not able to provide any documentation that showed Residents #1 and #3 had complaints/grievances about CNA A. During an interview on 03/07/24 at 09:22 AM, CNA G revealed Resident #1 reported he did not want CNA A to care for him. CNA G did not ask why Resident #1 felt this way about CNA A, but shared this information with the ADON. CNA G further revealed she could have helped Resident #1 fill out a grievance form to address his complaint. During an interview on 03/08/24 at 10:22 AM, Resident #3 revealed CNA A yelled at him and he did not want CNA A to be in his area. He could not express how he felt during the interview, but he told a CNA, the ADON, and the Administrator D about CNA A but Administrator D didn't do anything about it. During an interview on 03/06/24 at 09:40 AM, the ADON revealed NA E came to Administrator D about abuse on 01/11/24. After this, the ADON interviewed staff about CNA A and 2 other staff (the Activities Director and MA H) confessed more incidents involving CNA A exhibiting abusive behaviors. The ADON revealed CNA A was immediately suspended pending investigations. During an interview on 03/06/24 at 10:13 AM, CNA F revealed CNA A had little patience with residents and should probably not have worked with the individuals in the women's secure unit. CNA F recalled since November 2023 CNA A would be more aggressive with residents in the women's secure unit and should have been more patient. CNA F revealed she had to tell CNA A to calm down with the residents. CNA F reported to her nurse about CNA A's behavior. CNA F further revealed residents would complain to CNA F about CNA A not being nice to them. CNA F further revealed she did not observe any abuse. CNA F could not remember any resident names, nurse names, or specific dates. CNA F revealed she had been trained after this incident on Abuse, Neglect, and Exploitation and was aware to contact the Administrator. During an interview on 03/06/24 at 10:42 AM, LVN B revealed CNA A was not physically or verbally abusive towards residents. LVN B mentioned residents would complain about not being able to understand CNA A and CNA A needed to speak more clearly when providing care with residents for them to not be confused and accepting of care. After 01/11/24 incidents of abuse from CNA A, LVN B revealed he reported to ADON prior behaviors he witnessed from other residents to CNA A due to their frustration with the miscommunication and care they would receive from CNA A. He further revealed this may have caused CNA A's inappropriate responses to the residents, which were unacceptable. LVN B revealed he had been trained and was aware of letting ADON, DON, and the Administrator know of suspected abuse, neglect, and exploitation. During an interview on 03/06/24 at 04:17 PM, MA H revealed she was passing out medications when she observed CNA A was impatient and had inappropriate tone/behavior [MA H did not reveal any arguing]. MA H further revealed she had not seen CNA A act like this towards residents before, but she had expressed stress with residents in the past. MA H revealed NA E came to her after NA E saw CNA A pinching residents when CNA A thought NA E was not looking. MA H further revealed NA E expressed she did not know what to do. After this conversation, MA H revealed she went with NA E to report to the nurse and the ADON. MA H was unable to identify the nurse that was working. MA H revealed she had been trained after incident and was aware of reporting abuse, neglect, and exploitation to the Administrator. During a combined interview on 03/07/24 at 09:49 AM with the Administrator and the ADON, the ADON revealed last week staff were trained on abuse, neglect, and exploitation. The Administrator showed documentation of safe surveys being done for every resident. Agency staff or anyone who comes into work for the facility is trained on abuse, neglect, and exploitation and reporting prior to working their shift. The Administrator and the ADON revealed agency staff and new staff members are trained on Abuse, Neglect, Exploitation and Reporting Incidents before they worked with residents. During an interview on 03/07/24 at 01:06 PM the Administrator and the ADON ensured staff are assessing residents to make sure they are safe in the facility. The Administrator revealed he will also check in with staff regularly to ensure they are aware of the facility's abuse, neglect, and exploitation policy. The following were interviews showing staff as educated on the Abuse, Neglect, and Exploitation policy: During an interview on 03/06/24 at 03:08 PM, the Director of Rehab, PT O, and OT P identified what abuse, neglect, and exploitation was and to report to the Administrator if they had any concerns. During an interview on 03/06/24 at 03:10 PM, the DM revealed he trained his staff on Abuse, Neglect, and exploitation and the Administrator is the Abuse Coordinator. During an interview on 03/07/24 at 02:50 PM LVN M shared examples of abuse and how to report abuse, neglect, and exploitation. He further revealed nurses are mandated reporters and he would report it to the state as well During an interview on 03/07/24 at 02:59 PM, LVN L identified examples of abuse, neglect, and exploitation and knew to report to the ADON, the DON, and the Administrator. She further revealed she will report to the state if she did not feel heard. During an interview on 03/07/24 at 03:01 PM, NA N revealed she was trained on abuse, neglect, and exploitation and knew the Administrator was the Abuse Coordinator. During an interview on 03/08/24 at 12:12 PM, HSK I, HSK J, and HSK K were able to identify what abuse, neglect, and exploitation were and knew to report straight to the administrator if they had any suspicion of residents being mistreated. During an interview on 03/07/24 at 04:01 PM, Human Resources revealed CNA A was suspended 1/11/24 and did not physically come into the facility. CNA A's time sheet revealed she clocked in on 01/16/24, 01/17/24, and 01/18/24. She further revealed the facility cannot terminate an employee until their Paid Time Off was paid out. Unable to connect with NA E via telephone on 03/22/24 at 12:17 PM and 04:25 PM. Observations from 03/05/24 through 03/08/24 revealed no incidents of abuse, neglect, exploitations. Observations revealed interactions between staff and residents yielded appropriate care with no deficiencies noted. Record Review of the facilities investigation report revealed NA E and MA H reported incidents involving CNA A to ADON at 04:15 PM. CNA A was immediately suspended. The facility reported to [state agency] at 07:28 PM. Record Review of 16 Resident Safe Surveys for the residents in the women's secure unit on 01/11/24 revealed compliance with the abuse, neglect, exploitation facility policy because residents reported feeling safe in the facility. Record Review of Residents #2. 4, 5, 6, and 7 revealed trauma-informed assessments were done 01/17/24 and staff requested evaluation for mental health by psychiatry. Record Review of the in-service attendance sheet, dated 01/12/24, presented by the ADON, revealed a topic of ABUSE/NEGLECT that included reviewing facility policies Abuse Prevention Program and Preventing Resident Abuse. Record review revealed 100% of the regular staff was trained, including Agency Staff that was available. Record Review of CNA A's human resources packet revealed CNA A was hired 04/14/23 and suspended 01/11/24. Record review of CNA A's Timesheet showed hours for 01/16/24, 01/17/24, and 01/18/24, to pay out her PTO(paid time off) although not physically worked. During a combined interview on 03/08/24 at 12:28 PM with the ADON and the Administrator, the ADON revealed staff got trained on grievances/complaints upon hire and yearly. The Administrator revealed he will combine training on grievances along with abuse, neglect, exploitation training. The Administrator further revealed he will train the staff to document all relevant concerns so he can solve any grievances or complaints that residents may have. The Administrator further revealed he believed addressing grievances/complaints prevented issues like abuse, documented any concerns, and monitored any possible trends. Record Review of the facility's Abuse Prevention Program policy, revised January 2011, revealed: Policy Statement: Our residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion . 1. Our facility is committed to protecting our residents from abuse by anyone including, but not necessarily limited to: facility staff . 3. Comprehensive policies and procedures have been developed to aid our facility in preventing abuse, neglect, or mistreatment of our residents. Our abuse prevention program provides policies and procedures that govern, as a minimum: c. Identification of occurrences and patterns of potential mistreatment/abuse; f. Timely and thorough investigations of all reports and allegations of abuse . Record Review of the facility's Preventing Resident Abuse policy, revised November 2010, revealed: 1. The facility's goal is to achieve and maintain an abuse-free environment. 2. Our abuse prevention/intervention program includes, but is not necessarily limited to, the following: a. Training all staff and practitioners how to resolve conflicts appropriately. q. Encouraging all personnel, residents, family members, visitors, etc., to report any signs or suspected incidents of abuse to facility management immediately. The noncompliance was identified as past noncompliance IJ (Immediate Jeopardy). The noncompliance began on 01/11/24 and ended on 01/12/24. The facility had corrected the noncompliance before the investigation began. The facility implemented interventions to prevent further abuse and neglect risks to include educating staff about abuse, neglect, exploitation, performing resident safe surveys to ensure safety of residents, and terminating the alleged perpetrator.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to consult with the physician when the resident experienced a change in condition for 1 of 1 resident (Resident #1) reviewed for a change of condition, in that:. The facility failed to notify the physician when Resident #1 had bleeding to the bridge of the nose on 12/17/23 at 2:00 AM. LVN A was aware that Resident #1 had a fall with injury on 12/12/23 and neuro checks were done for 72 hours. The facility staff did not document an assessment, vital signs and communications with the physician for a period of 22 hours when the resident had a change of condition. Resident #1 was taken to the ER on [DATE] at 12:46 AM and diagnosed with a subdural hematoma, nasal fracture, and rib fractures. An Immediate Jeopardy was identified on 01/12/24 at 12:05 PM. While the Immediate Jeopardy was removed on 01/13/24 at 5:10 PM, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not Immediate Threat due to the facility's need to monitor and evaluate the effectiveness of the plan of removal and corrective actions. This failure could affect residents by placing them at risk for serious injury, harm, impairment, or death. The findings included: Record review of Resident #1's Face Sheet printed 12/21/22 revealed Resident #1 was a [AGE] year-old male admitted on [DATE] and discharged to the ER on [DATE]. Resident #1's diagnoses included: cerebral infarction (stroke), lack of coordination, dementia with agitation, cognitive communication deficits, and essential hypertension (primary). The RP was listed as a family member. Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed his primary reason for admission was coded as Other Neurological Conditions related to cerebral infarction [a brain lesion in which a cluster of brain cells die when they do not get enough blood; stroke]. Other active diagnosis included non-Alzheimer's vascular dementia [a group of symptoms that affects memory, thinking and interferes with daily life]. Resident #1 had a BIMS summary score of 3, indicative of severe cognitive deficits. Resident #1 had one fall since admission with a non-major injury. Resident #1 was coded as walking 50 feet with set-up assistance only and coded as contact guard assistance for walking 150 feet. Record review of Resident #1's Care Plan, undated, revealed he had a problem area in the category of Falls with a start date of 12/07/23. Additional problem area in the category of ADLs Functional Status related to cognitive impairment, lack of coordination and muscle weakness with a start date of 8/24/2023. Record review of Resident #1's physician orders dated December 2023 revealed Resident #1 was administered the following medications: *clopidogrel, tablet, 75 mg, 1 tablet daily (blood thinner) and *aspirin, tablet, chewable, 81 mg, 1 tablet daily (blood thinner). In a record review of a written statement dated 12/18/2023, CNA E stated she observed Resident #1 with blood on the bridge of his nose and immediately reported it to LVN A & B during shift change on 12/17/2023 at 6:00 a.m. (Note: Resident #1 was on blood thinners.) Record review of Resident #1's clinical record revealed no SBAR or head-to toe assessment was for Resident #1 on 12/17/23. Record review of Resident #1's Progress Notes revealed a late entry entered on 12/19/23 at 8:48 AM by LVN A for 12/17/23 5:38 AM of observed superficial abrasion approx[imately] 1.5 cm in legth[sic] .cleaned the dry blood from his nose and place a dressing on top to keep it clean from dirt and debri[sic]. Will inform oncoming nurse. [LVN B] Record review of Resident #1's Progress Notes revealed entry on 12/17/23 at 6:33 PM by LVN B that upon arrival of shift [12/17/23 6:00 AM] resident was found to [sic] bleeding from forehead and bridge of nose. No explanation given as to what occurd[sic] .Resident c/o [complained of] headache and face pain. Record review of Resident#1's Nurse Note dated 12/18/23 at 11:24 PM, authored by LVN C, read Off going nurse [LVN B] reported resident was found this morning with bleeding to his face. When I went to assess resident it was observed that he has nasal swelling and right facial swelling as well as abrasions to his [forehead]. Resident was at baseline for resident which is alert to self and able to follow very basic instruction. When asked resident if was in pain he stated yes and touched his nose. I could hear him trying to breathe through his nose. I asked if it was difficult to breathe through his nose and he stated yes. VS 133/81, 105, 95% room air, 21, 99.1. Resident ambulated throughout unit per his usual routine. Call placed to . Physicians expressing concern and they gave orders to send him out to . ER to be evaluated . Ambulance was called, and he is pending transport. Record review of Resident #1's Progress Notes revealed entry on 12/18/23 at 12:45 AM by LVN C observed that he has nasal swelling and right facial swelling as well as abrasions to forehead . Further documentation indicated resident stated yes when asked if he was in pain and yes to difficulty breathing through nose. Resident transferred to local emergency room on [DATE] at 12:46 AM. Record review of Resident #1's ER CT Scan of the Head without intravenous contrast, dated 12/18/23 at 2:25 AM, revealed an acute subdural hemorrhage throughout the left supratentorial (upper part of brain) brain and along the left greater than right tentorial (brain fold) leaflets .Punctate intraparenchymal (blood in tissue of brain) in the left occipital lobe (visual processing area of the brain) .Mild diffuse left cerebral edema. No midline shift. Review of CT Maxillofacial [related to the upper jaw, face, and neck] dated 12/18/2023 at 2:25 AM, revealed Nondisplaced right nasal bone fracture. Sharp angulation of the bony nasal septum. No other acute facial fractures. soft tissue swelling overlying the nose. Intracranial hemorrhage better evaluated on same day CT head. Review of CT Chest/Abdomen/Pelvis dated 12/18/2023 at 2:25 AM, revealed acute left posterolateral [back and side] 7th, 8th, 9th, 10th, and 11th left rib fractures. Record review of Resident #1's admitting hospital record dated 12/18/23 revealed reason for admissions was fall and rib fracture and SDH (subdural hematoma). Admitting diagnosis was SDH: sent to the ICU for SDH monitoring and treatment. Record review of Resident #1's Progress Notes revealed entry on 12/18/23 at 5:53 AM by the ADON that resident was transferred to higher acuity facility, due to subdural hematoma [bleeding inside the skull, but outside the actual brain tissue], large intraparenchymal hemorrhage [bleeding in the brain tissue], nasal fracture [broken bones], and multiple left rib fractures. Further documentation indicated telephone line to on-call physician service was not working properly, and the nurse notified resident's responsible party. Record review of Resident #1's Progress Notes revealed entry on 12/18/23 at 11:46 AM by Nurse F, PCP made aware of resident's [Resident #1's] transfer to higher level acuity facility. Record review of written statement authored by LVN B revealed that, on 12/17/23 at 6:00 AM, Resident #1 was still bleeding from his nose; first aide applied; sitting in a chair in the hallway. Resident#1 removed the bandaged off nose multiple times. Resident complained about a headache. At the end of her shift 6:00 PM, he was stable. Resident #1 stated he felt better. Record review of an email from LVN B dated 12/19/23 8:08 PM, LVN B stated the overnight nurse LVN A did not provide information on what happened to Resident #1 prior to the start of LVN B's shift on 12/17/23 at 6:00 AM. In an interview on 12/20/2023 at 2:00 PM, CNA E stated at the start of her shift on 12/17/2023, shortly after 6:00 AM, she alerted the overnight nurse, LVN A, and the oncoming nurse, LVN B, that Resident #1 was bleeding from the bridge of his nose. CNA E stated she was asked to clean Resident #1 up so that he could be better assessed by LVN B. CNA E stated Resident #1 ate breakfast like his normal self, but after breakfast stated he was not feeling well. CNA E stated she reported to LVN B that Resident #1 vomited, and wanted to lay down after breakfast, which was not his normal. CNA E stated Resident #1 did not eat lunch or dinner and wanted to sleep most of the day. CNA E stated throughout the day Resident #1 was found in the sleeping TV area, Dining area and once curled up in a fetal position in the hallway. CNA E stated she reported that information to LVN B as it occurred. CNA E stated, on occasion Resident #1 would not sleep well during the night and would nap during the day. CNA E stated it was not his normal to be sleeping in common areas. In an interview on 12/20/2023 at 4:35 PM, LVN B stated that the aide told her Resident #1 was bleeding from the bridge of his nose. LVN B stated she applied pressure for 15 minutes to stop the bleeding. LVN B stated the resident was on multiple blood thinners that made it difficult for the bleeding to stop completely. LVN B stated Resident #1 also had a known behavior of skin picking and was restless frequently. LVN B stated she applied a dressing to the wound, but Resident #1 removed it within 15 minutes. LVN B stated she put an alarm on her phone to remind her to check up on Resident #1 every 45 minutes to an hour. LVN B stated she instructed the aides to round more frequently on Resident #1. LVN B stated she did not recall any staff member alerting her to a change in Resident #1. LVN B stated when she assessed him that morning [12/17/2023] she had a suspicion the residents' nose was broken due to the change in the shape of the nose and the sound of his breathing. LVN B stated there was some bruising under the jaw from a fall earlier in the week. LVN B stated she did not assess his chest or back for further injuries. LVN B stated when the night shift nurse, LVN C, arrived on 12/17/2023 at 6:00 PM, LVN B insisted on walking rounds to give report on Resident #1. LVN B stated it took a few minutes to find Resident #1, as he was not in his designated room, and was actually standing in the last, empty room at the end of the hall with out the lights on. LVN B stated he laughed at them when she told him they were looking for him. LVN B stated Resident #1 could be heard to audibly be breathing through his nose, but it was labored. LVN B stated facial swelling and discoloration was now visible and that Resident #1 stated, it kind of hurts. LVN B stated she explained to LVN C that the previous overnight shift nurse, LVN A, did not provide an explanation as to what happened to Resident #1. In an interview on 12/20/2023 at 5:22 PM, LVN C stated that upon arrival to her shift on 12/17/2023 at 6:00 PM, LVN B requested that the two of them go look at Resident #1 for shift report. LVN C stated it looked like Resident #1 had a broken nose, and he admitted to some pain when asked. LVN C stated she told LVN B that she would be sending Resident #1 out to the emergency room because he didn't look right. LVN C stated she did not assess his chest or back for further injuries. LVN C stated she believed Resident #1 left via ambulance around 11:30 PM. LVN C stated she prioritized the evening medications on the secured unit for the men's hall, and the secured unit for the women's hall over sending Resident #1 out. LVN C stated that normally there was a certified medication aide, but that night [12/17/2023] there was not. LVN C stated on the few occasions there was not medication aide on the shift, it made the shift very hectic when she had to pass her own medications. LVN C stated she contacted the on-call physicians' group but was unable to leave a message. LVN C stated she contacted the residents responsible party and was also unable to leave a message. LVN C stated she called the ADON at that time but did not leave a message. LVN C stated she contacted the emergency room at the end of her shift [12/18/2023 at 6:00 AM] for an update on Resident #1 and was informed he was being transferred to a higher level of care [the local emergency room is free standing and does not have the ability to admit residents as there is no associated hospital with it]. LVN C stated it was after that phone call that she alerted the facility management to the situation. During an interview in Spanish on 01/11/24 at 11:56 AM, NA D stated he found Resident #1 ambulatory on Hall A on 12/17/23 at 2:00 AM and informed LVN A and returned to his duties. NA D stated that Resident #1 provided him with no explanation on the cause of the bleeding to the nose. During an interview on 01/11/24 at 11:35 AM, the ADON stated Resident#1 was found in A Hall, standing up and ambulatory, on 12/17/ 23 AM at 2:00 AM by NA D. The Nurse on duty was LVN A (agency) and she described in her Nurse Notes dated 12/17/23 at 5:38 AM that Resident #1 had superficial abrasion approximately 1.5 cm to the bridge of the nose. LVN A provided first aide. There was no description from NA D or LVN A on how the injury occurred on 12/17/23. Resident #1's BIMS score was 3 (severely impaired) and the resident did not state he had an injury. Resident, previous to the incident on 12/17/23, had a fall on 12/12/23 with injury to the bridge of the nose. On 12/12/23, the resident was not sent to the ER per recommendation by the physician. During an interview on 01/11/24 at 12:18 PM, the ADON stated: per nursing practice, if a head injury was suspected, neuro checks were started immediately. Neuro checks were done for 72 hours; namely, 15 minutes X4, 30 minutes X4; hourly X4 Q shift until 72 hours are completed. The ADON stated, no neuro checks were done on 12/17/23, she stated the bleeding to the nose was an old scab and nurses assumed it was an old injury from fall on 12/12/23 as stated in the nurses' notes . The ADON stated x-ray results on 12/18/23 from the ER (local hospital) revealed a non-displaced right rib fracture, sharp angulation of boney nasal septum reflected the resident's normal anatomy rather than a fracture, and no blood inside of nose. However, the ADON stated CT scan revealed an acute subdural hemorrhage throughout the left side of the head. Resident #1 did not return to the facility. The ADON stated the assumption was that the resident scratched his scab on 12/17/23 and neuro checks for the fall on 12/12/23 revealed no neuro issues. An attempted telephone interview on 01/11/24 at 12:39 PM to LVN B. LVN B's telephone would not accept messages. During a joint interview on 01/11/24 at 2:24 PM, with the ADON and the Director of Quality (Corporate), the Director of Quality (Corporate) stated: on the day of the incident 