**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as possible and provided supervision to prevent avoidable accidents for 1 of 5 residents (Resident #134) reviewed for supervision. The facility failed to ensure Resident #134 received adequate supervision to prevent exiting the facility without facility knowledge on 01/25/2025, when Resident #134 was found outside sitting on the curb of the facility's parking lot with her wheelchair tipped over. The facility failed to ensure adequate interventions were placed for Resident #134 after exit seeking attempts on 11/18/2024 and 01/25/2025. The facility failed to review Resident #134's exit incidents to determine triggers that increased her risk for elopement and develop person centered interventions to prevent elopement. An Immediate Jeopardy (IJ) was identified on 02/04/2025 at 3:20 PM. The IJ template was provided to the facility on [DATE] at 3:40 PM. While the IJ was removed on 02/06/2025, the facility remained out of compliance at no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could place residents at risk of unsafe wandering, accidents, and injuries. Findings included: Record review of a face sheet dated 02/04/2025 indicated Resident #134 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance , mood disturbance, and anxiety (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life), chronic obstructive pulmonary disease (chronic inflammatory lung condition that affects the respiratory system), and nicotine dependence (use of tobacco products, cigarettes). Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #134 was understood and understood others. The MDS assessment indicated Resident #134's BIMS score was a 3, which indicated her cognition was severely impaired. Resident #134's MDS assessment indicated she did not exhibit wandering. The MDS assessment indicated Resident #134 used a wheelchair. The MDS assessment indicated Resident #134 was dependent on staff for toileting, showering/bathing and lower body dressing and required partial/moderate assistance with personal hygiene and substantial/maximal assistance with upper body dressing. Record review of Resident #134's care plan last reviewed 01/03/2025 indicated, she was at increased risk of confusion and disorientation related to a diagnosis of dementia to assist her with decision making, observe for changes in mental status, and use diversional activities as needed. Resident #134's care plan indicated she required supervision with smoking per the facility policy that she was to be supervised by staff until cigarette was finished and properly disposed of. Resident #134's care plan indicated she exhibited exit seeking behavior with a goal that the resident would not leave the building unattended through the next review date. Interventions included to admit to the special care unit, attempt diversional activities as needed, contact the physician and family of attempts to leave the facility, observe frequently, personal secure alarm as ordered, redirect resident as needed, and routine risk assessment. Record review of Resident #134's Order Summary Report dated 02/06/2025 indicated admit to special care unit (secure unit) with a start date of 01/25/2025. Record review of Resident #134's January 2025 Treatment Administration Record indicated: Check functionality and visualization of wander guard/exit management system through wand or alarmed door every night shift with a start date of 11/18/2024 and discontinued date of 01/27/2024 indicated it was completed 01/01/2025-01/25/2025. Visualization of wander guard/exit management system to right wrist of resident every day shift with a start date of 11/19/2024 and a discontinue date of 01/26/2025 indicated it was completed 01/01/2025-01/26/2025. Record review of Resident #134's Elopement Evaluations indicated: Effective date: 11/18/2024 indicated Resident #134 had a history of elopement or attempted leaving the facility without informing the staff, resident verbally expressed the desire to go home packed belongings to go home or stayed near an exit door, wandering behavior with a pattern, and goal directed (specific destination in mind, going home), there were no clinical suggestions indicated. Effective date: 12/12/2024 indicated Resident #134 had a history of elopement or attempted leaving the facility without informing the staff, resident verbally expressed the desire to go home packed belongings to go home or stayed near an exit door and did not wander. Effective date: 01/25/2025 indicated Resident #134 had a history of elopement or attempted leaving the facility without informing staff, resident wandered aimlessly or non-goal-directed (confused, moves with purpose, may enter others' rooms and explore others' belongings), resident's wandering behavior was likely to affect the privacy or others and likely to affect the safety or well-being of self/others, no clinical suggestions were indicated. Record review of Resident #134's progress notes indicated: 11/18/2024 at 10:15 AM, Called to front lobby for fall. Upon arrival resident was seated on the floor in front of her wheelchair. No staff witnessed the fall. Resident was confused and searching for her family member. Resident will be staying in close proximity to a staff member to ensure safety. No noted injury. Assisted back to wheelchair using gait belt and two staff. Signed by RN OOO 11/18/2024 at 10 15 AM, LATE ENTRY Elopement Evaluation: History of elopement while at home: No. Wandering behavior a pattern or goal-directed: Yes. Wanders aimlessly or non-goal-directed: No. Wandering behavior likely to affect the safety or well-being of self / others: No. Wandering behavior likely to affect the privacy of others: No. Recently admitted or re-admitted (within past 30 days) and has not accepted the situation: No. Elopement Score: 3.0 (Score value of 1 or higher indicates Risk of Elopement) Actioned clinical suggestions: (none were listed). Signed by LVN V. 11/18/2024 at 10:15 AM, Date / Time of Fall: 11/18/2024 10:14 AM Fall was not witnessed. Fall occurred elsewhere. Other fall location: Lobby Activity at the time of fall: Attempting to leave The reason for the fall was not evident. Pre-Fall: Fall Risk Score: 2 Post-Fall: Fall Risk Score: 2 Did an injury occur as a result of the fall: No. Did fall result in an ER visit/hospitalization: No. Provider: medical director Time notified: 11/18/2024 Notified of: Unwitnessed fall with no injury and attempt to elope . Signed by LVN V 11/18/2024 at 12:00 PM, Intervention put in place: 1.) Resident added to The Falling Star Program; resident to be monitored and observed by staff for any unsafe practices with staff intervening if/when needed as a part of The Falling Star Program. 2.) Placement of a wanderguard to her wrist as she presents with intermittent confusion - staff will be alerted via system if/when resident leaves facility. This resident's current Fall Care Plan to be reviewed and revised as appropriate. This Quality Assurance Nurse in collaboration with Unit Manager, Charge Nurse and CNA's regarding most recent fall encounter, details of fall encounter and interventions placed for implementation . Signed by RN BBB 11/18/2024 at 1:52 PM, Resident was sitting on the floor with her right knee bent leaning against the bed, grippy socks on call light within reach, wheelchair on opposite side of the bed out of reach, fall mat in place. Resident had pajama's on with housecoat on. Resident was chatting and laughing about fall. Resident stated, I just slid off the bed, I was going to check on my family member. I just slid off the bed, I was going to check on my family member. Signed by LVN V 11/18/2024 at 2:58 PM, Resident was going through the front door in her wheelchair, notified by peer. Resident stated she was looking for I-30, I just need to get home I'm looking for I-30 and my family member brought me here last night. Notified RN Supervisor and assisted in reorienting resident to the present. Resident was assisted back into the facility and taken down to her room, attempted to reinforce this is where she lives now. Showed her the room with her name on it. She acknowledged it was room however she continued to think she would be leaving to go home with her family member. She was offered a snack which she accepted and placed in front of her TV with the show she likes to watch. Resident appeared to be settled at that time. Instructed the CNAs to monitor her whereabouts. Signed by LVN V 11/18/2024 at 3:05 PM, Elopement Evaluation: History of elopement while at home: No. Wandering behavior a pattern or goal-directed: No. Wanders aimlessly or non-goal-directed: No. Wandering behavior likely to affect the safety or well-being of self / others: No. Wandering behavior likely to affect the privacy of others: No. Recently admitted or re-admitted (within past 30 days) and has not accepted the situation: No. Elopement Score: 0.0 Actioned clinical suggestions: (none listed). Signed by LVN V. 11/18/2024 at 3:22 PM, Resident was attempting to go through the front doors and fell on the floor when attempting to open the door. Notified by receptionist. Resident has nonslip socks on, pajamas and housecoat on sitting directly in front of the wheelchair. I don't know what happened, I fell. RN Supervisor was present, resident was assessed for injury and had none. Blood pressure 150/96, Pulse 114, Respirations 20, Temperature 97.5, oxygen saturation-97% on room air. A complete body assessment was performed no injuries were noted. Neuro checks initiated and gait belt was placed around the resident, and she was assisted to a standing position and placed back in her chair. A wander guard was placed on her right wrist. Notified the doctor, notified resident responsible party and family member stated they had been with her yesterday and they did not notice increased confusion. Resident is very confused today stating she needs to leave and find her family member. Resident went into the transport office and sat with an employee had some snacks and neuro checks were initiated. Labs ordered and pending. Signed by LVN V 11/18/2024 at 3:24 PM, Elopement Evaluation: History of elopement while at home: No. Wandering behavior a pattern or goal-directed: Yes. Wanders aimlessly or non-goal-directed: No. Wandering behavior likely to affect the safety or well-being of self / others: No. Wandering behavior likely to affect the privacy of others: No. Recently admitted or re-admitted (within past 30 days) and has not accepted the situation: No. Elopement Score: 3.0 Actioned clinical suggestions: (none listed). Signed by LVN V 01/25/2025 at 7:48 PM, This nurse was notified by oncoming staff that resident was sitting outside on the front porch curb, upon going to assess resident noted sitting on the curb on her buttocks with her wheelchair tipped over in front of her over the curb. Resident voiced I was going to go have a cigarette Vital signs as follows temperature 97.3 blood pressure 132/89 pulse 62 blood sugar 101 respirations 18 oxygen saturation 93%: Resident noted with