12/17/23 LVN C (Agency) did an SBAR on 12/17/23 at 10:00 PM. Resident #1 had right facial swelling and the resident complained of pain and had difficulties breathing through his nose. LVN A did not do an SBAR at 2:00 AM on 12/17/23 - she state the reason why the SBAR was not completed was unknown. The ADON stated she had no explanation as to why an SBAR was not done at 2:00 AM. The Director of Quality and the ADON stated no head-to-toe assessment was required based on history of fall with existing abrasion. They state there was no documented vitals taken on 01/17/23 at 2:00 AM. During a telephone interview on 01/11/24 at 2:35 PM, LVN A stated that she did not do a head-to-toe assessment or SBAR on the incident involving Resident #1 on 12/17/23 at 2:00 AM because the resident only had bleeding to the bridge of the nose and first aid was applied. LVN A stated she was aware Resident #1 had a fall on 12/12/23 and neuro checks were done for 72 hours. LVN A stated she did vital signs but could not remember whether the vital signs were documented. LVN A stated she did not communicate with the physician on 12/17/23 at 2:00 AM and did not seek a physician order to initiate neuro checks. During a telephone interview on 01/11/24 at 3:45 PM, the facility MD stated: if there was no evidence of a fall on 12/17/23 at 2:00 AM, there was no requirement that vitals or neurological checks be done since there was no evidence of trauma or change of condition. The MD stated what was given to Resident #1 was standard care rather than best care which would have involved vitals or neurological checks. The MD stated he nor the on-call physician were notified of the bleeding on 12/17/23 at 2:00 AM. The MD stated that during the delay of 22 hours standard care did not require vitals or neuro checks be done. The MD stated that a significant change, SDH, could have been occurring during the gap of 22 hours (01/17/23 at 2:00 AM to 01/18/23 at 12:46 AM). During a telephone interview on 01/11/24 at 4:45 PM, LVN A stated there was no evidence Resident #1 vomited on 12/17/23 or had a fall or change of condition. LVN A stated vitals and assessments were done but not documented because there was a shift change at 6:00 AM and the facility did not pay Agency Nurses for documentation after the shift change. LVN A stated that she was aware of Resident #1's fall on 12/12/23 and that 72 hour neurological checks had been completed on 12/15/23. LVN A stated that the physician was not notified on 12/17/23 at 2:00 AM or at the end of her shift at 6:00 AM. During an interview on 01/11/24 at 4:05 PM, the Director of Quality stated: given the circumstances LVN A fully assessed Resident #1 on 12/17/23 at 2:00 AM. LVN A did not document a change of condition in the resident, and vitals and neurological checks were not done for a period of 22 hours by nursing staff because Resident #1 did not reveal signs of a change of condition. During joint interview on 01/11/24 at 5:00 PM, the Director of Quality and the Administrator stated overtime was permitted for agency staff to document in the clinical record. Record review of Abuse Prevention Program revised January 2011, revealed, policy statement: residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion. Under step 3.) Comprehensive policies and procedures have been developed to aid our facility in preventing abuse, neglect .b.) Mandated staff training/ orientation programs that include such topics as abuse prevention, identifying and reporting of abuse . Record review of Preventing Resident Abuse policy revised November 2010 revealed under step 3j.) assessing, care planning, and monitoring residents with needs and behaviors that may lead to conflict or neglect; 3p.) ensure that the needs of each resident are met; 3q.) report any signs or suspected incidents . Record review of Abuse and Neglect: Clinical Protocol revised April 2013, revealed the nurse will assess the individual and document related findings. under Step 2.) The nurse will report findings to the physician . Record review of Reporting Abuse to Facility Management, revised December 2013, revealed policy statement, it is the responsibility of our employees .etc. to promptly report any incident or suspected incident of neglect or resident abuse, including injuries of unknown source .to facility management. Definitions provided of injuries of unknown source: 1.) Source of the injury was not observed by any person, or the source of the injury could not be explained by the resident; and 2.) the injury is suspicious because of a.) the extent of the injury, b.) the location of the injury. Neglect defined as: failure to provide goods and services necessary to avoid physical harm . Record review of Recognizing Signs and Symptoms of Abuse/Neglect, revised April 2012, revealed policy statement, facility will not condone any form of resident abuse or neglect .report any signs and symptoms of abuse/neglect to their supervisor .immediately. Examples of abuse/neglect provided included: inadequate provision of care, caregiver indifference to residents' care and needs. The Administrator was given the IJ template and was notified of the Immediate Jeopardy (IJ) on 01/12/2024 at 12:05 PM and a plan of removal (POR) was requested. On 01/12/2024 at 5:44 PM, the POR was accepted. It was documented as follows: Plan to remove immediate jeopardy. The facility failed to ensure that, based on the comprehensive assessment of a resident, the resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 1 of 1 resident (Resident #1) reviewed for receiving nursing services in that: Facility staff failed to respond appropriately when Resident #1 had a bleeding to the bridge of the nose on 12/17/2023 at 2:00 a.m. for documented assessment, vital signs and communications with the physician for a period of 18 hours when the resident had a change of condition; requiring an ER visit. F580 On 01/12/2024 the Administrator notifies Medical Director of immediate jeopardy. On 01/12/2024 resident #1 no longer resides in the facility. On 01/12/2024 all residents in the facilities will be assessed by Director of Quality/RN Designee for any changes in condition. Any findings will be communicated to the Medical Director for further interventions/orders and Resident/RP will be notified. On 01/12/2024 DOQ (Director of Quality, RN) completed one-on-one in-service with Assistant Director of Nursing on Changes in Condition, including timely assessment, physician notification, and follow physician recommendations. On 12/22/2023 Assistant Director of Nursing/Designee completed 100% in-service training on Notification to Management (IDT Team) of Any Injury or Change of Condition, training on Abuse/Neglect, training on Appropriate Assessments of Residents will be done in a Timely Manner on any Change of Condition or Injuries, and training on Notification to MD of any Injury or Change of Condition. Starting on 01/12/2024 the Assistant Director of Nursing/Designee initiated in-service with nurses on changes in condition, including timely assessment, physician notification, and follow physician recommendations. Education to be completed on 01/12/2024. Any staff that is not available will be trained prior to their next scheduled workday, including PRN and Agency staff. Ad-Hoc QAPI meeting was held on 01/12/2024, with the Medical Director, NHA (Nursing Home Administrator), Director of Quality, and Assistant Director of Nursing to review the alleged deficiencies, policy and procedure, and the plan for removal of immediacy. The policy pertaining to Change in condition and timely reporting was reviewed on 01/12/2024 by the NHA (Nursing Home Administrator), Assistant Director of Nursing, DOQ (Director of Quality), and Medical Director. Starting on 01/12/2024, IDT (Interdisciplinary team), including Administrator, Assistant Director of Nursing, and MDS Coordinator will review any changes in condition and events daily Monday to Friday, and Manager on Duty Saturday and Sunday to determine if timely notification and assessment was completed due to changes in condition. The findings will be immediately brought to the Administrator for further action, if necessary. On 01/12/2024 the RNC (Regional Nurse Consultant)/DOQ (Director of Quality) will start reviewing Events/Changes in Condition for validation of thorough assessment and timely notification weekly for four (4) weeks followed by monthly for 2 months. The Administrator/designee will monitor compliance by completing audit of five (5) residents per week for four (4) weeks. This was initiated on 01/12/2024. Any identified concern will be addressed immediately and if trends and patterns are identified, the facility will conduct an Ad-Hoc QAPI meeting to discuss if additional interventions are needed to ensure compliance for next 2 months. The Administrator will be responsible for ensuring this plan is completed on 01/12/2024. The COO will provide oversight of Administrator to ensure that the items on the plan of removal are reviewed and completed. Verification of the Plan of Removal: In an interview on 01/13/24 at 9:35 AM, the ADON stated there were three residents who had a recent change in their condition in the past week. Record review of the 3 residents who were identified with a change in their condition revealed each resident had been assessed by the nurse, the physician was notified, orders received were initiated and a SBAR was completed. Record review of facility's nurse staffing revealed: total of 27 (24 NAs, 3 LVNs). Record review of the 4 in-services on 12/22/23 revealed 59 signatures with a completion rate of 100%. During an interview on 01/11/24 at 11:10 AM, the ADON stated an in-service was conducted on 12/22/23 for 59 staff, the in-services as follows: *Notification to Management of Any Injury or Change of Condition, *Abuse and Neglect for 59 staff, *Appropriate Assessment Done in a Timely Manner, and *Notification too MD for 59 staff. Interviews on 01/13/24 10:24 AM to 4:00 PM with 3 of 5 facility nurses (3 LVNs) who worked on the 6 AM to 6 PM shift revealed they had been in-serviced on 01/12/24 on changes in condition, timely assessment, physician notification, and to follow physician recommendations. Interviews on 01/13/24 from 10:24 AM to 4:00 PM with 3 of 6 agency nurses (3 LVNs) who worked on the 6 PM to 6 AM shift revealed they had been in-serviced on 01/12/24 on changes in condition, timely assessment, physician notification, and to follow physician recommendations. In an interview on 1/13/24 at 11:07 AM, the Regional Nurse Consultant (RNC) stated she assisted the DOQ with assessing all the residents on 01/12/24. The RNC stated she assessed the 2 secured units and the DOQ assessed the residents on the other side of the building. RNC stated there were 2 residents whom she noticed there was a change from their normal baseline, which the floor nurse had already identified earlier in the day, the residents' physicians had been notified and she made sure an SBAR had been completed for those residents. The Regional Nurse Consultant stated she participated in the Ad Hoc QAPI meeting held on 01/12/24 with the Administrator, ADON, DOQ present in person and the Medical Director present via telephone. In a telephone interview on 01/13/24 at 2:05 PM, the Medical Director stated he was informed of the IT situation on 01/12/24, he participated via telephone in the Ad Hoc QAPI meeting held in the late afternoon on 01/12/24, and he approved the measures the facility was going to implement. The Medical Director stated the policy about Change in Condition and Timely Reporting was reviewed with him during the Ad-Hoc QAPI meeting. In an interview on 01/13/24 at 2:52 PM the RNC stated she would weekly run a report in the electronic charting system to see which residents had a new SBAR completed to identify residents who had a change in their condition and would do this for two months to monitor residents who had a change in their condition. In an interview on 01/13/24 at 2:58 PM, the ADON stated all the residents were assessed on 01/12/24 by the DOQ and RNC. The ADON stated she was in-serviced by the DOQ on change of resident's condition, timely notification to the physician, following the physician recommendations and on Abuse & Neglect. The ADON stated she had in-service all 12 nurses on changes in condition, timely assessment, physician notification, following physician recommendations and abuse and neglect. The ADON said an Ad Hoc QAPI meeting was held on 01/12/24 in the afternoon; she, the RNC, the DOQ and administrator were present, and the Medical Director attended via phone. The ADON stated the policy pertaining to Change in Condition and Timely reporting was reviewed during the ad-hoc QAPI meeting held on 01/12/24. ADON said on weekends, the Manager on Duty would monitor any changes in condition to the residents; and during the week the IDT would do the monitoring. The ADON stated if there was a change in the resident's condition the resident would be assessed, the physician would be notified, new orders received would be implemented and the resident's RP would be notified. The ADON stated she completed the monitoring of changes in resident's condition on 01/13/24, using a Daily Census Sheet, for the weekend Manager on Duty, any new findings would be assessed by the nurse and the Daily Census sheet was placed in the facility's POR white binder. In an interview on 01/13/24 at 3:15 PM, the Administrator stated all the residents were assessed by the RNC and the DOQ on 01/12/24, and the medical director was notified on 01/12/24 after the facility was informed of the IT. The Administrator said the DOQ conducted an in-service with the ADON on Changes in Condition, timely assessment, physician notification and following physician recommendations and 100% of the nurses were in-serviced by the ADON on 01/12/2024 on Notification to Management of any injury or change of condition, appropriate assessments of residents being done in a timely manner, notify the physician of change of condition, following physician recommendations, and abuse and neglect. The Administrator stated an Ad Hoc QAPI meeting was held on 01/12/24 after the facility's POR had been accepted with the Medical Director via phone, and the RNC, ROQ and ADON in person. The Administrator said the policy pertaining to Change in Condition and Timely Reporting was reviewed during the AD Hoc QAPI meeting. The Administrator stated changes in a residents' condition would be monitored by the IDT during the morning meeting; the facility activity report would be printed to show progress notes written in the past 24-hours; the nurses would attend the morning meeting and report on residents who had a change in their condition. He stated on the weekends the Manager on Duty would review the report for any changes of condition and notify the ADON or the Administrator if a resident had a change in their condition. The Administrator stated he would audit the activity report weekly to see if there was an event or change in a resident's vital signs, then he would review the resident's clinical record to see if it was a change in the residents' condition and notify the ADON. The Administrator said the COO would be consult the RNC and ROQ for monitoring of residents' change of condition, there would be weekly calls with the COO and the COO would visit the facility monthly to monitor the facility and his progress. Record review of the Daily Census Report dated 01/13/24 revealed Resident #1 was no longer in the facility. Record review of the facility's white binder with the POR documents revealed the following: *a Training In-Service Sign-in Sheets, dated 12/22/23, revealed 59 of 59 employees had been in-serviced by the ADON on Notification to MD of Any Injury or Change of Condition, Notification to Management (IDT Team) of Any Injury or Change of Condition, Appropriate Assessments of Residents Will be Done in a Timely Manner on Any Change of Condition or Injuries, and Abuse and Neglect. * an Ad Hoc QA Meeting Sign-in Sheet dated 01/12/24 was in the binder with the signature of the Administrator, ADON, Director of Quality, and the Regional Nurse Consultant. The Medical Director was listed as being in attendance via telephone. * a Census Report dated 01/13/24 with each residents' name highlighted to indicate the residents had been monitored for a change of their condition and was signed by the ADON at the bottom of the sheet. * an undated Review Change of Condition and Timely Notification of Assessments monitoring form had been created * a Daily Census Report dated 01/12/24 with each resident's name checked off and a copy of the progress note from the Director of Quality or the Regional Nurse Consultant for each resident assessed. Record review of the Training In-Service Sign-in Sh[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that, based on the comprehensive assessment of a resident, the resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 1 of 1 resident (Resident #1) reviewed for nursing services, in that: Facility staff failed to respond appropriately when Resident #1 had a bleeding to the bridge of the nose on 12/17/23 at 2:00 AM. The facility staff did not document an assessment, vital signs, and communications with the physician for a period of 22 hours when the resident had a change of condition. Resident #1 was taken to the ER on [DATE] at 12:46 AM and diagnosed with a subdural hematoma. An Immediate Jeopardy was identified on 01/12/24 at 12:05 PM. While the Immediate Jeopardy was removed on 01/13/24 at 5:10 PM., 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 monitor and evaluate the effectiveness of the plan of removal and corrective actions. This failure could affect residents by placing them at risk for serious injury, harm, impairment, or death. The findings included: Record review of Resident #1's ER CT Scan dated 12/18/23 revealed an acute subdural hemorrhage throughout the left supratentorial (upper part of brain) brain and along the left greater than right tentorial (brain fold) leaflets .Punctate intraparenchymal (blood in tissue of brain) in the left occipital lobe (visual processing area of the brain).Mild diffuse left cerebral edema. No midline shift. Review of CT Maxillofacial [related to the upper jaw, face, and neck] dated 12/18/2023 at 2:25 AM, revealed Nondisplaced right nasal bone fracture. Sharp angulation of the bony nasal septum. No other acute facial fractures. Soft tissue swelling overlying the nose. Intracranial hemorrhage better evaluated on same day CT head. Review of CT Chest/Abdomen/Pelvis dated 12/18/2023 at 2:25 AM, revealed acute left posterolateral [back and side] 7th, 8th, 9th, 10th, and 11th left rib fractures. Record review of Resident #1's admitting hospital record dated 12/18/23 revealed reason for admissions was fall and rib fracture and SDH (subdural hematoma). Admitting diagnosis was SDH: sent to the ICU for SDH monitoring and treatment. Record review of Resident #1's Face Sheet printed 12/21/22 revealed Resident #1 was a [AGE] year-old male admitted on [DATE] and discharged to the ER on [DATE]. Resident #1's diagnoses included: cerebral infarction (stroke), lack of coordination, dementia with agitation, cognitive communication deficits, and essential hypertension (primary). The RP was listed as a family member. Record review of Resident #1's physician orders dated December 2023 revealed: clopidogrel, tablet, 75 mg, 1 tablet daily (blood thinner) and aspirin, tablet, chewable, 81 mg, 1 tablet daily (blood thinner). Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed his primary reason for admission was coded as Other Neurological Conditions related to cerebral infarction [a brain lesion in which a cluster of brain cells die when they do not get enough blood; stroke]. Other active diagnosis included non-Alzheimer's vascular dementia [a group of symptoms that affects memory, thinking and interferes with daily life]. Resident #1 had a BIMS summary score of 3, indicative of severe cognitive deficits. Resident #1 had one fall since admission with a non-major injury. Resident #1 was coded as walking 50 feet with set-up assistance only and coded as contact guard assistance for walking 150 feet. Record review of Resident #1's Care Plan, undated, revealed he had a problem area in the category of Falls with a start date of 12/07/23; with the following interventions: refer to therapy, edited 12/12/23; attempt to discover cause and resolve reason for falls, created 12/08/2023; fall assessment per policy, created 12/08/2023. Additional problem area of Falls with a start date of 8/24/2023, with the following interventions: call light in reach at all times, created 8/25/2023; fall risk assessment per policy, created 8/25/2023; monitor routines, habits, tendencies preferences, behavior, ADL deficits, created 8/25/2023. Record review of Resident #1's clinical record revealed no SBAR, or head-to toe assessment done on Resident #1 by LVN A at 2:00 AM. [No documented evidence showed that vitals were taken or that the physician was notified on 12/17/23 at 2:00 AM.] Record review of Resident #1's Nurse Note dated 12/17/23 at 5:38 AM, authored by LVN A, reflected: Resident #1 was bleeding from his nose; assessed which revealed a superficial abrasion; appeared that he scratched some form of scab. First Aide was provided, and she (LVN A) would inform the on-coming nurse (LVN B). [No evidence existed that the physician was notified.] Record review of Resident #1's Progress Notes revealed entry on 12/17/23 at 6:33 PM by LVN B that upon arrival of shift [12/17/23 6:00 AM] resident was found to [sp] bleeding from forehead and bridge of nose. No explanation given as to what occurd[sp] .Resident c/o [complained of] headache and face pain. [No evidence existed that the physician was notified.] Record review of Resident#1's Nurse Note dated 12/18/23 at 11:24 PM, authored by LVN C, read Off going nurse [LVN B] reported resident was found this morning with bleeding to his face. When I went to assess resident, it was observed that he has nasal swelling and right facial swelling as well as abrasions to his [forehead]. Resident was at baseline for resident which is alert to self and able to follow very basic instruction. When asked resident if was in pain he stated yes and touched his nose. I could hear him trying to breathe through his nose. I asked if it was difficult to breathe through his nose and he stated yes. VS 133/81, 105, 95% room air, 21, 99.1. Resident ambulated throughout unit per his usual routine. Call placed to . Physicians expressing concern and they gave orders to send him out to . ER to be evaluated . Ambulance was called, and he is pending transport. Record review of Resident #1's Progress Notes revealed a late entry entered on 12/17/23 at 8:48 AM by LVN A for 12/17/23 5:38 AM of observed superficial abrasion approx. 1.5 cm in legth[sp] .cleaned the dry blood from his nose and place a dressing on top to keep it clean from dirt and debri[sp]. Will inform oncoming nurse. [No evidence existed that the physician was notified.] Record review of Resident #1's Progress Notes revealed entry on 12/18/23 at 12:45 AM by LVN C of observed that he has nasal swelling and right facial swelling as well as abrasions to forehead . Further documentation indicated resident stated yes when asked if he was in pain and yes to difficulty breathing through nose. Resident transferred to local emergency room on [DATE] at 12:46 AM. [Timeline was 22 hours.] Record review of Resident #1's Progress Notes revealed entry on 12/18/23 at 5:53 AM by ADON that resident was transferred to higher acuity facility, due to subdural hematoma [bleeding inside the skull, but outside the actual brain tissue], large intraparenchymal hemorrhage [bleeding in the brain tissue], nasal fracture [broken bones], and multiple left rib fractures. Further documentation indicated telephone line to on-call physician service was not working properly, and the nurse notified resident's responsible party. Record review of Resident #1's Progress Notes by Nurse F revealed entry on 12/18/23 at 11:46 AM that PCP made aware of resident's [Resident #1's] transfer to higher level acuity facility. In a record review of a written statement dated 12/18/2023, CNA E stated she observed Resident #1 with blood on the bridge of his nose and immediately reported it to LVN A & B during shift change on 12/17/2023 at 6:00 a.m. (Note: Resident #1 was on blood thinners.) In a record review of an email from LVN B dated 12/19/23 8:08 PM, LVN B stated the overnight nurse LVN A did not provide information on what happened to Resident #1 prior to the start of LVN B's shift on 12/17/23 at 6:00 AM. [No evidence existed that the physician was notified.] Recorded as Late Entry on 12/19/23 8:48 AM and authored by LVN A read Entry missing from 12/17 This nurse was informed by the aide that this resident was bleeding from his nose. This nurse went to assess the resident and observed a superficial abrasion approx[imately] 1.5cm in length [sic] to his nose which looked as perhaps he scratched off some of the formed scab that was there. This nurse cleaned the dry blood from his nose and placed a dressing on top to keep it clean from dirt and debri [sic]. Will inform oncoming nurse. Record review of statement on 12/29/23 authored by LVN B revealed that, on 12/17/23 at 6:00 AM, Resident #1 was still bleeding from his nose; first aide applied; sitting in a chair in the hallway. Resident#1 removed the bandaged off nose multiple times. Resident complained about a headache. At the end of her shift 6:00 PM, he was stable. Resident #1 stated he felt better. [No evidence existed that the physician was notified.] In an interview on 12/20/2023 at 2:00 PM, CNA E stated at the start of her shift on 12/17/2023, shortly after 6:00 AM, she alerted the overnight nurse, LVN A, and the oncoming nurse, LVN B, that Resident #1 was bleeding from the bridge of his nose. CNA E stated she was asked to clean Resident #1 up so that he could be better assessed by LVN B. CNA E stated Resident #1 ate breakfast like his normal self, but after breakfast stated he was not feeling well. CNA E stated she reported to LVN B that Resident #1 vomited, and wanted to lay down after breakfast, which was not his normal. CNA E stated Resident #1 did not eat lunch or dinner and wanted to sleep most of the day. CNA E stated throughout the day Resident #1 was found in the sleeping TV area, Dining area and once curled up in a fetal position in the hallway. CNA E stated she reported that information to LVN B as it occurred. CNA E stated, on occasion Resident #1 would not sleep well during the night and would nap during the day. CNA E stated it was not his normal to be sleeping in common areas. In an interview on 12/20/2023 at 4:35 PM, LVN B stated that the aide [CNA E] told her Resident #1 was bleeding from the bridge of his nose. LVN B stated she applied pressure for 15 minutes to stop the bleeding. LVN B stated the resident was on multiple blood thinners that made it difficult for the bleeding to stop completely. LVN B stated Resident #1 also had a known behavior of skin picking and was restless frequently. LVN B stated she applied a dressing to the wound, but Resident #1 removed it within 15 minutes. LVN B stated she put an alarm on her phone to remind her to check up on Resident #1 every 45 minutes to an hour. LVN B stated she instructed the aides to round more frequently on Resident #1. LVN B stated she did not recall any staff member alerting her to a change in Resident #1. LVN B stated when she assessed him that morning [12/17/2023] she had a suspicion the residents' nose was broken due to the change in the shape of the nose and the sound of his breathing. LVN B stated there was some bruising under the jaw from a fall earlier in the week. LVN B stated she did not assess his chest or back for further injuries. LVN B stated when the night shift nurse, LVN C, arrived on 12/17/2023 at 6:00 PM, LVN B insisted on walking rounds to give report on Resident #1. LVN B stated it took a few minutes to find Resident #1, as he was not in his designated room, and was actually standing in the last, empty room at the end of the hall with out the lights on. LVN B stated he laughed at them when she told him they were looking for him. LVN B stated Resident #1 could be heard to audibly be breathing through his nose, but it was labored. LVN B stated facial swelling and discoloration was now visible and that Resident #1 stated, it kind of hurts. LVN B stated she explained to LVN C that the previous overnight shift nurse, LVN A, did not provide an explanation as to what happened to Resident #1. In an interview on 12/20/2023 at 5:22 PM, LVN C stated that upon arrival to her shift on 12/17/2023 at 6:00 PM, LVN B requested that the two of them go look at Resident #1 for shift report. LVN C stated it looked like Resident #1 had a broken nose, and he admitted to some pain when asked. LVN C stated she told LVN B that she would be sending Resident #1 out to the emergency room because he didn't look right. LVN C stated she did not assess his chest or back for further injuries. LVN C stated she believed Resident #1 left via ambulance around 11:30 PM. LVN C stated she prioritized the evening medications on the secured unit for the men's hall, and the secured unit for the women's hall over sending Resident #1 out. LVN C stated that normally there was a certified medication aide, but that night [12/17/2023] there was not. LVN C stated on the few occasions there was not medication aide on the shift, it made the shift very hectic when she had to pass her own medications. LVN C stated she contacted the on-call physicians' group but was unable to leave a message. LVN C stated she contacted the residents responsible party and was also unable to leave a message. LVN C stated she called the ADON at that time but did not leave a message. LVN C stated she contacted the emergency room at the end of her shift [12/18/2023 at 6:00 AM] for an update on Resident #1 and was informed he was being transferred to a higher level of care [the local emergency room is free standing and does not have the ability to admit residents as there is no associated hospital with it]. LVN C stated it was after that phone call that she alerted the facility management to the situation. During an interview on 01/11/24 at 11:35 AM, the ADON stated: Resident#1 was found in A Hall, standing up and ambulatory, on 12/17/ 23 AM at 2:00 AM by NA D. The Nurse on duty was LVN A (agency) and she described in her Nurse Notes dated 12/17/23 at 5:38 AM that Resident #1 had superficial abrasion approximately 1.5 cm to the bridge of the nose. LVN A provided first aide. There was no description from NA D or LVN A on how the injury occurred on 12/17/23. Resident #1's BIMS score was 3 (severely impaired) and the resident did not state he had an injury. Resident, previous to the incident on 12/17/23, had a fall on 12/12/23 with injury to the bridge of the nose. On 12/12/23, the resident was not sent to the ER per recommendation by the physician. During an interview in Spanish on 01/11/24 at 11:56 AM, NA D stated he found Resident #1 ambulatory in Hall A on 12/17/23 at 2:00 AM and informed LVN A and returned to his duties. NA D stated that Resident #1 provided him with no explanation on the cause of the bleeding to the nose. During an interview 01/11/24 at 12:18 PM, the ADON stated: per nursing practice, if a head injury was suspected, neuro checks were started immediately. She stated Neuro checks were done for 72 hours; namely, 15 minutes X4, 30 minutes X4; hourly X4 Q shift until 72 hours are completed. The ADON stated, no neuro checks were done on 12/17/23 .the bleeding to the nose was an old scab and nurses assumed it was an old injury from fall on 12/12/23 as stated in the nurses' notes . The ADON added that x-ray results on 12/18/23 from the ER (local hospital) revealed a non-displaced right rib fracture, sharp angulation of boney nasal substance reflected the resident's normal anatomy rather than a fracture, and no blood inside of nose. However, the ADON stated CAT Scan revealed an acute subdural hemorrhage throughout the left side of the head. Resident #1 did not return to the facility. The ADON stated the assumption was that the resident scratched his scab on 12/17/23 and neuro checks for the fall on 12/12/23 revealed no neuro issues. Attempted telephone call on 01/11/24 at 12:39 PM to LVN B. LVN B's telephone would not accept messages. During a joint interview on 01/11/24 beginning at 2:24 PM, with the ADON and the Director of Quality (Corporate) stated: on the day of the incident 12/17/23 LVN C (Agency) did an SBAR on 12/17/23 at 10:00 PM. Resident #1 had right facial swelling and the resident complained of pain and had difficulties breathing through his nose. LVN A did not do an SBAR at 2:00 AM on 12/17/23 -she stated the reason why the SBAR was not completed was unknown. The ADON stated she had no explanation as to why an SBAR was not done at 2:00 AM. The Director of Quality and the ADON stated no head-to-toe assessment was required based on history of fall with existing abrasion. The [NAME] stated, no documented vitals were taken on 01/17/23 at 2:00 AM. During a telephone interview on 01/11/24 at 2:35 PM, LVN A stated that she did not do a head-to-toe assessment or SBAR on the incident involving Resident #1 on 12/17/23 at 2:00 AM because the resident only had bleeding to the bridge of the nose and first aid was applied. LVN A stated she was aware Resident #1 had a fall on 12/12/23 and neuro checks were done for 72 hours. LVN A stated she did vital signs but could not remember whether the vital signs were documented. LVN A stated she did not communicate with the physician on 12/17/23 at 2:00 AM and did not seek a physician order to initiate neuro checks. During a telephone interview on 01/11/24 at 3:45 PM, the facility MD stated: if there was no evidence of a fall on 12/17/23 at 2:00 AM, there was no requirement that vitals or neurological checks be done since there was no evidence of trauma or change of condition. The MD stated what was given to Resident #1 was standard care rather than best care which would have involved vitals or neurological checks. The MD stated he nor the on-call physician were notified of the bleeding on 12/17/23 at 2:00 AM. The MD stated that during the delay of 22 hours standard care did not require vitals or neuro checks be done. The MD stated that a significant change, SDH, could have been occurring during the gap of 22 hours (01/17/23 at 2:00 AM to 01/18/23 at 12:46 AM). During a telephone interview on 01/11/24 at 4:45 PM, LVN A stated there was no evidence Resident #1 vomited on 12/17/23 or had a fall or change of condition. LVN A stated vitals and assessments were done but not documented because there was a shift change at 6:00 AM and the facility did not pay Agency Nurses for documentation after the shift change. LVN A stated that she was aware of Resident #1's fall on 12/12/23 and that 72-hour neurological checks had been completed on 12/15/23. LVN A stated that the physician was not notified on 12/17/23 at 2:00 AM or at the end of her shift at 6:00 AM. During an interview on 01/11/24 at 4:05 PM, the Director of Quality stated: given the circumstances LVN A fully assessed Resident #1 on 12/17/23 at 2:00 AM. LVN A did not document a change of condition in the resident, and vitals and neurological checks were not done for a period of 22 hours by nursing staff because Resident #1 did not reveal signs of a change of condition. During joint interview on 01/11/24 at 5:00 PM, the Director of Quality and the Administrator stated overtime was permitted for agency staff to document in the clinical record. Record review of Abuse Prevention Program revised January 2011, revealed, policy statement: residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion. Under step 3.) Comprehensive policies and procedures have been developed to aid our facility in preventing abuse, neglect .b.) Mandated staff training/ orientation programs that include such topics as abuse prevention, identifying and reporting of abuse . Record review of Preventing Resident Abuse policy revised November 2010 revealed under step 3j.) assessing, care planning, and monitoring residents with needs and behaviors that may lead to conflict or neglect; 3p.) ensure that the needs of each resident are met; 3q.) report any signs or suspected incidents . Record review of Abuse and Neglect: Clinical Protocol revised April 2013, revealed the nurse will assess the individual and document related findings. under Step 2.) The nurse will report findings to the physician . Record review of Reporting Abuse to Facility Management, revised December 2013, revealed policy statement, it is the responsibility of our employees .etc. to promptly report any incident or suspected incident of neglect or resident abuse, including injuries of unknown source .to facility management. Definitions provided of injuries of unknown source: 1.) Source of the injury was not observed by any person, or the source of the injury could not be explained by the resident; and 2.) the injury is suspicious because of a.) the extent of the injury, b.) the location of the injury. Neglect defined as: failure to provide goods and services necessary to avoid physical harm . Record review of Recognizing Signs and Symptoms of Abuse/Neglect, revised April 2012, revealed policy statement, facility will not condone any form of resident abuse or neglect .report any signs and symptoms of abuse/neglect to their supervisor .immediately. Examples of abuse/neglect provided included: inadequate provision of care, caregiver indifference to residents' care and needs. The Administrator was given the IJ template and was notified of the Immediate Jeopardy (IJ) on 01/12/2024 at 12:05 PM and a plan of removal (POR) was requested. On 01/12/2024 at 5:44 PM, the POR was accepted. It was documented as follows: Plan to remove immediate jeopardy. The facility failed to ensure that, based on the comprehensive assessment of a resident, the resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 1 of 1 resident (Resident #1) reviewed for receiving nursing services in that: Facility staff failed to respond appropriately when Resident #1 had a bleeding to the bridge of the nose on 12/17/2023 at 2:00 a.m. for documented assessment, vital signs and communications with the physician for a period of 22 hours when the resident had a change of condition; requiring an ER visit. On 01/12/2024 the Administrator notifies Medical Director of immediate jeopardy. On 01/12/2024 Resident #1 no longer resides in the facility. On 01/12/2024 all residents in the facilities will be assessed by Director of Quality/RN Designee for any changes in condition. Any findings will be communicated to the Medical Director for further interventions/orders and Resident/RP will be notified. On 01/12/2024 DOQ (Director of Quality, RN) completed one-on-one in-service with Assistant Director of Nursing on Changes in Condition, including timely assessment, physician notification, and follow physician recommendations. On 12/22/2023 Assistant Director of Nursing/Designee completed 100% in-service training on Notification to Management (IDT Team) of Any Injury or Change of Condition, training on Abuse/Neglect, training on Appropriate Assessments of Residents will be done in a Timely Manner on any Change of Condition or Injuries, and training on Notification to MD of any Injury or Change of Condition. Starting on 01/12/2024 the Assistant Director of Nursing/Designee initiated in-service with nurses on changes in condition, including timely assessment, physician notification, and follow physician recommendations. Education to be completed on 01/12/2024. Any staff that is not available will be trained prior to their next scheduled workday, including PRN and Agency staff. Ad-Hoc QAPI meeting was held on 01/12/2024, with the Medical Director, NHA (Nursing Home Administrator), Director of Quality, and Assistant Director of Nursing to review the alleged deficiencies, policy and procedure, and the plan for removal of immediacy. The policy pertaining to Change in condition and timely reporting was reviewed on 01/12/2024 by the NHA (Nursing Home Administrator), Assistant Director of Nursing, DOQ (Director of Quality), and Medical Director. Starting on 01/12/2024, IDT (Interdisciplinary team), including Administrator, Assistant Director of Nursing, and MDS Coordinator will review any changes in condition and events daily Monday to Friday, and Manager on Duty Saturday and Sunday to determine if timely notification and assessment was completed due to changes in condition. The findings will be immediately brought to the Administrator for further action, if necessary. On 01/12/2024 the RNC (Regional Nurse Consultant)/DOQ (Director of Quality) will start reviewing Events/Changes in Condition for validation of thorough assessment and timely notification weekly for four (4) weeks followed by monthly for 2 months. The Administrator/designee will monitor compliance by completing audit of five (5) residents per week for four (4) weeks. This was initiated on 01/12/2024. Any identified concern will be addressed immediately and if trends and patterns are identified, the facility will conduct an Ad-Hoc QAPI meeting to discuss if additional interventions are needed to ensure compliance for next 2 months. The Administrator will be responsible for ensuring this plan is completed on 01/12/2024. The COO will provide oversight of Administrator to ensure that the items on the plan of removal are reviewed and completed. Verification of the Plan of Removal: In an interview on 01/13/24 at 9:35 AM, the ADON stated there were three residents who had a recent change in their condition in the past week. Record review of the 3 residents who were identified with a change in their condition revealed each resident had been assessed by the nurse, the physician was notified, orders received were initiated and a SBAR was completed. Record review of facility's nurse staffing revealed: total of 27 (24 NAs, 3 LVNs). Record review of the 4 in-services dated 12/22/23 revealed 59 signatures with a completion rate of 100%. During an interview on 01/11/24 at 11:10 AM, the ADON stated: in-service was conducted from on 12/22/23 for 59 staff on (Notification to Management of Any Injury or Change of Condition; In-services for Abuse and Neglect for 59 staff; In service for Appropriate Assessment Done in a Timely Manner for 59 staff; In- service on Notification too MD for 59 staff.; Interviews on 01/13/24 at 10:24 AM to 4:00 PM with 3 of 5 facility nurses (3 LVNs) who worked on the 6 AM to 6 PM shift revealed they had been in-serviced on 01/12/24 on changes in condition, timely assessment, physician notification, and to follow physician recommendations and knew how to respond to a future change of condition. Interviews on 01/13/24 from 10:24 AM to 4:00 PM with 3 of 6 agency nurses (3 LVNs) who worked on the 6 PM to 6 AM shift revealed they had been in-serviced on 01/12/24 on changes in condition, timely assessment, physician notification, and to follow physician recommendations; and knew how to respond to a change of condition. In an interview on 1/13/24 at 11:07 AM, the Regional Nurse Consultant (RNC) stated she assisted the DOQ with assessing all the residents on 01/12/24. The RNC stated she assessed the 2 secured units and the DOQ assessed the residents on the other side of the building. RNC stated there were 2 residents whom she noticed there was a change from their normal baseline, which the floor nurse had already identified earlier in the day, the residents' physicians had been notified and she made sure an SBAR had been completed for those residents. The Regional Nurse Consultant stated she participated in the Ad Hoc QAPI meeting held on 01/12/24 with the Administrator, ADON, DOQ present in person and the Medical Director present by telephone. In a telephone interview on 01/13/24 at 2:05 PM, the Medical Director stated he was informed of the IJ situation on 01/12/24, he participated via telephone in the Ad Hoc QAPI meeting held in the late afternoon on 01/12/24, and he approved the measures the facility was going to implement. The Medical Director stated the policy about Change in Condition and Timely Reporting was reviewed with him during the Ad-Hoc QAPI meeting. In an interview on 01/13/24 at 2:52 PM the RNC stated she would weekly run a report in the electronic charting system to see which residents had a new SBAR completed to identify residents who had a change in their condition and would do this for two months to monitor residents who had a change in their condition. In an interview on 01/13/24 at 2:58 PM, the ADON stated all the residents were assessed on 01/12/24 by the DOQ and RNC. ADON stated she was in-serviced by the DOQ on change of resident's condition, timely notification to the physician, following the physician recommendations and on Abuse & Neglect. ADON stated she had in-service all 12 nurses on changes in condition, timely assessment, physician notification, following physician recommendations and abuse and neglect. ADON said an Ad Hoc QAPI meeting was held on 01/12/24 in the afternoon; she, the RNC, the DOQ and administrator were present, and the Medical Director attended via phone. ADON stated the policy pertaining to Change in Condition and Timely reporting was reviewed during the ad-hoc QAPI meeting held on 01/12/24. ADON said on weekends, the Manager on Duty would monitor any changes in condition to the residents; and during the week the IDT would do the monitoring. The ADON stated if there was a change in the resident's condition the resident would be assessed, the physician would be notified, new orders received would be implemented and the resident's RP would be notified. The ADON stated she completed the monitoring of changes in resident's condition on 01/13/24, using a Daily Census Sheet, for the weekend Manager on Duty, any new findings would be assessed by the nurse and the Daily Census sheet was placed in the facility's POR white binder. In an interview on 01/13/24 at 3:15 PM, the Administrator stated all the residents were assessed by the RNC and the DOQ on 01/12/24, and the medical director was notified on 01/12/24 after the facility was informed of the IJ. Administrator said the DOQ conducted an in-service with the ADON on Changes in Condition, timely assessment, physician notification and following physician recommendations and 100% of the nurses were in-serviced by the ADON on 01/12/2024 on Notification to Management of any injury or change of condition, appropriate assessments of residents being done in a timely manner, notify the physician of change of condition, following physician recommendations, and abuse and neglect. Administrator stated an Ad Hoc QAPI meeting was held on 01/12/24 after the facility's POR had been accepted with the Medical Director via phone, and the RNC, ROQ and ADON in person. Administrator said the policy pertaining to Change in Condition and Timely Reporting was reviewed during the AD Hoc QAPI meeting. Administrator stated changes in a residents' condition would be monitored by the IDT during the morning meeting; the facility activity report would be printed to show progress notes written in the past 24-hours; the nurses would attend the morning meeting and report on residents who had a change in their condition. He stated on the weekends the Manager on Duty would review the report for any changes of condition and notify the ADON or the Administrator if a resident had a change in their condition. Administrator stated he would audit the activity report weekly to see if there was an event or change in a resident's vital signs, then he would review the resident's clinical record to see if it was a change in the residents' condition and notify the ADON. Administrator said the COO would be consult the RNC and ROQ for monitoring of residents' change of condition, there would be w[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to protect a resident's right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 of 4 residents (Resident #1) reviewed for abuse, in that: The facility failed in that they used physical and chemical restraints on Resident #1 when he began exibiting aggressive and exit seeking behaviors. Resident #1's behaviors included; hitting, scratching, pulling, pushing, kicking and grabbing clothes. These failures resulted in an IJ on 8/31/23 at 6:01 p.m. While the IJ was removed on 9/1/23 at 8:19 p.m., the facility remained out of compliance at a level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy with a scope of pattern. This deficient practice placed residents at risk of psychosocial harm, feeling disrespected or uncomfortable, decreased self-esteem, impaired quality of life and abuse. The findings included: Record review of Resident #1's face sheet, dated 8/26/23 revealed a [AGE] year old male admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included schizophrenia (a disorder that affects a person's ability to think, feel and behave clearly), delusional disorders (a mental health condition in which a person can't tell what's real from what's imagined), anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), dementia without behavioral disturbance and impulse disorder (characterized by urges and behaviors that are excessive and/or harmful to oneself or others). Record review of Resident #1's most recent quarterly MDS assessment, dated 8/2/23 revealed the resident was severely cognitively impaired for daily decision-making skills. Record review of Resident #1's comprehensive care plan, edit date 8/23/23 listed the problem Mood State which included the following approaches: -Allow resident to have control over situations, if possible -Assign consistent staff member -Do not confront, argue against, or deny resident's thoughts -Maintain a calm environment and approach to the resident Further review of Resident #1's comprehensive care plan listed the problem Behavioral Symptoms, edit date 7/3/23, included the following approaches: -If elopement occurs, maintain supervision at a distance as tolerated by resident for safety concerns. Redirect resident when calm -Initiate one on one staff to resident observation. Maintain appropriate safety measures at all times -Consider placement on secure unit if wandering, elopement attempts continue Record review of the progress note written by LVN A, titled Elopement, dated 5/18/23 and time stamped 10:57 a.m. revealed in part, Resident #1 was very agitated and wanted to go off the property for a walk .resident on the walking trail for a few minutes and we were able to get him back into the facility without incident . Record review of the progress note written by LVN A, titled Elopement, dated 5/18/23 and time stamped 11:00 a.m. revealed in part, .Psychiatric NP B .was notified and saw the patient via telehealth. New order received for one time dose of Clonazepam 1mg (a benzodiazepine prescribed to treat generalized anxiety), administered by this nurse . Record review of the Psych Encounter note written by Psychiatric NP B, dated 5/18/23 revealed in part, .Resident #1 with a history of dementia, generalized anxiety disorder, impulse disorder, and delusional disorder .Today he is being seen for increased agitation. Staff reports he is eloped out of the building and when staff tried to bring him back, he became combative. He did not want to come back in, was very resistant and agitated .Denies paranoia. Denies past trauma. Denies suicidal ideation, homicidal ideation, audio hallucinations and visual hallucinations .No GDR recommended at this time. Resident #1 continues to display agitation and anxiety. Will continue current dose . Further review of the Psych Encounter Note revealed Give Clonazepam (a sedative) 1 mg x 1 dose for agitation .Start Trazadone (an anti-depressant and sedative) 25 mg at 4 PM for agitation .return appointment 1 month with Psychiatric NP B . Record review of the Psych Encounter note written by Psychiatric NP B, late entry 6/13/23 for visit date 6/7/23 revealed in part, .Resident #1 with history of dementia, generalized anxiety disorder, impulse disorder, and delusional disorder .Staff report he is always aggressive, exit seeking and would fight before coming back to the building .Resident continues to display agitation and anxiety .Start Haldol (an antipsychotic used to treat mental disorders) 5mg/ml. Give 2.5mg IM every 6 hours PRN for 'restlessness and agitation.' Order to expire in 14 days . Record review of the Psych Encounter note written by Psychiatric NP B, late entry 6/23/23 for visit date 6/21/23 revealed in part, .Resident with a history of dementia, generalized anxiety disorder, impulse disorder, and delusional disorder .constantly tries to elope the building .was getting angry and agitated talking to me .No GDR recommended at this time. Resident continues to display agitation and anxiety .Start Haldol 1mg gel. Apply 2 mg every 6 hours as needed, to wrist area, for 'restlessness and agitation' for dementia with behavioral disturbance. Order valid for 14 days. Start Haldol 5mg/ml. Give 2.5 mg IM every 6 hours PRN for 'restlessness and agitation.' Order to expire in 14 days . Record review of the progress note written by LVN C, dated 6/23/23 and time stamped 5:37 p.m. revealed in part, .Shift nurse heard the alarms going off on the hall when the nurse went all [sic] the hall found the door open and the resident (Resident #1) in the yard hiding in the bushes .MD gave new PRN orders nurse will carry those orders out . Record review of the facility Event Report dated 7/5/23 and completed by LVN D revealed Resident #1 had a psychotic episode that caused injuries to others. The Event Report revealed, multiple staff members were pushed, punched and grabbed very aggressively. Under the section, Indicate Pharmacological measures taken, Other was checked and indicated, Haldol IM given by ADON per MD orders. Record review of the Neuropsychological Assessment by the Licensed Psychologist, dated 8/16/23 revealed in part, .Referred by medical for neurocognitive evaluation to clarify diagnosis and assist with treatment plan in the context of aggressive behaviors, and to assess for depression, anxiety, or any other psychiatric conditions that might be focus of attention at this time .Patient is NOT currently a danger to self/others .Treatment Plan/Recommendations .Psychiatric and psychological treatment .Follow up with neuropsychological testing as soon as feasible . Record review of the progress note written by the DON, dated 8/27/23 and time stamped 1:15 p.m. revealed in part, .obtaining verbal consent for new medication ABH (made from a combination of Ativan, a sedative to relieve anxiety, Benadryl an anti-histamine and, Haldol an anti-psychotic used to treat mental disorders) gel for 'aggressive behaviors' .resident (Resident #1) behaviors had increased in frequency with increased agitation and aggressiveness towards other residents and staff . Record review of the progress note written by LVN A, dated 8/27/23 and time stamped 9:15 p.m. revealed in part, .Resident #1 coming out of the locked hall and acting aggressive toward staff . I am the nurse that administered ABH gel to the resident . During a telephone interview on 8/28/23 at 10:30 a.m., the Medical Director stated, We don't think the resident [Resident #1] is appropriate for this facility. He has proved he is not appropriate for this facility. The Medical Director further stated, [Psychiatric NP B] is perfectly capable of making medication adjustments and they are supervised by a licensed psychiatrist. No reason why this should not have been handled. The Medical Director further stated, I have recommended the facility to either contact [Psychiatric NP B] or give Haldol IM as needed. During an interview on 8/28/23 at 12:14 p.m., the ADON revealed, Resident #1 had been seen by Psychiatric NP B and stated, but I don't believe she made any real medication changes other than PRN Haldol. During an interview on 8/28/23 at 5:52 p.m., LVN A revealed, Resident #1 had a behavior on 8/27/23 and was surrounded by 3 male aides and Resident #1 was getting really mad at one of the male aides, Nurse Aide F. LVN A revealed, the next thing she knew, Resident #1 was by the front door sitting on the ground, and Nurse Aide G holding Resident #1 by one arm facing forward and Nurse Aide H holding the resident by the other arm and the third aide, Nurse Aide F holding down the resident's legs. LVN A stated she told the Aides to let Resident #1 go and then LVN A applied the ABH gel to Resident #1. LVN A stated, we are a restraint free facility, no we should not have been restraining [Resident #1]. LVN A revealed she told Nurse Aide F he could not do that, restrain Resident #1 to which Nurse Aide F replied, am I in trouble now? LVN A stated, what I did see is [Nurse Aide F] and the other two male aides restrain [Resident #]1. During an interview on 8/28/23 at 7:22 p.m., LVN D revealed Resident #1 resided in the male secure unit and had gotten out multiple times. LVN D revealed approximately one month ago, June 2023, Resident #1 barged outside of the secure unit. LVN D revealed Resident #1 was held back by multiple staff members after the resident pushed the MDS Coordinator. LVN D stated, staff tried to hold [Resident #1] under the arms as he was swinging. LVN D revealed, Resident #1 was eventually held down in a chair and the ADON gave the resident a Haldol injection. LVN D stated, I feel bad they had to tranquilize [Resident #1] to get him to calm down. LVN D stated, the [ADON], the [DON] and the [Administrator] were all here in the facility when this incident (with the MDS Coordinator) occurred, and they were aware [Resident #1] was held down. LVN D stated, I do not feel like anyone here is trained to deal with [Resident #1's] behaviors. LVN D stated, Agency LVN E, who no longer worked for the facility, used to work in a psychiatric facility and told other staff how to hold Resident #1 in a seated position. During an interview on 8/28/23 at 7:23 p.m., Nurse Aide F revealed he was assigned one to one to Resident #1 on 8/27/23. Nurse Aide F revealed, Resident #1 became agitated on 8/27/23 after Nurse Aide G asked the resident if he was okay and the resident started kicking the air and moving his hands rapidly. Nurse Aide F stated, Resident #1 moved towards the door leading to the front with Nurse Aide G and himself following and Resident #1 pushed open the door from the locked unit and moved toward the inner facility. Nurse Aide F stated, Nurse Aide H came to assist as Resident #1 grabbed Nurse Aide F's shirt from the front. Nurse Aide F stated, they both [Nurse Aide G and Nurse Aide H] took [Resident #1] by an arm and held him back and we got him to the ground so the nurses could apply the ABH cream on him. Nurse Aide F stated, [Resident #1] wasn't able to get up. Nurse Aide F stated, I don't think [Resident #1] is appropriate for this facility, he needs to be somewhere where staff are trained for that. I am not trained to deal with that on a regular basis. Nurse Aide F stated, We have been instructed to keep [Resident #1] in the unit but didn't really get any instruction on how to keep him in the unit. During an interview on 8/29/23 at 8:59 a.m., the Assistant BOM revealed, an incident occurred on 8/27/23 at approximately 7:00 p.m. or 7:30 p.m., before preparing to leave her office. The Assistant BOM stated, Resident #1 was observed heading in the direction past the nurse's station toward the front door. The Assistant BOM stated, her office was close to the facility front door and observed Resident #1 followed by Nurse Aide F, Nurse Aide G and Nurse Aide H. The Assistant BOM stated, LVN A had her gloves on ready to apply the ABH gel when Resident #1 hit Nurse Aide F on the upper chest, then grabbed Nurse Aide F's shirt and started to shake him. The Assistant BOM stated, at that point [Nurse Aide G[ and [Nurse Aide H] come in and they are right by my office door wall and in the meantime, I am trying to call the [Administrator]. At this point, the guys are trying to hold [Resident #1] and they are holding his arms, like under his elbows and [Nurse Aide F] is still trying to get loose. Everybody goes down, they fall down, and [Resident #1] starts to kick. The Assistant BOM revealed, LVN A then applied the ABH gel to Resident #1's hands. The Assistant BOM stated, it had been discussed during in-services that staff were not to touch Resident #1 because it would escalate his anxiety and aggression. During a telephone interview on 8/29/23 at 3:02 p.m., Agency LVN E revealed she had worked at the facility through a contracted agency but discontinued her contract after 30 days. Agency LVN E revealed, Resident #1 had behaviors that were sometimes avoidable but sometimes not. Agency LVN E revealed an incident occurred in June 2023 in which Resident #1 pushed the MDS Coordinator and had also made contact with the Activity Director. Agency LVN E stated, everyone swarms, [Resident #1] seems like he is going towards everybody and there is a lot of yelling, I step back because less is more. Agency LVN E further stated, [Resident #1] had a hold of the [Activity Director] and is not letting go. [Resident #1] was restrained, because that is what it was called. But [Resident #1] could still move. Agency LVN E revealed, the physical restraint used on Resident #1 was called bear paws so as not to cause bruising while being restrained. Agency LVN E stated, she and CNA I restrained Resident #1 and once we got him to the ground, he [Resident #1] starts to relax. Agency LVN E stated, the restraint to Resident #1 lasted a total time of 15 to 20 minutes until the police arrived. Agency LVN E revealed, the facility had not provided training on anything related to the incident, nothing on dementia, nothing on aggression, nothing on behaviors. Agency LVN E stated she did not know who the Abuse Coordinator was and approximately a month ago was given a paper to sign on an in-service on abuse and neglect. Agency LVN E stated, I do not think we are supposed to touch them (residents) but there was no way of getting around it. During an interview on 8/29/23 at 5:47 p.m., the DON stated, Resident #1 could not be stopped from having behaviors and just to keep him safe. The DON revealed staff could not lay hands on Resident #1 and to make sure all the residents were safe. The DON stated, our policy is to follow [Resident #1], keep him safe and call police to help us get him back into the building safely. During an interview on 8/30/23 at 2:38 p.m., Nurse Aide G revealed an incident occurred on 8/27/23 at approximately 7:00 p.m., after the residents had eaten. Nurse Aide G stated Nurse Aide F had been assigned Resident #1's one to one staff when Resident #1 got out of the secure unit with Nurse Aide F following. Nurse Aide G stated, Resident #1 grabbed Nurse Aide F's shirt and Nurse Aide G came behind [Resident #1] and put my arms around his upper shoulder as if to grab him and [Resident #1] took his arm and swung it back and that's how we fell on the floor. Nurse Aide G stated, he, Resident #1, Nurse Aide F and Nurse Aide H fell together on the floor with the force of Resident #1 trying to swing at them and Resident #1 still holding onto Nurse Aide F's shirt. Nurse Aide G stated, I have never seen any staff hold him [Resident #1], we try to talk to him and calm him down. Nurse Aide G revealed he did not consider the incident on 8/27/23 resulted in Resident #1 being restrained. During an interview on 8/30/23 at 3:29 p.m., the Administrator revealed, the Assistant BOM contacted him by phone on 8/27/23 at approximately 7:20 p.m. regarding the incident in which Resident #1 came out of the secure unit and was followed by Nurse Aide F, Nurse Aide G and Nurse Aide H. The Administrator stated, the Assistant BOM was giving the Administrator a narrative while it was going on. The Administrator stated, basically, [Resident #1] rushed [Nurse Aide F] and grabbed him, and two other aides pulled the resident off of [Nurse Aide F]. The Administrator stated, [Nurse Aide F] was standing in front of [Resident #1] because another resident was in [Resident #1's] path. The Administrator further stated, the other two aides grabbed [Resident #1] by the arms and pulled him back while [Resident #1] was holding onto [Nurse Aide F's] shirt, and they all fell down. The Administrator stated, [Nurse Aide F] held one of[ Resident #1's] legs because he was kicking him, just didn't want him to hurt anybody and then the nurse put the cream on him and then [Resident #1] got up by himself and went for a walk with them. [Resident #1] was not restrained. The Administrator stated, I have never been informed [Resident #1] had ever been restrained. The Administrator revealed he recalled the incident in which Resident #1 pushed the MDS Coordinator. The Administrator stated, [Resident #1] pushed the [MDS Coordinator] and the staff, don't recall who it was, held [Resident #1] down. I think it was one (staff) on each side of him, to calm him down. The Administrator stated, again [Resident #1] was not hurt. The Administrator stated, the incident with the [MDS Coordinator], we didn't know what to do and [Resident #1] was held down to keep him from hurting other people, I'm sure. The Administrator revealed, the staff at the facility were not trained to deal with that kind of behavior. During an interview on 8/30/23 at 4:11 p.m., the MDS Coordinator revealed he recalled the incident in which Resident #1 pushed him. The MDS Coordinator revealed, staff were guiding Resident #1 to sit in a wheelchair, holding the resident's arms and the resident was resistive and combative. The MDSCoordinator stated, Resident #1 got up from the wheelchair and two staff, could not recall who, had their arms under the resident's upper arms and they backed up until they backed up against the wall and slid down the wall still holding the resident by the arms and talking to him and then the police showed up. The MDS Coordinator revealed, there was one nurse, Agency LVN E who stated she was trained for this (restraints). The MDS Coordinator stated, they were restraining him, I would think, but it was reasonable intervention because it was a very erratic behavior, he [Resident #1] was kind of out of control. During a follow up interview on 8/31/23 at 8:22 a.m., the DON revealed, the facility did not do behavioral health training of staff and staff were only instructed to remove them (residents) and calm the situation. The DON stated, most of our residents don't have violent behaviors. [Resident #1] seemed to be the one factor in these situations. During an interview on 8/31/23 at 1:18 p.m., CNA I stated, he had not heard or seen residents being restrained. CNA I revealed, residents, including Resident #1, could not be restrained, and staff should not provoke or argue with the residents, leave them be and keep residents safe. CNA I denied ever having restrained Resident #1. Record review of the facility's policy and procedure titled Abuse Prevention Program, revision date April 2013, revealed in part, .Our residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion .1. Our facility is committed to protecting our residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies providing services to our residents, family members, legal guardians, surrogates, sponsors, friends, visitors or any other individual .a. Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish .5. Along with other staff and management, the Medical Director will help identify situations that might constitute or could be constituted as neglect; for example .inappropriate management of problematic behavior .repeated failure to check for correct application of restraints . The Administrator was given the IJ template and was notified of the Immediate Jeopardy {IJ} on 8/31/23 at 6:01 p.m. and a plan of removal was requested. On 9/1/23 at 8:38 a.m., the facility provided a plan of removal that was accepted. It was documented as follows: SURVEY TYPE: Complaint Survey SURVEY DATE: 8/31/23 Plan for REMOVAL Plan to remove immediate jeopardy. F600 On 8/31/23, Resident #1 no longer resided at the facility On 8/31/2023 the Regional Nurse Consultant completed in-service with the DON, ADON and the Administrator on abuse and neglect, abuse and neglect reporting guidelines/policy, abuse, and neglect CE pathways, and on reporting then investigating to follow the current regulatory provider letter. On 8/31/2023 DON and ADON assessed residents residing on Hall A (secure unit) for signs and symptoms of abuse, no negative findings. The Medical Director was notified of no changes in condition by DON on 8/31/2023. On 8/31/2023 the Director of Nursing and ADON initiated in-service with facility staff on abuse and neglect, abuse, and neglect reporting guidelines/policy, reporting abuse to management staff/abuse coordinator. Education to be completed on 8/31/23. Any staff that is not available will be educated prior to their next scheduled workday. The in-service was completed on 9/1/23. On 8/31/23 the Administrator and the Regional Reimbursement Consultant will complete safe surveys with residents, to ensure the health and safety of all residents. The IDT, NHA (Nursing Home Administrator), DON, ADON, Regional Nurse Consultant, and MDS Coordinator will review the findings and will immediately notify the Administrator for further action, if necessary. The safety survey was completed on 9/1/23. On 8/31/23 an Ad-Hoc QAPI meeting was held with the Medical Director, NHA (Nursing Home Administrator), DON, Regional Nurse Consultant, Assistance Director of Nursing, Regional MDS, Regional Director of Operations and MDS Coordinator to review the deficiency and the plan for removal of immediacy. Sign-in sheet was reviewed on 9/1/23. Starting on 8/31/2023, IDT (Interdisciplinary team), including Administrator, DON, ADON and MDS Coordinator will review abuse and neglect monitoring Monday to Friday, and Manager on Duty Saturday and Sunday for 1 month to ensure the health and safety of the residents. The findings will be immediately brought up to the Administrator for further action, if necessary. A sign-in sheet was provided of the IDT meeting with the aforementioned staff on 9/1/23. The Administrator/designee will monitor compliance by completing an audit of residents that have behaviors/aggression every week for four (4) weeks, MD being notified, Family being notified, and behavioral services to be notified. If Behavioral Services is not available, then the Medical Director will be notified for any psychosocial concerns. This will be initiated on 8/31/2023. Any identified concerns will be addressed immediately and if trends and patterns are identified, the facility will conduct an Ad-Hoc QAPI meeting to discuss if additional interventions are needed to ensure compliance for the next 2 months. The facility provided an audit dated 8/31/23, initiated by the administrator on 9/1/23. The Administrator will be responsible for ensuring this plan is completed on 8/31/2023. The RDO will provide oversight of Administrator and DON to ensure that the items on the plan of removal are reviewed and completed. Monitoring of the implementation of the POR: Plan to remove immediate jeopardy. During an observation and interview on 9/1/23 at 8:03 p.m., Resident #2 was in his room lying in bed watching television. Resident #2 revealed he felt safe and had been asked by facility staff about abuse/neglect. Resident #2 stated, you're the third person who has asked me. Resident #2 did not appear to be in any obvious distress or discomfort. During an observation and interview on 9/1/23 at 8:08 p.m., Resident #3 was in her room sitting up in a wheelchair. Resident #3 did not appear to be in any obvious distress or discomfort. Resident #3 stated the ADON had talked to her on 8/31/23 about abuse/neglect. Resident #3 stated she felt safe in the facility. During an observation and interview on 9/1/23 at 8:11 p.m., Resident #4 appeared well-groomed and appropriately dressed and did not appear to be in any obvious distress or discomfort. Resident #4 stated she had been asked by the ADON about abuse and revealed she wanted to be with her boyfriend. Record review of the facility interviews with 70 residents on 8/30/23 revealed the safety survey was completed. Most of the residents in the facility were not interview able, and those that were did not make any new allegations of abuse or neglect. Record review of the facility Ad-Hoc QAPI meeting held on 8/31/23 revealed signatures for the Medical Director, NHA (Nursing Home Administrator), DON, Regional Nurse Consultant, Regional MDS, Regional Director of Operations and the MDS Coordinator. A log was created for the IDT to review and monitor for abuse and neglect Monday to Friday and the Manager on Duty for Saturday and Sunday to be monitored for 1 month to ensure the health and safety of the residents. Any adverse findings would be reported to the Administrator for further action if necessary. Record review of the facility IDT meeting held on 8/31/23 included the Administrator, DON, ADON and MDS coordinator revealed the Administrator would monitor for compliance by completing an audit of 5 residents per week for the next 4 weeks of residents with behaviors/aggression with MD notification for request of behavioral services, initiated on 8/31/23. The log dated 9/1/23 revealed 5 random residents were chosen for the audit and signed by the Administrator. During a joint interview on 9/1/23 at 5:36 p.m., the DON, ADON, Regional Nurse Consultant, the COO and RN Director of Quality revealed review of the POR for abuse/neglect highlighted training on identifying and reporting suspected abuse. Record review of the facility in-service dated 8/31/23, titled Abuse Neglect Policy/Reporting Guidelines/Abused and Neglect Pathways revealed 67 facility employed staff signed the sign-in sheet. The facility had 55 total facility employees and utilized agency staff. During a joint interview on 9/1/23 at 5:22 p.m., the DON and the Administrator revealed the abuse/neglect in-service highlighted identifying forms of abuse, reporting suspected abuse for investigation and adhering to reporting guidelines. 1. During an interview on 9/1/23 at 3:50 p.m., Housekeeping Staff J revealed she had worked for the facility for just 4 months and worked Monday through Saturday from 2:00 p.m. to 10:00 p.m. Housekeeping Staff J revealed she had been in-serviced on abuse/neglect that morning and revealed she was to report abuse/neglect to the Administrator and to keep the residents safe. 2. During an interview on 9/1/23 at 3:55 p.m., CNA L revealed she had worked for the facility off and on since January 2023 and worked 6:00 a.m. to 6:00 p.m. on a rotating schedule. CNA L revealed she had been in-serviced on abuse/neglect on 9/1/23 and the in-serviced covered identifying abuse/neglect and to report to the Administrator while keeping the residents safe. 3. During an interview on 9/1/23 at 4:00 p.m., the Assistant BOM revealed she worked every day with varying hours and had been in-serviced on abuse/neglect in the morning on 9/1/23. The Assistant BOM stated, abuse/neglect was to be reported to the DON and the Administrator. The Assistant BOM stated, remove the resident from an unsafe environment and keep them safe. 4. During an interview on 9/1/23 at 4:05 p.m., the BOM stated she had worked for the facility for 5 years and worked Monday to Friday. The BOM stated she had been in-serviced on abuse/neglect last week and was to report suspicion of wrongdoing to the residents to the Administrator. The BOM stated, if the Administrator was not available, abuse and neglect should be reported to the DON and the charge nurse. 5. During an interview on 9/1/23 at 4:12 p.m., CNA L revealed she had worked for the facility for 2 years and worked from 6:00 a.m. to 6:00 p.m. on a rotating schedule. CNA L stated she had been in-serviced by the ADON on 9/1/23 on abuse/neglect. CNA L revealed the highlight of the in-service covered identifying abuse/neglect and the process for reporting. CNA L revealed abuse/neglect was reported to the Administrator while keeping the resident safe. 6. During an interview on 9/1/23 at 4:16 p.m., CNA M revealed she had worked for the facility for about a month but had been employed over a year ago and had been working the 6:00 a.m. to 6:00 p.m. on a rotating schedule. CNA M stated she had been in-serviced on 9/1/23 on abuse/neglect. CNA M stated, abuse was physical, verbal, and emotional. CNA M stated if abuse/neglect was suspected, report to the Administrator and if not available, report to the DON and the charge nurse. 7. During an interview on 9/1/23 at 4:23 p.m., Nurse Aide N revealed she had worked for the facility for 6 months and worked from 6:00 a.m. to 6:00 p.m. on a rotating schedule. Nurse Aide N stated she had received an in-service by the ADON on abuse/neglect on 8/31/23. Nurse Aide N stated abuse could be verbal, physical, or making a resident do something they did not want. Nurse Aide N stated she was supposed to report abuse/neglect to the Administrator and to the nurse. 8. During an interview on 9/1/23 at 4:28 p.m., CNA O revealed she had worked for the facility for 2 years and worked from 6:00 a.m. to 6:00 p.m. on a rotating shift. CNA O revealed she had been in-serviced on abuse/neglect in the morning on 9/1/23. CNA O revealed the in-service highlighted types of abuse such as verbal, physical, restraints, and yelling at residents. CNA O revealed abuse/neglect was to be reported to the Administrator while keeping the residents safe. 9. During an interview on 9/1/23 at 4:35 p.m., Nurse Aide P revealed she had worked for the facility for 2 weeks and worked the 6:00 a.m. to 6:00 p.m. shift on a rotating schedule. Nurse Aide P stated she had been in-serviced on abuse/neglect this week and the in-service highlighted on identifying abuse/neglect and reporting to the Administrator. 10. During an interview on 9/1/23 at 4:40 p.m., Kitchen Staff Q revealed she had worked for the facility for the past 6 weeks and had been in-serviced on abuse/neglect this week. Kitchen Staff Q stated abuse/neglect was physical or verbal and was not allowed. Kitchen Staff Q revealed if she suspected abuse/neglect she was supposed to report it to the Administrator and keep the residents safe. 11. During an interview on 9/1/23 at 4:46 p.m., LVN C revealed she had worked for the facility for 8 years and worked varying shifts and had been in-serviced this week. LVN C stated, abuse/neglect was

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents were free from physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms for 1 of 4 residents (Resident #1) reviewed for freedom from physical and chemical restraints, in that: The facility failed to ensure Resident #1 was free from any physical or chemical restraints when exhibiting aggressive behaviors These failures resulted in an IJ on 8/31/23 at 6:01 p.m. While the IJ was removed on 9/1/23 at 8:19 p.m., the facility remained out of compliance at noactual harm with a 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 their plan of removal. This deficient practice could place residents at risk of unnecessary restriction of their freedom of movement (any change in place or position for the body or any part of the body that the person is physically able to control). The findings included: Record review of Resident #1's face sheet, dated 8/26/23 revealed a [AGE] year old male admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included schizophrenia (a disorder that affects a person's ability to think, feel and behave clearly), delusional disorders (a mental health condition in which a person can't tell what's real from what's imagined), anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), dementia without behavioral disturbance and impulse disorder (characterized by urges and behaviors that are excessive and/or harmful to oneself or others). Record review of Resident #1's most recent quarterly MDS assessment, dated 8/2/23 revealed the resident was severely cognitively impaired for daily decision-making skills. Record review of Resident #1's comprehensive care plan, edit date 8/23/23 listed the problem Mood State which included the following approaches: -Allow resident to have control over situations, if possible -Assign consistent staff member -Do not confront, argue against, or deny resident's thoughts -Maintain a calm environment and approach to the resident Further review of Resident #1's comprehensive care plan listed the problem Behavioral Symptoms, edit date 7/3/23, included the following approaches: -If elopement occurs, maintain supervision at a distance as tolerated by resident for safety concerns. Redirect resident when calm -Initiate one on one staff to resident observation. Maintain appropriate safety measures at all times -Consider placement on secure unit if wandering, elopement attempts continue Further review of Resident #1's comprehensive care plan did not address an assessment for the use of restraints or the need for the use of restraints. Record review of the progress note written by LVN A, titled Elopement, dated 5/18/23 and time stamped 10:57 a.m. revealed in part, Resident #1 was very agitated and wanted to go off the property for a walk .resident on the walking trail for a few minutes and we were able to get him back into the facility without incident . Record review of the progress note written by LVN A, titled Elopement, dated 5/18/23 and time stamped 11:00 a.m. revealed in part, .Psychiatric NP B .was notified and saw the patient via telehealth. New order received for one time dose of Clonazepam 1mg (a benzodiazepine prescribed to treat generalized anxiety), administered by this nurse . Record review of the Psych Encounter note written by Psychiatric NP B, late entry 6/13/23 for visit date 6/7/23 revealed in part, .Resident #1 with history of dementia, generalized anxiety disorder, impulse disorder, and delusional disorder .Staff report he is always aggressive, exit seeking and would fight before coming back to the building .Resident continues to display agitation and anxiety .Start Haldol (an antipsychotic used to treat mental disorders) 5mg/ml. Give 2.5mg IM every 6 hours PRN for 'restlessness and agitation.' Order to expire in 14 days . Record review of the Psych Encounter note written by Psychiatric NP B, late entry 6/23/23 for visit date 6/21/23 revealed in part, .Resident with a history of dementia, generalized anxiety disorder, impulse disorder, and delusional disorder .constantly tries to elope the building .was getting angry and agitated talking to me .No GDR recommended at this time. Resident continues to display agitation and anxiety .Start Haldol 1mg gel. Apply 2 mg every 6 hours as needed, to wrist area, for 'restlessness and agitation' for dementia with behavioral disturbance. Order valid for 14 days. Start Haldol 5mg/ml. Give 2.5 mg IM every 6 hours PRN for 'restlessness and agitation.' Order to expire in 14 days . Record review of the progress note written by LVN C, dated 6/23/23 and time stamped 5:37 p.m. revealed in part, .Shift nurse heard the alarms going off on the hall when the nurse went all [sic] the hall found the door open and the resident (Resident #1) in the yard hiding in the bushes .MD gave new PRN orders nurse will carry those orders out . Record review of the facility Event Report dated 7/5/23 and completed by LVN D revealed Resident #1 had a psychotic episode that caused injuries to others. The Event Report revealed, multiple staff members were pushed, punched and grabbed very aggressively. Under the section, Indicate Pharmacological measures taken, Other was checked and indicated, Haldol IM given by ADON per MD orders. Record review of the progress note written by the DON, dated 8/27/23 and time stamped 1:15 p.m. revealed in part, .obtaining verbal consent for new medication ABH (made from a combination of Ativan, a sedative to relieve anxiety, Benadryl an anti-histamine and, Haldol an anti-psychotic used to treat mental disorders) gel for 'aggressive behaviors' .resident (Resident #1) behaviors had increased in frequency with increased agitation and aggressiveness towards other residents and staff . Record review of the progress note written by LVN A, dated 8/27/23 and time stamped 9:15 p.m. revealed in part, .Resident #1 coming out of the locked hall and acting aggressive toward staff . I am the nurse that administered ABH gel to the resident . During a telephone interview on 8/28/23 at 10:30 a.m., the Medical Director stated, We don't think the resident [Resident #1] is appropriate for this facility. He has proved he is not appropriate for this facility. The Medical Director further stated, [Psychiatric NP B] is perfectly capable of making medication adjustments and they are supervised by a licensed psychiatrist. No reason why this should not have been handled. The Medical Director further stated, I have recommended the facility to either contact [Psychiatric NP B] or give Haldol IM as needed. During an interview on 8/28/23 at 12:14 p.m., the ADON revealed, Resident #1 had been seen by Psychiatric NP B and stated, but I don't believe she made any real medication changes other than PRN Haldol. During an interview on 8/28/23 at 5:52 p.m., LVN A revealed, Resident #1 had a behavior on 8/27/23 and was surrounded by 3 male aides and Resident #1 was getting really mad at one of the male aides, Nurse Aide F. LVN A revealed, the next thing she knew, Resident #1 was by the front door sitting on the ground, one male aide holding him by one arm facing forward and the other aide holding the resident by the other arm and the third aide, Nurse Aide F holding down the resident's legs. LVN A stated she told the Aides to let Resident #1 go and then LVN A applied the ABH gel to Resident #1. LVN A stated, we are a restraint free facility, no we should not have been restraining [Resident #1]. LVN A revealed she told Nurse Aide F he could not do that, restrain Resident #1 to which Nurse Aide F replied, am I in trouble now? LVN A stated, what I did see is [Nurse Aide F] and the other two male aides restrain [Resident #1]. During an interview on 8/28/23 at 7:22 p.m., LVN D revealed Resident #1 resided in the male secure unit and had gotten out multiple times. LVN D revealed approximately one month ago, June 2023, Resident #1 barged outside of the secure unit. LVN D revealed Resident #1 was held back by multiple staff members after the resident pushed the MDS Coordinator. LVN D stated, staff tried to hold [Resident #1] under the arms as he was swinging. LVN D revealed, Resident #1 was eventually held down in a chair and the ADON gave the resident a Haldol injection. LVN D stated, I feel bad they had to tranquilize him to get him to calm down. LVN D stated, the [ADON], the [DON] and the [Administrator] were all here in the facility when this incident with [MDS Coordinator] occurred, and they were aware [Resident #1] was held down. LVN D stated, I do not feel like anyone here is trained to deal with [Resident #1's] behaviors. LVN D stated, Agency LVN E, who no longer worked for the facility, used to work in a psychiatric facility and had told other staff how to hold Resident #1 in a seated position. During an interview on 8/28/23 at 7:23 p.m., Nurse Aide F revealed he was assigned one to one to Resident #1 on 8/27/23. Nurse Aide F revealed, Resident #1 became agitated on 8/27/23 after Nurse Aide G asked the resident if he was okay and the resident started kicking the air and moving his hands rapidly. Nurse Aide F stated, Resident #1 moved towards the door leading to the front with Nurse Aide G and himself following and Resident #1 pushed open the door from the locked unit and moved toward the inner facility. Nurse Aide F stated, Nurse Aide H came to assist as Resident #1 grabbed Nurse Aide F's shirt from the front. Nurse Aide F stated, they both [Nurse Aide G] and [Nurse Aide H] took [Resident #1] by an arm and held him back and we got him to the ground so the nurses could apply the ABH cream on him. Nurse Aide F stated, [Resident #1] wasn't able to get up. Nurse Aide F stated, I don't think [Resident #1] is appropriate for this facility, he needs to be somewhere where staff are trained for that. I am not trained to deal with that on a regular basis. Nurse Aide F stated, We have been instructed to keep [Resident #1] in the unit but didn't really get any instruction on how to keep him in the unit. During an interview on 8/29/23 at 8:59 a.m., the Assistant BOM revealed, an incident occurred on 8/27/23 at approximately 7:00 p.m. or 7:30 p.m., before preparing to leave her office. The Assistant BOM stated, Resident #1 was observed heading in the direction past the nurse's station toward the front door. The Assistant BOM stated, her office was close to the facility front door and observed Resident #1 followed by Nurse Aide F, Nurse Aide G and Nurse Aide H. The Assistant BOM stated, LVN A had her gloves on ready to apply the ABH gel when Resident #1 hit Nurse Aide F on the upper chest, then grabbed Nurse Aide F's shirt and started to shake him. The Assistant BOM stated, at that point [Nurse Aide G] and [Nurse Aide H] come in and they are right by my office door wall and in the meantime, I am trying to call the [Administrator]. At this point, the guys are trying to hold [Resident #1] and they are holding his arms, like under his elbows and [Nurse Aide F] is still trying to get loose. Everybody goes down, they fall down, and [Resident #1] starts to kick. The Assistant BOM revealed, LVN A then applied the ABH gel to Resident #1's hands. The Assistant BOM stated, it had been discussed during in-services that staff were not to touch Resident #1 because it would escalate his anxiety and aggression. During a telephone interview on 8/29/23 at 3:02 p.m., Agency LVN E revealed she had worked at the facility through a contracted agency but discontinued her contract after 30 days. Agency LVN E revealed, Resident #1 had behaviors that were sometimes avoidable but sometimes not. Agency LVN E revealed an incident occurred in June 2023 in which Resident #1 pushed the MDS Coordinator and had also made contact with the Activity Director. Agency LVN E stated, everyone swarms, [Resident #1] seems like he is going towards everybody and there is a lot of yelling, I step back because less is more. Agency LVN E further stated, [Resident #1] had a hold of the [Activity Director] and is not letting go. [Resident #1] was restrained, because that is what it was called. But [Resident #1] could still move. Agency LVN E revealed, the physical restraint used on Resident #1 was called bear paws so as not to cause bruising while being restrained. Agency LVN E stated, she and CNA I restrained Resident #1 and once we got him to the ground, [Resident #1] starts to relax. Agency LVN E stated, the restraint to Resident #1 lasted a total time of 15 to 20 minutes until the police arrived. Agency LVN E revealed, the facility had not provided training on anything related to the incident, nothing on dementia, nothing on aggression, nothing on behaviors. Agency LVN E stated she did not know who the Abuse Coordinator was and approximately a month ago was given a paper to sign on an in-service on abuse and neglect. Agency LVN E stated, I do not think we are supposed to touch them (residents) but there was no way of getting around it. During an interview on 8/29/23 at 5:47 p.m., the DON stated, Resident #1 could not be stopped from having behaviors and just to keep him safe. The DON revealed staff could not lay hands on Resident #1 and to make sure all the residents were safe. The DON stated, our policy is to follow [Resident #1], keep him safe and call police to help us get him back into the building safely. During an interview on 8/30/23 at 2:38 p.m., Nurse Aide G revealed an incident occurred on 8/27/23 at approximately 7:00 p.m., after the residents had eaten, in which Resident #1 got out of the secure unit with Nurse Aide F following, who was assigned the resident's 1 to 1. Nurse Aide G stated, Resident #1 grabbed Nurse Aide F's shirt and Nurse Aide G came behind [Resident #1] and put my arms around his upper shoulder as if to grab him and [Resident #1] took his arm and swung it back and that's how we fell on the floor. Nurse Aide G stated, he, Resident #1, Nurse Aide F and Nurse Aide H fell together on the floor with the force of Resident #1 trying to swing at them and Resident #1 still holding onto Nurse Aide F's shirt. Nurse Aide G stated, I have never seen any staff hold [Resident #1], we try to talk to him and calm him down. Nurse Aide G revealed he did not consider the incident on 8/27/23 resulted in Resident #1 being restrained. During an interview on 8/30/23 at 3:29 p.m., the Administrator revealed, the Assistant BOM contacted him by phone on 8/27/23 at approximately 7:20 p.m. regarding the incident in which Resident #1 came out of the secure unit and was followed by Nurse Aide F, Nurse Aide G and Nurse Aide H. The Administrator stated, the Assistant BOM was giving the Administrator a narrative while it was going on. The Administrator stated, basically, [Resident #1] rushed [Nurse Aide F] and grabbed him, and two other aides pulled the resident off of [Nurse Aide F.] The Administrator stated, [Nurse Aide F] was standing in front of [Resident #1] because another resident was in [Resident #1's] path. The Administrator further stated, the other two aides grabbed [Resident #1] by the arms and pulled him back while [Resident #1] was holding onto [Nurse Aide F's] shirt, and they all fell down. The Administrator stated, [Nurse Aide F] held one of [Resident #1's] legs because he was kicking him, just didn't want him to hurt anybody and then the nurse put the cream on him and then [Resident #1] got up by himself and went for a walk with them. [Resident #1] was not restrained. The Administrator stated, I have never been informed [Resident #1] had ever been restrained. The Administrator revealed he recalled the incident in which Resident #1 pushed the MDS Coordinator. The Administrator stated, [Resident #1] pushed the [MDS Coordinator] and the staff, don't recall who it was, held [Resident #1] down. I think it was one (staff) on each side of him, to calm him down. The Administrator stated, again [Resident #1] was not hurt. The Administrator stated, the incident with the [MDS Coordinator], we didn't know what to do and [Resident #1] was held down to keep him from hurting other people, I'm sure. The Administrator revealed, the staff at the facility were not trained to deal with that kind of behavior. During an interview on 8/30/23 at 4:11 p.m., the MDS Coordinator revealed he recalled the incident in which Resident #1 pushed him. The MDS Coordinator revealed, staff were guiding Resident #1 to sit in a wheelchair, holding the resident's arms and the resident was resistive and combative. The MDS Coordinator stated, Resident #1 got up from the wheelchair and two staff, could not recall who, had their arms under the resident's upper arms and they backed up until they backed up against the wall and slid down the wall still holding [Resident #1] by the arms and talking to him and then the police showed up. The MDS Coordinator revealed, there was one nurse, Agency LVN E who stated she was trained for this (restraints). The MDS LVN stated, they were restraining [Resident #1], I would think, but it was a reasonable intervention because it was a very erratic behavior. [Resident #1] was kind of out of control. During a follow up interview on 8/31/23 at 8:22 a.m., the DON revealed, the facility did not do behavioral health training of staff and staff were only instructed to remove them (residents) and calm the situation. The DON stated, most of our residents don't have violent behaviors. [Resident #1] seemed to be the one factor in these situations. During an interview on 8/31/23 at 1:18 p.m., CNA I stated, he had not heard or seen residents being restrained. CNA I revealed, residents, including Resident #1, could not be restrained, and staff should not provoke or argue with the residents, leave them be and keep residents safe. CNA I denied ever having restrained Resident #1. Record review of the facility policy and procedure titled Abuse Prevention Program, revision date April 2013, revealed in part, .Our residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion .1. Our facility is committed to protecting our residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies providing services to our residents, family members, legal guardians, surrogates, sponsors, friends, visitors or any other individual .a. Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish .5. Along with other staff and management, the Medical Director will help identify situations that might constitute or could be constituted as neglect; for example .inappropriate management of problematic behavior .repeated failure to check for correct application of restraints . Record review of the facility's policy and procedure titled Use of Restraints, revision date December 2007 revealed in part, .Restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience .6. Prior to placing a resident in restraints, there shall be a pre-restraining assessment and review to determine the need for restraints. The assessment shall be used to determine possible underlying causes of the problematic medical symptoms and to determine if there are less restrictive interventions (programs, devices, referrals, etc.) that may improve the symptoms .19. Documentation regarding the use of restraints shall include: a. Full documentation of the episode leading to the use of the physical restraint. This includes not only the resident symptoms but also the conditions, circumstances, and environment associated with the episode; b. A description of the resident's medical symptoms (i.e., an indication or a characteristic of a physical or psychological condition) that warranted the use of restraints; c. How the restraint use benefits the resident by addressing the medical symptom; d. The type of the physical restraint used; e. The length of effectiveness of the restraint time; and f. Observation, range of motion and repositioning flow sheets . The Administrator was given the IJ template and was notified of the Immediate Jeopardy {IJ} on 8/31/23 at 6:01 p.m. and a plan of removal was requested. On 9/1/23 at 8:38 a.m., the facility provided a plan of removal that was accepted. It was documented as follows: SURVEY TYPE: Complaint Survey SURVEY DATE: 8/31/23 Plan for REMOVAL Plan to remove immediate jeopardy. F604 On 8/31/23, Resident #1 no longer resided at the facility, confirmed on 8/31/23. On 8/31/2023 the Regional Nurse Consultant completed in-service with the DON, ADON and the Administrator on abuse and neglect, abuse and neglect reporting guidelines/policy, abuse, and neglect, physical and chemical restraint prevention and how to care for patients with aggressive behavior. On 8/31/2023 DON and ADON assessed residents for any signs or symptoms of physical or chemical restraints with no other residents identified. The Medical Director was notified there were no changes in condition by the DON on 8/31/23. On 8/31/2023 the Director of Nursing and ADON initiated in-service with facility staff on abuse and neglect, physical and chemical restraint prevention and dealing with residents with aggressive behaviors. Education to be completed on 8/31/23. The in-service was completed on 9/1/23. On 8/31/23 the Administrator and the Regional Reimbursement Consultant will complete safe surveys with residents, to ensure the health and safety of all residents. The IDT, NHA (Nursing Home Administrator), DON, ADON, Regional Nurse Consultant, and MDS Coordinator will review the findings and will immediately notify the Administrator for further action, if necessary. The safety survey was completed on 9/1/23. On 8/31/23 an Ad-Hoc QAPI meeting was held with the Medical Director, NHA (Nursing Home Administrator), DON, Regional Nurse Consultant, Assistance Director of Nursing, Regional MDS, Regional Director of Operations and MDS Coordinator to review the deficiency and the plan for removal of immediacy. Sign-in sheet was reviewed on 9/1/23. Starting on 8/31/2023, IDT (Interdisciplinary team), including Administrator, DON, ADON and MDS Coordinator will review abuse and neglect monitoring Monday to Friday, and Manager on Duty Saturday and Sunday for 1 month to ensure the health and safety of the residents. The findings will be immediately brought up to the Administrator for further action, if necessary. A sign-in sheet was provided of the IDT meeting with the aforementioned staff on 9/1/23. The Administrator/designee will monitor compliance by completing an audit of residents that have behaviors/aggression every week for four (4) weeks, MD being notified, Family being notified, and behavioral services to be notified. If Behavioral Services is not available, then the Medical Director will be notified for any psychosocial concerns. This will be initiated on 8/31/2023. Any identified concerns will be addressed immediately and if trends and patterns are identified, the facility will conduct an Ad-Hoc QAPI meeting to discuss if additional interventions are needed to ensure compliance for the next 2 months. The facility provided an audit dated 8/31/23, initiated by the administrator on 9/1/23. The Administrator will be responsible for ensuring this plan is completed on 8/31/2023. The RDO will provide oversight of Administrator and DON to ensure that the items on the plan of removal are reviewed and completed. Monitoring of the implementation of the POR: Plan to remove immediate jeopardy. During an observation and interview on 9/1/23 at 8:03 p.m., Resident #2 was in his room lying in bed watching television. Resident #2 revealed he felt safe and had been asked by facility staff about abuse/neglect. Resident #2 stated, you're the third person who has asked me. Resident #2 did not appear to be in any obvious distress or discomfort. During an observation and interview on 9/1/23 at 8:08 p.m., Resident #3 was in her room sitting up in a wheelchair. Resident #3 did not appear to be in any obvious distress or discomfort. Resident #3 stated the ADON had talked to her on 8/31/23 about abuse/neglect. Resident #3 stated she felt safe in the facility. During an observation and interview on 9/1/23 at 8:11 p.m., Resident #4 appeared well-groomed and appropriately dressed and did not appear to be in any obvious distress or discomfort. Resident #4 stated she had been asked by the ADON about abuse and revealed she wanted to be with her boyfriend. Record review of the facility interviews with 70 residents on 8/30/23 revealed a safety survey was completed. Most of the residents in the facility were not interview able, and those that were did not make any new allegations of abuse or neglect. Record review of the facility Ad-Hoc QAPI meeting held on 8/31/23 revealed signatures for the Medical Director, NHA (Nursing Home Administrator), DON, Regional Nurse Consultant, Regional MDS, Regional Director of Operations and the MDS Coordinator. A log was created for the IDT to review and monitor for abuse and neglect Monday to Friday and the Manager on Duty for Saturday and Sunday to be monitored for 1 month to ensure the health and safety of the residents. Any adverse findings would be reported to the Administrator for further action if necessary. Record review of the facility IDT meeting held on 8/31/23 included the Administrator, DON, ADON and MDS coordinator revealed the Administrator would monitor for compliance by completing an audit of 5 residents per week for the next 4 weeks of residents with behaviors/aggression with MD notification for request of behavioral services, initiated on 8/31/23. The log dated 9/1/23 revealed 5 random residents were chosen for the audit and signed by the Administrator. During a joint interview on 9/1/23 at 5:36 p.m., the DON, ADON, Regional Nurse Consultant, the COO and RN Director of Quality revealed review of the POR for abuse/neglect highlighted training on identifying and reporting suspected abuse, restraints and dealing with residents with aggressive behaviors. Record review of the facility in-service dated 8/31/23, titled Abuse Neglect Policy/Reporting Guidelines/Abused and Neglect Pathways revealed 67 facility employed staff signed the sign-in sheet. The facility had 55 total facility employees and utilized agency staff. Record review of the facility in-service dated 8/31/23, titled Restraints Prevention/How to Care for Patients with Aggressive Behaviors revealed 67 facility employed staff signed the sign-in sheet. The facility had 55 total facility employees and utilized agency staff. Record review of the facility in-service dated 8/31/23, titled Managing Difficult Behavior in Residents with Dementia revealed 67 facility employed staff signed the sign-in sheet. The facility had 55 total employees and utilized agency staff. During a joint interview on 9/1/23 at 5:22 p.m., the DON and the Administrator revealed the abuse/neglect in-service highlighted identifying forms of abuse, reporting suspected abuse for investigation and adhering to reporting guidelines. 1. During an interview on 9/1/23 at 3:50 p.m., Housekeeping Staff J revealed she had worked for the facility for just 4 months and worked Monday through Saturday from 2:00 p.m. to 10:00 p.m. Housekeeping Staff J revealed she had been in-serviced on abuse/neglect and the use of restraints that morning and revealed she was to report abuse/neglect to the Administrator and to keep the residents safe. Housekeeping Staff J stated, we do not restrain, try not to touch the resident and be patient. 2. During an interview on 9/1/23 at 3:55 p.m., CNA L revealed she had worked for the facility off and on since January 2023 and worked 6:00 a.m. to 6:00 p.m. on a rotating schedule. CNA L revealed she had been in-serviced on abuse/neglect and the use of physical/chemical restraint prevention on 9/1/23 and the in-serviced covered identifying abuse/neglect and to report to the Administrator while keeping the residents safe. CNA L further revealed, Residents who have dementia can become aggressive and forms of distraction had to be used but residents could not be restrained. CNA L revealed, if the resident became aggressive, keep other residents safe and report to the nurse. 3. During an interview on 9/1/23 at 4:00 p.m., the Assistant BOM revealed she worked every day with varying hours and had been in-serviced on abuse/neglect and physical/chemical restraint prevention in the morning on 9/1/23. The Assistant BOM stated, abuse/neglect was to be reported to the DON and the Administrator. The Assistant BOM stated, remove the resident from an unsafe environment and keep them safe. The Assistant BOM stated, we do not do restraints, we can't force a resident to stay in a chair and no one can hold down or pull down a resident. The Assistant BOM stated, it was facility policy to try to de-escalate a behavior by talking in a nice tone, acknowledging the resident by name and keep the environment calm. The Assistant BOM stated, aggression in residents would be reported to the nurse. 4. During an interview on 9/1/23 at 4:05 p.m., the BOM stated she had worked for the facility for 5 years and worked Monday to Friday. The BOM stated she had been in-serviced on abuse/neglect last week and was to report suspicion of wrongdoing to the residents to the Administrator. The BOM stated, if the Administrator was not available, abuse and neglect should be reported to the DON and the charge nurse. The BOM stated, an in-service on restraints was given and highlighted how restraints were a form of abuse and were not practiced in the facility. The BOM revealed if a resident exhibited aggressive behavior, the staff were supposed to keep other residents safe and divert the resident exhibiting aggression by offering snacks, take them for a walk or watch a movie. The BOM revealed, residents exhibiting aggressive behaviors should be reported to the Administrator and the nursing staff. 5. During an interview on 9/1/23 at 4:12 p.m., CNA L revealed she had worked for the facility for 2 years and worked from 6:00 a.m. to 6:00 p.m. on a rotating schedule. CNA L stated she had been in-serviced by the ADON on 9/1/23 on abuse/neglect, restraints and how to handle residents with aggressive behavior. CNA L revealed the highlight of the in-service covered identifying abuse/neglect and the process for reporting, not restraining residents because it was a form of abuse and using diversion tactics for residents who exhibited aggressive behavior. CNA L revealed abuse/neglect was reported to the Administrator while keeping the resident safe. CNA L revealed the use of restraints was against facility policy and aggressive behavior was to be reported to the Administrator and nursing staff. 6. During an interview on 9/1/23 at 4[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the Resident(s) environment remained as free of accident hazards as possible and each resident received supervision and assistance devices to prevent accidents for 1 of 4 residents (Resident #1) reviewed for elopements in that: The facility failed to provide adequate safety interventions to prevent Resident #1 from elopement. Resident #1 had elopement events recorded on 5/18/23, 5/27/23, 8/22/23, 8/25/23. On 8/26/23, Resident #1 was found in the middle of the street a half mile down the road from the secure unit. These failures resulted in an IJ on 8/26/23 at 6:00 p.m. While the IJ was removed on 9/1/23 at 8:19 p.m., the facility remained out of compliance at a level of no actual harm with a 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 their plan of removal. This failure placed residents at risk for harm, injury, or death due to elopement. The findings included: Record review of Resident #1's face sheet, dated 8/26/23 revealed a [AGE] year old male admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included schizophrenia (a disorder that affects a person's ability to think, feel and behave clearly), delusional disorders (a mental health condition in which a person can't tell what's real from what's imagined), anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), dementia without behavioral disturbance and impulse disorder (characterized by urges and behaviors that are excessive and/or harmful to oneself or others). Record review of Resident #1's most recent quarterly MDS assessment, dated 8/2/23 revealed the resident was severely cognitively impaired for daily decision-making skills and required set up only for bed mobility and transfers. Record review of Resident #1's comprehensive care plan, edit date 8/23/23 listed the problem Mood State which included the following approaches: -Allow resident to have control over situations, if possible -Assign consistent staff member -Do not confront, argue against, or deny resident's thoughts -Maintain a calm environment and approach to the resident Further review of Resident #1's comprehensive care plan listed the problem Behavioral Symptoms, edit date 7/3/23, included the following: Potential/high risk for injury related to identified elopement risk factors and or exit seeking behavior related to: Cognitive Impairment/loss, poor safety awareness, history of elopement. Unsuccessful elopement attempt 5/18/23-No injury. Unsuccessful Elopement attempt 5/27/23-no injury. New event 6/3/23 (7:37 a.m.)-Unsuccessful Elopement attempt/no injury. New event 6/3/23 (8:50 a.m.)-Unsuccessful Elopements attempt/no injury. And included the following approaches: -If elopement occurs, maintain supervision at a distance as tolerated by resident for safety concerns Redirect resident when calm -Initiate one on one staff to resident observation. Maintain appropriate safety measures at all times -Consider placement on secure unit if wandering, elopement attempts continue Record review of Resident #1's current order summary, undated revealed the following: -Admit to facility male secure unit for wandering, with start date 4/6/23 and no end date Record review of Resident #1's Elopement Risk Assessment, dated 4/6/23 revealed the resident was at risk of elopement with interventions that included for routine monitoring and re-direction. Record review of Resident #1's Secure Unit Consent, dated 4/6/23 revealed the following: -Based on the Elopement Assessment, the resident has the following indicators for an appropriate admission unto the Secure Unit: Diagnosis of dementia or Alzheimer's or confusion, ambulates independently, pace, wander, try to get out of the door and exhibit signs of sundowners. Benefits of a Secure Unit: allows the resident to ambulate independently in a controlled, safe environment; protection for external stressors and expectations that may increase anxiety. Potential Risks of Secure Unit: anxiety due to inability to come and go at will, Residents may wander into others personal space and pick up/take personal items. Record review of Resident #1's Elopement Risk Assessment, dated 8/26/23 revealed the resident was at risk of elopement with interventions that included for routine monitoring, re-direction, and involvement of psychosocial and/or activity program. Record review of Resident #1's history and physical dated 4/7/23 revealed the resident was previously at another facility and was moved due to elopement with police report filed as a missing person. Further review of Resident #1's history and physical revealed the resident was found 2.5 miles away from the facility by CNA staff. [Resident #1] is now admitted to the facility in memory care locked unit. Record review of the Event Report created by LVN A, dated 5/18/23 and time stamped 10:23 a.m., revealed Resident #1 was off of A hall with staff members walking on the trail right behind the building. [Resident #1] left A hall without the nurse but was intercepted prior to leaving the property. This nurse and 2 other staff members walked on the walking trail with [Resident #1] and got him back inside without incident. Record review of the Event Report created by LVN A, dated 5/27/23 and time stamped 10:30 a.m., revealed Resident #1 went out the back door of A hall due to the alarm being disabled. Staff and other residents saw the patient and was able to get him before he was able to get off property. Record review of the progress note by LVN C, dated 6/3/23 and time stamped 7:37 a.m. revealed, roughly around 7:15 a.m., nursing staff heard the alarms going off at the back door in A hall (secure unit) when the aides followed the resident, she found the fence magnetic unlocked and the fence door open. Shift nurse went to look for the resident along with nursing staff, [Resident #1] was found behind the laundry room on a walking path and was brought back to the facility. Record review of the progress note by LVN C, dated 6/3/23 and time stamped 8:50 a.m. revealed around 8:30 a.m. the shift nurse heard the alarms go off again and nursing staff ran out the door to look for [Resident #1], and once again the fence was opened, and the magnetic lock was opened again. Nursing staff and aides went looking for [Resident #1] and found him walking on the pathway again, [Resident #1] was found by nursing staff and brought the resident back to the facility. Record review of the progress note by the Regional Nurse Consultant dated 8/22/23 and time stamped 9:38 a.m. revealed Resident #1 became upset and busted through the doorway on the secure unit then exited outside front door, accompanied by facility staff. The Regional Nurse consultant wrote, when I got outside [Resident #1] was across the parking lot heading towards the highway in front of the facility. The [Administrator] and [ADON] were walking behind [Resident #1]. Record review of the progress note by LVN C, dated 8/25/23 and time stamped 9:00 a.m., revealed Resident #1 started to yell and hitting the air and stated, 'I am going through those door [sic]. The progress notes further revealed, Resident #1 did bust through the door of the secured unit and then resident began to go towards the font door and Resident #1 was within eyesight the whole time. [Resident #1] began to walk down the street, 911 and ambulance was called for assist, [Resident #1] ended up being in police custody. Record review of the Observation Detail List Report created by LVN S, dated 8/26/23 and time stamped 2:40 p.m., revealed Resident #1 forced door open and walked half mile down the road. During interview with Police on 8/26/23 at 10:28 a.m. , they state a call was received from facility staff stating that Resident #1 walked out of the front door and was headed toward the duck pond that was located across the street. During an interview on 8/26/23 at 12:17 p.m., CNA X revealed Resident #1 had tried to leave several times and if that happens, we follow the resident. CNA X stated, [Resident #1] tried to leave today (8/26/23, from the secure unit), has left at least two times this month and had been caught in the front yard. CNA X stated, Resident #1 had gotten as far as the street up to the little park with the ducks across the street. CNA X stated he was assisting a resident with a shower in the secure unit and heard the door alarm go off. CNA X stated, I saw the back door open, and I went to see, and I didn't see anybody. I called the nurse and [Laundry Staff Y] followed [Resident #1] out. During an interview on 8/26/23 at 12:17 p.m., Laundry Staff Y stated, Resident #1 left on 8/26/23 before 10:00 a.m., from the back door (of secure unit) and Laundry Staff Y followed him. Laundry Staff Y revealed Resident #1 kept telling her he just wanted to walk and pushed the back gate open. Laundry Staff Y stated, [Resident #1] kept saying he wanted to go to the main street where the cars were driving. Laundry Staff Y revealed she used her cell phone to call for help and LVN S took over and walked with Resident #1. During an interview on 8/26/23 at 1:13 p.m., LVN S stated he was working on B Hall on 8/26/23 and heard the alarm going off at approximately 8:00 a.m. LVN S stated, CNA X told him he believed Resident #1 went out of the unit but did not see Resident #1 push the door. LVN S stated he saw Resident #1 with Laundry Staff Y and Resident #1 repeatedly said I'm walking. LVN S stated he was on the phone with the ADON and was instructed by the ADON to call the police and to stay with Resident #1. LVN S stated when the police came, he and Resident #1 were driven back to the facility. LVN S stated, the DON instructed staff that Resident #1 was not to be physically stopped when he left and only to follow Resident #1 anytime he left the unit or the building. During an interview on 8/26/23 at 1:40 p.m., LVN C stated she was working in C hall on 8/26/23 at approximately 7:30 a.m. or 7:45 a.m. when she saw Resident #1 walking by outside of a resident's window. LVN C revealed she made her way to A hall secure unit and asked CNA X where Resident #1 was to which CNA X replied, he got out. LVN C stated she then went out the front door while calling the ADON and was told to go back to the facility as LVN S was already on the phone with police trying to get Resident #1 back to the facility. LVN C stated Resident #1 had walked on a specific route and stated, it's a very busy road. LVN S stated, the road has a sidewalk part of it, so I consider that off the property. LVN S stated, yesterday (8/25/23) at approximately 8:07 a.m., [Resident #1] hit the front door, gets down like a linebacker with his arm and punches the door and gets it open. LVN S stated, [Resident #1} did the same thing to the front door and went out. So, then me and [Resident #]1 went across the parking lot into the green grass and then he turned right, and we were going down the main road. LVN C stated, so then I called 911 and told them I am in the middle of the road, the Emergency Medical Technicians blocked one side of the street and then police blocked the other and I blocked the other, making a triangle. LVN C stated, if Resident #1] is off the property he's off the property but I don't know if I would consider that an elopement, I was with him the whole time. During an interview on 8/26/23 at 2:55 p.m., the ADON stated, the incident on 8/25/23 occurred around 8:00 a.m. when Resident #1 busted from the secure unit, hit the egress door from the front entry door with staff following. The ADON revealed, Resident #1 was followed by herself and LVN C when LVN C called 911 to get police and EMS to help. The ADON stated Resident #1 kept saying he was going for a stroll. The ADON revealed, Resident #1 was gone from the facility from approximately 8:14 a.m. to 8:37 a.m. after Resident #1 was placed in the EMS vehicle. The ADON stated, this was not the first time [Resident #1] had left (the facility). I don't consider it was elopement because we had sight of [Resident #1] the entire time. The ADON revealed, the last time Resident #1 tried to leave was on 8/22/23 at 9:19 a.m. During an interview on 8/26/23 at 3:48 p.m., the MDS Coordinator revealed, on 8/25/23 he was informed by LVN C Resident #1 had gone out the door and left and the ADON had called the police. The MDS Coordinator stated, I saw[ Resident #1] come into the facility with a police officer and [Resident #1] appeared calm and chuckled a little bit saying, 'everything was ok' and did not seem in distress. The MDS Coordinator revealed, that was not the first time Resident #1 had left the facility and revealed a similar incident occurred earlier in the week. The MDS Coordinator stated, according to the definition, I would say yes, that would be considered an elopement or at least an attempt. The MDS Coordinator revealed he relied on his superiors to determine if that type of incident would be reportable. The MDS Coordinator stated, if [Resident #1] was in that situation, because of aggressiveness and behavior to only follow [Resident #1] if he leaves but not to physically prevent him from leaving and follow and stay to keep safe and talk to the resident. During an interview on 8/26/23 at 5:54 p.m., the DON stated, according to our policy, we don't consider it an elopement, we stay with [Resident #1] when he has left the unit. [Resident #1] is never out of our site. I don't believe that is a true elopement. The DON further stated, Resident #1 leaving was not an elopement and out policy is no because he was never missing, but I know that it's not safe when [Resident #1] leaves. We can't take him down; we are not trained. During an interview on 8/26/23 at 6:14 p.m., the Administrator revealed he believed Resident #1 leaving the facility was not considered an elopement because staff followed the resident, kept the resident within their sight and the resident did not have any injuries. The Administrator further stated, we call the police when [Resident #1] leaves but during that time we verbally prompt him to come back. During a follow up interview on 8/27/23 at 9:16 a.m., the Administrator stated, when [Resident #1] first admitted , he was automatically placed in the secure unit, we knew [Resident #1] had a history of elopement from the other facility. The Administrator re-iterated, every time [Resident #1] had left the building he had never been hurt. We have never had injuries. During an interview on 8/27/23 at 10:18 a.m., Resident #1 stated he had been in the facility a little while, recalled being in the hospital the day before but did not know why. Resident #1 stated the police had taken him to the hospital but he was not sick. Resident #1 stated, the police hold me down, they have guns. During a telephone interview on 8/28/23 at10:30 a.m., the Medical Director revealed he believed Resident #1 was not appropriate for the facility due to aggressive behaviors. The Medical Director stated, I am informed every time [Resident #1] attempts an elopement. [Resident #1] will intermittently kick out a window. The Medical Director revealed, Resident #1 could initially be re-directed, did not believe Resident #1 leaving the facility was a true elopement because when the resident leaves, staff follow. The Medical Director stated he had been given information that Resident #1 had made it to the street, staff are with him, but only that [Resident #1] had made it out. During an interview on 8/28/23 at 12:51 p.m., RN Z revealed she had been in the facility when Resident #1 had tried to leave the facility. RN Z stated, we stay with [Resident #1], we walk with him. We call other staff, re-set the alarm, and do a head count. RN Z stated, I know [Resident #1] wanted to cross the street but have not witnessed him going into the street. RN Z revealed she was not sure if Resident #1's attempts to leave were considered an elopement. Record review of the facility policy and procedure titled, Wandering, Unsafe Resident, revision date August 2014 revealed in part, .The facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk of elopement .A missing resident is considered a facility-wide emergency .If a resident is missing, the elopement/missing resident emergency procedure will be initiated .If the resident was not authorized to leave, initiate a search of the building(s) and premises .If the resident is not located, notify the Administrator and the Director of Nursing Services .Initiate an extensive search of the surrounding area .When the resident returns to the facility, the Director of Nursing Services or Charge Nurse shall .Examine the resident for injuries .Complete and file an incident report . The Administrator was given the IJ template and was notified of the Immediate Jeopardy {IJ} on 8/26/23 at 6:00 p.m. and a plan of removal was requested. On 8/29/23 at 11:03 a.m. the facility provided a plan of removal that was accepted. It was documented as follows: SURVEY TYPE: Complaint SURVEY DATE: 8/26/2023 Plan for REMOVAL F689 Residents #1 was assessed by DON on 8/26/2023 and support was provided as accepted, physician was notified of the alleged deficiency on 8/26/23. Order was provided by Physician to send patient to the hospital for evaluation, RP was notified by Administrator of alleged deficiencies and plan of correction. Upon return to the facility from the hospital Resident #1 will be observed 1:1 on 8/26/23 and will continue until another placement is obtained. Medication management was reviewed by Physician and new orders in place as of 8/26/2023 with monitoring by nurses' effectiveness, facility will redirect resident by taking him for walks/outing as needed; including decrease active attempts of eloping, plan of care updated. On 8/26/23 all residents on Secure units were assessed by DON/Designee - no other residents have active attempt to elope. The Medical Director was notified - no new orders were provided. On 8/26/2023 the Administrator and Director of Nurses notified the Medical Director of immediate jeopardy. Starting on 8/26/2023 the Director of Nursing/Designee will initiate in-service with staff on adequate supervision to prevent a resident from leaving the facility, including policies on elopement/missing resident, how to handle residents who become agitated/aggressive and or attempt to elope was included in the 8/26/23 education. The in-services will be completed on 8/26/2023. No staff member will be allowed to work without being in-serviced by DON/Designee. 9/1/23: DON and ADON initiated in-service on adequate supervision to prevent elopement and handling residents with agitation/aggression was reviewed and completed on 8/26/23. Ad-Hoc QAPI meeting was held on 8/26/2023, with the Medical Director, NHA (Nursing Home Administrator), RDO (Regional Director of Operations), Director of Nursing, Assistant Director of Nursing, and RNC (Regional Nurse Consultant) to review the alleged deficiency, policy and procedure, and the plan for removal of immediacy. 9/1/23: Sign in sheet provided for QAPI meeting held on 8/26/23 that included the Medical Director, DON, Regional Nurse Consultant, ADON, Regional MDS, MDS Coordinator and Regional Director of Operations. Starting on 8/26/2023, IDT (Interdisciplinary team), including Administrator, Director of Nursing, Assistant Director of Nursing, and MDS Coordinator will review headcount of all residents residing on secure units in the facility daily Monday to Friday, and Manager on Duty Saturday and Sunday to determine if any residents have active attempts to elope and was appropriate supervision provided, MD notified, and plan of care updated. IDT team will utilize daily census roster to visually verify residents in the facility at least once a day starting 8/26/2023. The findings will be immediately brought up to the Administrator for further action, if necessary. 9/1/23: The sign in sheet provided of IDT meeting review for elopement and supervision and facility monitoring Monday to Friday and Manager on Duty Saturday and Sunday with the findings reported to administrator initiated 8/26/23 was reviewed. The Administrator/designee will monitor compliance by completing an audit of five (5) residents on secure unit per week for four (4) weeks who are actively attempting to elope and were adequate supervision provided to prevent from patient eloping. This was initiated on 8/26/2023. Any identified concerns will be addressed immediately and if trends and patterns are identified, the facility will conduct an Ad-Hoc QAPI meeting to discuss if additional interventions are needed to ensure compliance for next 2 months. 9/1/23: The administrator to monitor for compliance of at least 5 residents each week for the next 4 weeks of residents that have behaviors/aggression, with MD notification for request of behavioral services, initiated on 8/26/23 was reviewed. The Administrator will be responsible for ensuring this plan is completed on 8/26/2023. The RDO will provide oversight of Administrator to ensure that the items on the plan of removal are reviewed and completed. Monitoring of the implementation of the POR: Plan to remove immediate jeopardy. During a joint interview on 9/1/23 at 5:36 p.m., the DON, ADON, Regional Nurse Consultant, the COO and RN Director of Quality revealed review of the POR for elopements highlighted training providing adequate supervision for preventing elopement and strategies for coping with residents who exhibited agitation and/or aggression. Record review of the facility in-service dated 8/29/23, titled De-Escalation tactics for behavioral residents and residents who attempt to elope from the facility and Wandering, Unsafe Resident, revealed 67 facility employed staff signed the sign-in sheet. The facility had 55 total facility employees and utilized agency staff. During a joint interview on 9/1/23 at 5:22 p.m., the DON and the Administrator revealed the elopement in-service highlighted strategies for addressing residents with aggression and strategies for prevention of elopements. 1. During an interview on 9/1/23 at 3:50 p.m., Housekeeping Staff J revealed she had worked for the facility for just 4 months and worked Monday through Saturday from 2:00 p.m. to 10:00 p.m. Housekeeping Staff J revealed she had been in-serviced on elopements and learned only to follow the resident who tried to elope and keep safe. Housekeeping Staff J revealed she was report to the nurse if a resident attempted to elope. Housekeeping J stated it was important to try to talk to the resident and distract to prevent elopement. 2. During an interview on 9/1/23 at 3:55 p.m., CNA L revealed she had worked for the facility off and on since January 2023 and worked 6:00 a.m. to 6:00 p.m. on a rotating schedule. CNA L revealed she had been in-serviced on elopement and dealing with residents who had aggression on 9/1/23. CNA L revealed if a resident attempted to leave to report to the nurse and try to talk to the resident, follow the resident and keep safe. CNA L acknowledged most residents in the facility had dementia and you have to talk to them and distract them, so they don't get aggressive. 3. During an interview on 9/1/23 at 4:00 p.m., the Assistant BOM revealed she worked every day with varying hours and had been in-serviced on elopement and how to care for residents with aggressive behaviors on the morning of 9/1/23. The Assistant BOM revealed, if a resident tried to elope, report it, talk to the resident, follow them and be aware of their surroundings. The Assistant BOM stated, if a resident goes missing, call the Administrator and if we can't find them call the police. The Assistant BOM revealed staff had to try to de-escalate the behavior by talking in a nice tone, acknowledge by name and if confuse or incoherent, try to converse with them. 4. During an interview on 9/1/23 at 4:05 p.m., the BOM stated she had worked for the facility for 5 years and worked Monday to Friday. The BOM stated she had been recently in-serviced on elopements and how to care for residents with aggressive behaviors. The BOM revealed the in-services highlighted how to keep other residents safe and diversion tactics for a resident who displayed aggression. The BOM revealed the resident could be diverted by offering snacks, take for a walk or watch a movie, talk to the resident, and offer an activity. The BOM revealed, if a resident tried to leave, verbally re-direct and report to the nurse. 5. During an interview on 9/1/23 at 4:12 p.m., CNA L revealed she had worked for the facility for 2 years and worked from 6:00 a.m. to 6:00 p.m. on a rotating schedule. CNA L stated she had been in-serviced by the ADON on 9/1/23 on elopement and residents with aggression. CNA L revealed staff had to report to the Administrator and nursing staff if a resident had displayed aggressive behavior. CNA L revealed, if a resident tried to leave, try to talk to them, calm them down, offer snacks. 6. During an interview on 9/1/23 at 4:16 p.m., CNA M revealed she had worked for the facility for about a month but had been employed over a year ago and had been working the 6:00 a.m. to 6:00 p.m. on a rotating schedule. CNA M stated she had been in-serviced on 9/1/23 on elopement and caring for residents who had aggression. CNA M revealed the in-services highlighted using verbal re-direction, diversions such as playing games, activities and offering snacks. CNA M revealed if a resident tried to leave, notify the nurse, and follow the resident to keep safe. 7. During an interview on 9/1/23 at 4:23 p.m., Nurse Aide N revealed she had worked for the facility for 6 months and worked from 6:00 a.m. to 6:00 p.m. on a rotating schedule. Nurse Aide N stated she had received an in-service by the ADON on 8/31/23 on elopements and dealing with residents who displayed aggression. Nurse Aide N revealed the in-services highlighted de-escalating aggression by offering snacks, put on a movie, play music and trying to keep the resident calm. Nurse Aide N revealed if a resident tried to leave the facility, report to the nurse, follow the resident and keep them safe. 8. During an interview on 9/1/23 at 4:28 p.m., CNA O revealed she had worked for the facility for 2 years and worked from 6:00 a.m. to 6:00 p.m. on a rotating shift. CNA O revealed she had been in-serviced on elopements and caring for residents who had aggression. CNA O revealed the in-services highlighted on keeping the residents safe, using diversion to keep the resident from elopement and keeping a calm environment. CNA O revealed if a resident attempted to elope, report to the nurse. 9. During an interview on 9/1/23 at 4:35 p.m., Nurse Aide P revealed she had worked for the facility for 2 weeks and worked the 6:00 a.m. to 6:00 p.m. shift on a rotating schedule. Nurse Aide P stated she had been in-serviced on elopements and working with residents who aggression this week. Nurse Aide P revealed the in-services highlighted tactics on diverting the behavior such as offering snacks, talking to the resident in a calm voice and finding a quiet place. Nurse Aide P revealed, for a resident who tried to elope, keep calm, keep them safe, follow the resident, report to the nurse, and get help. 10. During an interview on 9/1/23 at 4:40 p.m., Kitchen Staff Q revealed she had worked for the facility for the past 6 weeks and had been in-serviced on elopements and dealing with residents who had aggression this week. Kitchen Staff Q revealed the in-services given taught about keeping the residents safe from residents who exhibited aggression and reporting to the nurse. Kitchen Staff Q revealed, if a resident tried to elope, try to follow them, talk nicely to the resident, and get help. 11. During an interview on 9/1/23 at 4:46 p.m., LVN C revealed she had worked for the facility for 8 years and worked varying shifts and had been in-serviced this week. LVN C stated, residents with aggression had to be verbally re-directed to de-escalate the aggression. LVN C stated, staff should try diverting the behavior by offering going for a walk or playing music. LVN C stated if the resident's aggression continued to escalate, continue to verbally re-direct and report to administrative staff. LVN C revealed, if a resident tried to elope, make sure you are always with the resident, keep them safe, get help, try to re-direct and report to the Administrator. 12. During an interview on 9/1/23 at 4:59 p.m., Dietary Aide R revealed he had worked for the facility for approximately 2 weeks and was in-serviced on 9/1/23 on elopement and aggressive behaviors. Dietary Aide R revealed, if residents got aggressive, give them their space, do not touch them and report to the nurse. Dietary Aide R revealed if a resident tried to elope, follow the resident, and call for help. 13. During an interview on 9/1/23 at 5:02 p.m., LVN S revealed he had worked for the facility for less than a month and worked the weekend shifts. LVN S revealed he had been in-serviced on 9/1/23 on elopements and residents with aggressive behaviors. LVN S revealed the in-services highlighted on diversion tactics for de-escalating aggressive behaviors such as talking to the resident, keeping calm and offering an activity. LVN S revealed, if a resident tried to elope, try to verbally re-direct, follow the resident and report to the Administrator. 14. During an interview on 9/1/23 at 5:26 p.m., the Maintenance Director revealed he had worked for the facility for 2 months and worked varying hours and days and was on call 24/7. The Maintenance Director stated he had been in-serviced on 8/31/23 and 9/1/23 on various subjects including elopements and residents with aggression. The Maintenance Director revealed, if a resident got upset, give them room, and keep other residents safe, then report to the nursing staff. The Maintenance Director revealed, if a resident tried to elope, follow the resident and don't leave them out of your site and report to nursing. 15. During an interview on 9/1/23 at 7:51 p.m., Nurse Aide T revealed he had worked for the facility for 7 months and worked the 6:00 p.m. to 6:00 a.m. shift on a rotating schedule. Nurse Aide T revealed he had been in-serviced this week on residents with aggression and elopement. Nurse Aide T revealed, if a resident tried to elope or was showing aggression, do not touch them, talk calmly to them, keep the resident safe and report to the nurse. 16. During an interview on 9/1/23 at 7:57 p.m., Nurse Aide U revealed he had worked for the facility for 7 months and worked the 6:00 p.m. to 6:00 a.m. shift on a rotating schedule. Nurse Aide U revealed he had been in-serviced on elopements and residents who exhibited aggressive behaviors this week. Nurse Aide U revealed the in-services highlighted how to de-escalate the situation, so the resident does not get physical by verbally re-directing and keeping other residents safe. Nurse Aide U revealed, if a resident tried to elope, do not touch the resident, follow from a distance and report to the nurse. The Administrator was notified on 9/1/23 at 8:19 p.m., the Immediate Jeopardy was removed. While the immediacy was removed on 9/1/23, the facility remained out of compliance at[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 of 4 residents, (Resident #1) reviewed for behavioral health services in that: The facility failed to ensure Resident #1 was provided appropriate or timely behavioral health services after showing increased signs of aggression. This failure resulted in an IJ on 8/31/23 at 6:01 p.m. While the IJ was removed on 9/1/23 at 8:19 p.m., the facility remained out of compliance at a level of no actual harm with a 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 their plan of removal. This deficient practice could result in residents with depression and/or mood disorders failing to attain or maintain their highest practicable physical, mental, and psychosocial well-being. The findings included: Record review of Resident #1's face sheet, dated 8/26/23 revealed a [AGE] year old male admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included schizophrenia (a disorder that affects a person's ability to think, feel and behave clearly), delusional disorders (a mental health condition in which a person can't tell what's real from what's imagined), anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), dementia without behavioral disturbance and impulse disorder (characterized by urges and behaviors that are excessive and/or harmful to oneself or others). Record review of Resident #1's most recent quarterly MDS assessment, dated 8/2/23 revealed the resident was severely cognitively impaired for daily decision-making skills. Record review of Resident #1's comprehensive care plan, edit date 8/23/23 listed the problem Mood State which included the following approaches: -Administer medications as ordered. Monitor and record effectiveness. Monitor and report any adverse side effects -Allow resident to have control over situations, if possible -Assign consistent staff member -Do not confront, argue against, or deny resident's thoughts -Maintain a calm environment and approach to the resident Further review of Resident #1's comprehensive care plan listed the problem Behavioral Symptoms, edit date 7/3/23, included the following approaches: -If elopement occurs, maintain supervision at a distance as tolerated by resident for safety concerns. Redirect resident when calm -Initiate one on one staff to resident observation. Maintain appropriate safety measures at all times -Consider placement on secure unit if wandering, elopement attempts continue -Psych referral as ordered. Initiate any new orders. Record review of Resident #1's physician orders revealed the following: -May see Respiratory, Podiatrist, Dentist, Optometrist/Ophthalmologist, Wound Specialist, and Mental Health professional as indicated/needed with start date 4/6/23 and no end date -Follow up with Psychology Services, with start date 6/9/23 and no end date Record review of the Psych Note Encounter by Psych (Psychiatric) NP B, dated 5/18/23 revealed in part, .[Resident #1] with a history of dementia, generalized anxiety disorder, impulse disorder and delusional disorder .Today he is being seen for increased agitation .staff reports he is eloped out of the building and when staff tried to bring him back, he became combative .He did not want to come back, was very resistant and agitated .[Resident #1] denies paranoia, denies past trauma, denies suicidal ideation, homicidal ideation, audio hallucinations and visual hallucinations .[Resident #1] continues to display agitation and anxiety .Will continue current dose .Give Clonazepam (a sedative) 1 mg x 1 dose for agitation .start Trazadone (an anti-depressant and sedative) 25 mg at 4 p.m. for agitation .return appointment 1 month with [Psychiatric NP B] . Record review of the Psych Encounter note written by Psych NP B, late entry 6/13/23 for visit date 6/7/23 revealed in part, .[Resident #1] with history of dementia, generalized anxiety disorder, impulse disorder, and delusional disorder .Staff report he is always aggressive, exit seeking and would fight before coming back to the building .Resident continues to display agitation and anxiety .Start Haldol (an antipsychotic used to treat mental disorders) 5mg/ml. Give 2.5mg IM every 6 hours PRN for restlessness and agitation. Order to expire in 14 days .Return appointment 1 month with [Psych NP B] . Record review of the Psych Encounter note written by Psych NP B, late entry 6/23/23 for visit date 6/21/23 revealed in part, .Resident with a history of dementia, generalized anxiety disorder, impulse disorder, and delusional disorder .constantly tries to elope the building .was getting angry and agitated talking to me .No GDR recommended at this time. Resident continues to display agitation and anxiety .Start Haldol 1mg gel. Apply 2 mg every 6 hours as needed, to wrist area, for restlessness and agitation for dementia with behavioral disturbance. Order valid for 14 days. Start Haldol 5mg/ml. Give 2.5 mg IM every 6 hours PRN for restlessness and agitation. Order to expire in 14 days .Return Appointment: 1 month with [Psych NP B] . Record review of the Neuropsychological Assessment by the Licensed Psychologist, dated 8/16/23 revealed in part, .Referred by medical for neurocognitive evaluation to clarify diagnosis and assist with treatment plan in the context of aggressive behaviors, and to assess for depression, anxiety, or any other psychiatric conditions that might be focus of attention at this time .Treatment Plan/Recommendations .Psychiatric and psychological treatment .Follow up with neuropsychological testing as soon as feasible . Record review of Resident #1's clinical record revealed the resident did not receive any routine psychiatric services after 6/21/23 until 8/16/23. Record review of the facility Event Report dated 7/5/23 and completed by LVN D reflected Resident #1 had a psychotic episode that caused injuries to others. The Event Report reflected, multiple staff members were pushed, punched and grabbed very aggressively. Under the section, Indicate Pharmacological measures taken, Other was checked and indicated, Haldol IM given by ADON per MD orders. Record review of the progress note written by the DON, dated 8/27/23 and time stamped 1:15 p.m. reflected, .obtaining verbal consent for new medication ABH (made from a combination of Ativan, a sedative to relieve anxiety, Benadryl an antihistamine and, Haldol an anti-psychotic used to treat mental disorders) gel for 'aggressive behaviors' .resident (Resident #1) behaviors had increased in frequency with increased agitation and aggressiveness towards other residents and staff. Record review of the progress note written by LVN A, dated 8/27/23 and time stamped 9:15 p.m. revealed in part, .Resident #1 coming out of the locked hall and acting aggressive toward staff . I am the nurse that administered ABH gel to the resident. During an interview on 08/28/23 LVN D reported Resident #1 had gotten out of the secure until multiple times. LVN D reported Resident #1 was held back by multiple staff when pushed his way out of the secured unit and pushed the MDS coordinator in June of 2023. LVN D reported staff held Resident #1 under the arms as he was swinging, and Resident #1 was eventually held down in a chair and given a Haldol injection. LVN A reported the DON, ADON and Administrator were present when this occurred and she did not feel anyone had training to handle Resident #1's behaviors. During an interview on 08/28/23 Nurse Aide F reported he was assigned to Resident #1 on 08/27/23 and Resident #1 became agitated and began kicking the air as he made his way out of the locked unit into the inner part of the facility. Nurse Aide F reported Resident #1 grabbed his shirt from the front and Nurse Aide H was there to assist and they both took Resident #1 by the arm and held him back and got him to the ground. Nurse Aide F reported Resident #1 was not appropriate for the facility and should reside somewhere where staff are trained. Nurse Aide F reported he was not trained to deal with Resident #1. During an interview on 08/29/23 The Assistant BOM reported Resident #1 hit Nurse Aide F on the upper chest and grabbed his shirt and shook him. The Assistant BOM reported the nurse aides held Resident #1's arms under his elbows and staff and Resident #1 fell to the ground and Resident #1 began to kick. The Assistant BOM reported LVN A applied ABH gel to Resident #1's hands. During an interview on 08/29/23 LVN E reported Resident #1 had a behavior in June of 2023 when he pushed the MDS coordinator and Resident #1 had a hold on the Activity Director and Resident #1 was restrained by staff using a restraint called bear paws. LVN E reported she and CNA I restrained Resident #1 and got him to the ground, and he began to relax. LVN E reported she had not been provided training on behaviors, or aggression and she did not know who the abuse coordinator was. LVN E reported she did not think staff were supposed to touch residents, but she did not think there was a way of getting around it. During an interview on 08/30/23 Nurse Aide G reported Resident #1 grabbed Nurse Aide F's shirt and Nurse Aide G went behind Resident #1 and put his arms around Resident #1's upper shoulder as if to grab him and Resident #1 swung his arm back and that's how they all fell to the floor. During an interview on 8/27/23 at 12:39 p.m., the Administrator stated, former Psych NP B left about a month ago and the new Psych NP V took over August 2023. The Administrator stated the Medical Director was doing psych evaluations after Psych NP B left. During an interview on 8/27/23 at 1:11 p.m., the ADON revealed Psych NP B had been providing psych services until July 2023. The ADON stated, Psych NP B left on medical leave and Psych NP W was filling in doing tele-visits until Psych NP V took over. The ADON stated, she did not recall Psych NP B making any medication changes for Resident #1. The ADON stated she believed Psych NP W had probably seen Resident #1 one time in July 2023. During a telephone interview on 8/28/23 at 9:35 a.m., Psych NP B revealed she had left on medical leave 6/26/23 and the consulting firm she was contracted with had provided an on-call psychiatric consultant until Psych NP V could take over as the new consultant. Psych NP B stated, I am a nurse practitioner, I was doing psychiatric evaluations and I am able to adjust medications for psychiatric services. Psych NP B stated, Resident #1 was exhibiting constant aggression, was probably not appropriate for the facility and had been refusing his medications. Psych NP B stated, since [Resident #1] was not taking his medication, there is not much that I can do and that is beyond me. Psych NP B stated, I did not make contact with the [Medical Director.] I didn't know I need to make contact with them. Psych NP B revealed she would report to nursing about her observations and there was no discussion about getting another psychological evaluation for [Resident #1]. During a telephone interview on 8/28/23 at 10:01 a.m., Psych NP V revealed she had gone into the facility for psychiatric evaluation of residents for the first time on 8/25/23. Psych NP V revealed in addition to working for the consulting firm as a psychiatric consultant, Psych NP V stated she also had a full-time job. Psych NP V stated, I don't have a list of any of the patients (seen in the facility on 8/25/23), I don't remember [Resident #1]. Psych NP V revealed she was capable of making medication changes or adjustments and would notify the Medical Director and the nurses. Psych NP V revealed maybe Psych NP W could be more informative about Resident #1. During an interview on 8/28/23 at 10:10 a.m., the DON revealed, Resident #1 had been seen by Psych NP W during telehealth visits but could not recall any dates. The DON stated she believed the new Psych NP V had seen Resident #1 on 8/25/23 when she was in the building, but Psych NP V did not communicate with her before leaving the facility. The DON revealed, the ADON had given Psych NP V a list of residents for psychiatric evaluation and follow up and Resident #1 was priority on the list. The DON stated, it was her expectation the Psych NP should communicate any recommendations or any written orders. The DON revealed, it typically took a couple of days for the Psych NP to upload their recommendations into the electronic record and did not know if any of the information on the report was communicated to the medical director. The DON stated, I feel if [Psych NP V] had made any medication changes for [Resident #1], the nurses would have gotten that. No new orders were put into the system for [Resident #1]. During a follow up interview on 8/28/23 at 10:27 a.m., the ADON stated, I reached out to [Psych NP W] about getting reports of visits with [Resident #1]. The ADON stated, she was not sure if she had reached out to Psych NP W about doing a psychiatric evaluation on Resident #1, I can't find anything about [Psych NP W] seeing [Resident #1]. During a telephone interview on 8/28/23 at 10:30 a.m., the Medical Director stated he was also the attending physician to Resident #1 and revealed the corporate office wanted one psychiatric company to provide psychiatric services. The Medical Director stated, Unfortunately, they don't have any local folks, and no one was able to come down since like June. The Medical Director revealed the Psych NP could make medication adjustments and were supervised by a licensed psychiatrist. The Medical Director stated, I can contact them, the Psych NP but have never actually had the Psych NP contact me. The Medical Director stated, [Psych NP B] started [Resident #1] on Haldol gel on 7/21/23. At that time, we were probably not aware [Resident #1] had schizoaffective disorder. At that point that was what was recommended, I had recommended the facility to either contact [Psych NP B] or give Haldol IM as needed. During a follow up interview on 8/28/23 at 12:14 p.m., the ADON revealed she had provided Psych NP V a prioritized list of the residents that needed a psychiatric evaluation or follow up for Friday 8/25/23, and Saturday 8/26/23. The ADON stated, Resident #1 was first to be seen on the list. The ADON stated, Psych NP V did not communicate with her when she left, did not exit with anyone, and had only met Psych NP V when she entered the building on 8/25/23. The ADON stated, Psych NP V was supposed to be back on Saturday 8/26/23 and Sunday 8/27/23, but [Psych NP V[ did not come back on Sunday. The ADON stated, when Psych NP B had done psychiatric visits, [Psych NP B] would not give us any feedback either, she would tell us she was here, we would give her a list and then that was it. [Psych NP B] would either e-mail us orders and then add her notes into the electronic record. The ADON stated she did not believe Psych NP B had made any real medication changes other than prn Haldol for Resident #1. The ADON revealed it took probably a week for Psych NP B to upload her visit notes into the electronic record. During an interview on 8/28/23 at 1:09 p.m., LVN C revealed she had made a list of the residents that needed to be seen for psychiatric evaluation and for follow up provided to Psych NP V for the visit on 8/25/23 but was not sure if Psych NP V had seen Resident #1. LVN C stated, [Resident #1] was first on the list. LVN C revealed, Psych NP B was never in the building and did telehealth with Resident #1. LVN C stated, our complaint was that [Psych NP B] was not coming in the building and had been mentioned during morning meeting with Administrative staff and would be told they would take it up with corporate. LVN C stated, Psych NP B did not make any significant medication changes and Resident #1 continued to take the same medications since his admission. During an interview on 8/28/23 at 2:53 p.m., the Administrator revealed, Psych NP B physically made psychiatric evaluations and follow ups once a month and then did telehealth visits due to illness. The Administrator stated, this guy, [Psych NP W] took over in July 2023 for [Psych NP B]. The Administrator revealed he had not recalled seeing Psych NP W in the building and may have met Psych NP W once. The Administrator stated, the contracted psychiatric company could have done a better job. I don't think, personal opinion, they (the residents) would have been better served if the Psych NP was coming into the building to do an actual assessment. The Administrator stated, the NP and even the Medical Director would not be able to prescribe those medications or maybe the Medical Director was not comfortable with doing that, I don't know. The Administrator revealed he believed Resident #1's disease process had progressed and was referred to a neuro psychologist because the services provided by the psychiatric company were not adequate, that's the [Medical Director's] opinion and I agree with him. The Administrator revealed, Resident #1's medications should have been reviewed and modified by a psychiatric hospital. During a telephone interview on 8/29/23 at 10:30 a.m., Psych NP W revealed he could not recall doing a psychiatric evaluation or follow up with Resident #1. Psych NP W stated he had a lot of residents and did not have his computer in front of him to verify if he had seen Resident #1. Psych NP W stated, I'm just covering, I do visits virtually. Psych NP W stated he would call back with more information. During a voicemail message on 8/29/23 at 3:02 p.m., Psych NP W stated, I never saw [Resident #1], I was just covering for emergency issues. [Resident #1] was never bought to my attention. I never saw [Resident #1], I never evaluated [Resident #1]. During a follow up interview on 8/29/23 at 5:08 p.m., the DON revealed, most residents in the facility had dementia and some required psychiatric services or evaluation. The DON stated, I know that psych services were available via telehealth and [Psych NP W] was our contact person for those residents that needed to be seen, after [Psych NP B] left. I called [Psych NP W] and left a message probably during the first incident when [Resident #1] burst through the doors in July. [Psych NP W] did not give me a response. I never got a return call. Record review of the facility policy and procedure titled, Dementia Residents and Managing Behaviors, undated, revealed in part, .Aggressive behaviors may be verbal or physical. They can occur suddenly, with no apparent reason, or result from a frustrating situation. While aggressive behaviors can be hard to cope with, understanding that the person with Alzheimer's or dementia is not acting this way on purpose can help .Treating Behavioral Symptoms .Anyone experiencing behavioral symptoms should receive a thorough medical checkup, especially when symptoms appear suddenly. Treatments depends on a careful diagnosis, determining possible causes and the types of behavior the person is experiencing . The Administrator was given the IJ template and was notified of the Immediate Jeopardy {IJ} on 8/29/23 at 4:15 p.m. and a plan of removal was requested. On 8/30/23 at 4:26 p.m., the facility provided a plan of removal that was accepted. It was documented as follows: SURVEY TYPE: Complaint Survey SURVEY DATE: 8/29/23 Plan for REMOVAL Plan to remove immediate jeopardy. F740 Resident #1 no longer resided at the facility On 8/29/23 all residents with behaviors and who refuse medications were assessed by DON (Director of Nursing)/Designee - no other residents have active attempt to elope or have signs of being a danger to themselves or others. The Medical Director was notified, and medications were reviewed - no new orders were provided. Behavioral services were notified by Administrator of immediate jeopardy on 8/29/2023 and behavioral services were provided by NP for identified residents with behaviors on 8/30/2023. On 8/29/2023 the Administrator and DON notified Medical Director of immediate jeopardy. Starting on 8/29/2023 the DON/Designee will initiate in-service with staff on de-escalation tactics for behavioral residents and residents who attempt to elope from the facility. The in-services will be completed on 8/29/2023. No staff member will be allowed to work without being in-serviced by DON/Designee. 9/1/23: DON and ADON initiated in-service of staff on de-escalation tactics for behaviors and elopement attempts reviewed and completed on 9/1/23. Ad-Hoc QAPI meeting was held on 8/29/2023, with the Medical Director, NHA (Nursing Home Administrator), RDO (Regional Director of Operations), DON, ADON (Assistant Director of Nursing), and RNC (Regional Nurse Consultant) to review the alleged deficiency, policy and procedure, and the plan for removal of immediacy. 9/1/23: A Sign in sheet was provided for QAPI meeting held on 8/31/23 that included the Medical Director, DON, Regional Nurse Consultant, ADON, Regional MDS, MDS Coordinator and Regional Director of operations. Starting on 8/29/2023, IDT (Interdisciplinary team), including Administrator, Director of Nursing, Assistant Director of Nursing, and MDS Coordinator will review events and progress notes for all residents in the facility daily Monday to Friday, and Manager on Duty Saturday and Sunday to determine if any residents have active attempts to elope and has aggressive behaviors toward others, MD notification, and need for plan of care updates. Any identified resident with behaviors, including attempts to elope will be referred to Behavioral services for evaluation in person or via Telehealth, starting 8/29/2023. The behavioral services will provide schedule for on-site visits to DON and Administrator on 8/30/2023 and will be available via Telehealth as needed. If Behavioral services require changes to the schedule, they will notify DON/Administrator via email of the changes and new schedule starting 8/29/2023. If behavioral services are unable to provide services, the Medical Director will be notified by DON/Designee and will review and address behavioral needs as necessary, starting 8/29/2023. The findings will be immediately brought up to the Administrator for further action, if necessary. 9/1/23: An IDT sign in sheet was reviewed for meeting on 8/29/23 that included the Administrator, DON, ADON and MDS coordinator. The Administrator/designee will monitor compliance by completing an audit of five (5) residents per week for four (4) weeks who are actively attempting to elope and/or have aggressive behaviors toward others. This was initiated on 8/29/2023. Any identified concerns will be addressed immediately and if trends and patterns are identified, the facility will conduct an Ad-Hoc QAPI meeting to discuss if additional interventions are needed to ensure compliance for next 2 months. 9/1/23: The administrator to monitor for compliance of at least 5 residents each week for the next 4 weeks of residents that are actively eloping and/or displaying aggression. Concerns identifying trends and patterns to be addressed at QAPI for additional interventions initiated on 8/29/23 was reviewed. The Administrator will be responsible for ensuring this plan is completed on 8/29/2023. The RDO will provide oversight of Administrator to ensure that the items on the plan of removal are reviewed and completed. Monitoring of the implementation of the POR: Plan to remove immediate jeopardy. Record review of the facility interviews with 70 residents on 8/30/23 revealed checklists were completed. Most of the residents in the facility, including residents in the secure units were not interview able, and those that were did not make any new allegations. Ad-Hoc QAPI meeting was held on 8/29/2023, with the Medical Director, NHA (Nursing Home Administrator), RDO (Regional Director of Operations), Director of Nursing, Assistant Director of Nursing, and RNC (Regional Nurse Consultant) to review the alleged deficiency, policy and procedure, and the plan for removal of immediacy. On 9/1/23, a sign-in sheet was reviewed for the QAPI meeting held on 8/31/23 that included the Medical Director, DON, Regional Nurse Consultant, ADON, Regional MDS, MDS Coordinator and Regional Director of operations. The IDT held on 8/29/23 included the Administrator, DON, ADON and MDS Coordinator for review of events and progress notes for all residents in the facility daily Monday to Friday and the Manager on Duty to review on Saturday and Sunday in order to determine if any residents had actively attempted to elope and if any residents displayed behaviors towards others. The report to include MD notification and care plan update. Any residents identified with behaviors, including elopement attempts would be referred to behavioral health services for evaluation via telehealth as needed. Any changes to the behavioral health services would require notification to the DON/Administrator via e-mail. If behavioral services could not be provided, the DON/Designee would notify the Medical Director to review and address behavioral needs as necessary. Any new findings would be immediately brought to the Administrator for further action if necessary. The IDT sign-in sheet was reviewed on 9/1/23. Record review of the facility in-service dated 8/31/23, titled Managing Difficult Behavior in Residents with Dementia revealed 67 facility employed staff signed the sign-in sheet. The facility had 55 total facility employees and utilized agency staff. During a joint interview on 9/1/23 at 5:22 p.m., the DON and the Administrator revealed the behavioral health in-service highlighted de-escalation tactics for residents who displayed aggressive behaviors and for residents who attempted elopement from the facility. The DON and Administrator revealed, events and progress notes would be reviewed daily to identify residents with behaviors or residents who attempted elopements from the facility, prompting scheduled behavioral health services for on-site visits or for tele-health visits as needed. The DON and Administrator revealed, if there were a scheduling conflict, the Medical Director would be notified to address behavioral needs. During a joint interview on 9/1/23 at 5:36 p.m., the DON, ADON, Regional Nurse Consultant, the COO and RN Director of Quality revealed review of the POR for behavioral health services for residents who displayed aggressive behaviors highlighted training on de-escalation tactics for residents, including those residents who attempted elopement from the facility and providing behavioral health services. 1. During an interview on 9/1/23 at 3:50 p.m., Housekeeping Staff J revealed she had worked for the facility for just 4 months and worked Monday through Saturday from 2:00 p.m. to 10:00 p.m. Housekeeping Staff J revealed she had been in-serviced on how to manage residents with aggressive behaviors that morning and revealed she was not to intervene, to report the behavior to the nurse and to keep other residents safe. 2. During an interview on 9/1/23 at 3:55 p.m., CNA L revealed she had worked for the facility off and on since January 2023 and worked 6:00 a.m. to 6:00 p.m. on a rotating schedule. CNA L revealed she had been in-serviced on managing residents with aggressive behaviors on 9/1/23 and the in-serviced included using de-escalation tactics such as distractions and talking to the residents. CNA L stated, if a resident became aggressive, report to the nurses and keep the residents safe. 3. During an interview on 9/1/23 at 4:00 p.m., the Assistant BOM revealed she worked every day with varying hours and had been in-serviced on de-escalating behaviors in the morning on 9/1/23. The Assistant BOM stated, de-escalation tactics included talking to the resident in a nice tone, acknowledge the resident by name, and conversing with the resident if confused or incoherent and try to create a calm environment. The Assistant BOM stated the nurses were to be notified if residents displayed aggressive behaviors. 4. During an interview on 9/1/23 at 4:05 p.m., the BOM stated she had worked for the facility for 5 years and worked Monday to Friday. The BOM stated she had been in-serviced on de-escalation strategies for residents with aggressive behaviors last week and the in-service highlighted keeping other residents safe during the aggression, divert the resident by offering snacks, taking them for a walk or to watch a movie. The BOM stated, report to the nurse when a resident displayed aggressive behaviors. 5. During an interview on 9/1/23 at 4:12 p.m., CNA L revealed she had worked for the facility for 2 years and worked from 6:00 a.m. to 6:00 p.m. on a rotating schedule. CNA L stated she had been in-serviced by the ADON on 9/1/23 on de-escalation strategies for residents with aggressive behavior. CNA L revealed the highlight of the in-service covered trying to calm the resident down, offer them snacks, talk to the resident, and keep other residents safe from harm. CNA L revealed, report to the nurse when a resident displayed aggressive behaviors. 6. During an interview on 9/1/23 at 4:16 p.m., CNA M revealed she had worked for the facility for about a month but had been employed over a year ago and had been working the 6:00 a.m. to 6:00 p.m. on a rotating schedule. CNA M stated she had been in-serviced on 9/1/23 on managing residents with aggressive behaviors. CNA M stated, the in-service highlighted keeping other residents safe, divert the resident displaying aggression by offering an activity or snack and to report to the nurse a resident who displayed aggressive behaviors. 7. During an interview on 9/1/23 at 4:23 p.m., Nurse Aide N revealed she had worked for the facility for 6 months and worked from 6:00 a.m. to 6:00 p.m. on a rotating schedule. Nurse Aide N stated she had received an in-service by the ADON on managing residents with aggressive behaviors on 8/31/23. Nurse Aide N revealed, staff should try to calm the aggressive resident by offering a snack, play music, put on a movie. Nurse Aide N revealed she was to report to the nurse if a resident displayed aggressive behaviors. 8. During an interview on 9/1/23 at 4:28 p.m., CNA O revealed she had worked for the facility for 2 years and worked from 6:00 a.m. to 6:00 p.m. on a rotating shift. CNA O revealed she had been in-serviced on abuse/neglect in the morning on 9/1/23. CNA O revealed the in-service highlighted types of abuse such as verbal, physical, restraints, and yelling at residents. CNA O revealed abuse/neglect was to be reported to the Administrator while keeping the residents safe. 9. During an interview on 9/1/23 at 4:35 p.m., Nurse Aide P revealed she had worked for the facility for 2 weeks and worked the 6:00 a.m. to 6:00 p.m. shift on a rotating schedule. Nurse Aide P stated she had been in-serviced on residents who displayed aggression this week and the in-service highlighted trying to calm the resident, take them to a quiet place or offer an activity. Nurse Aide P revealed, report to the nurse when a resident displayed aggressive behaviors. 10. During an interview on 9/1/23 at 4:40 p.m., Kitchen Staff Q revealed she had worked for the facility for the past 6 weeks and had been in-serviced on managing residents with aggressive behaviors this week. Kitchen Staff Q stated if a resident [TRUNCATED]