no wander-guard on her wrist resident was assisted back to her wheelchair she is able to move all extremities without facial grimacing or pain. No internal or external rotation noted to bilateral lower extremities resident denies any pain and continues to voice that she wants to go smoke. Neuros initiated Full head to toe assessment completed with no injury noted. Environmental assessment completed with noted wander- guard observed intact sitting on her bedside table of her shared room: DON notified, Resident to be transferred to memory support unit (secure unit) for safety at this time. Responsible party notified of room change to memory support unit. Immediate Intervention is to transfer resident to memory support unit related to resident removing her wander-guard Medical Director notified of potential fall and room change. Signed by RN DDD 01/25/2025 at 7:48 PM, Elopement Evaluation: History of elopement while at home: No. Wandering behavior a pattern or goal-directed: No. Wanders aimlessly or non-goal-directed: Yes. Wandering behavior likely to affect the safety or well-being of self / others: Yes. Wandering behavior likely to affect the privacy of others: Yes. Recently admitted or re-admitted (within past 30 days) and has not accepted the situation: No. Elopement Score: 5.0 Actioned clinical suggestions: (none listed). Signed by RN DDD During an interview on 02/04/2025 at 9:58 AM, CNA CCC said when Resident #134 was not on the secure unit she wandered, and she tried to go out of the front door. CNA CCC said Resident #134 would just get to the doors. CNA CCC said Resident #134 always tried to get outside the door and she would do it after visiting with her family member. CNA CCC said Resident #134 had a wander guard. CNA CCC said the day Resident #134 was found outside she had left her shift at 6 PM. CNA CCC said when she left Resident #134 was in her room. During an interview on 02/04/2025 at 10:48 AM, Unit Manager U said on 01/25/2025, she was on call and was called in to work. Unit Manager U said that night she parked in the front parking spot when she came in and she could see somebody by the handicap parking space. Unit Manager U said when she went to park, she put her lights on, and she could tell it was Resident #134. Unit Manager U said she called the RN supervisor to tell her they needed a blood pressure cuff to assess Resident #134. Unit Manager U said Resident #134's wheelchair was on the left tipped over. Resident #134 was alert and oriented x2, which was her normal. Unit Manager U said she asked her what she was doing, and Resident #134 said she was going to smoke a cigarette. Unit Manager U said the RN supervisor came out and Resident #134 had no pain, no breaks to her skin. Resident #134 repeated she was going to smoke a cigarette. Unit Manager U said Resident #134 was taken back inside the facility, and they took her to smoke. Unit Manager U said Resident #134 continued to voice she was going back out, so they completed an elopement screen, and she was transferred to the unit. Unit Manager U said Resident #134 had pulled off her wander guard, that it was still snapped together, and it was laying on her over bed table. Unit Manager U said Resident #134 was moved to the secure unit that same night. Unit Manager U said, I want to say I came around 7 PM that night. Unit Manager U said RN DDD was the RN supervisor that night. Unit Manager U said she could not recall who the CNAs were that night. Unit Manager U said she did not recall if Resident #134 had a history of elopement, but she had exhibited exit seeking behaviors in November 2024. Unit Manager U reviewed Resident #134's electronic health record and indicated the incident for Resident #134 on 01/25/2025 was timed at 7:48 PM. Unit Manager U said if a resident was experiencing exit seeking behaviors they would run labs, if they continued they would complete an elopement screen, and they moved them to the memory care unit as applicable. Unit Manager U said if a resident was exit seeking they would bring the resident back in, conduct an assessment, and check if they had a physical need that needed to be addressed, check for urinary tract infections, constipation, if redirection was not effective a wander guard would be applied, and if the exit seeking continued the Resident would be placed on the secure unit. Unit Manager U said typically the wander guard was tried first, and if questionable they would go to the DON and collaborate with her to determine the need for placement on the secure unit vs use of the wander guard. Unit Manager U said the nurses should be actively looking to see that the wander guard was on the residents, and she encouraged them to put it on the resident's wrist, so they did not fall from messing with it if it was on the leg. During an interview on 02/04/2025 at 11:48 AM, the DON said on 11/18/2024 Resident #134 was trying to go through the front door, she fell, a wander guard was placed on her, labs were conduced because that was not normal for her. The DON said Resident #134 usually stayed in her bed and just got up to smoke. The DON said if a resident was having exit seeking behaviors that was out of their normal, they completed an elopement scree. It the resident was exit seeking and had a wander guard then they would go on the secure unit for their safety. The DON said they did a step procedure of putting the wander guard on first to see if they could be controlled. The DON said that was the first defense. If the resident was up and walking that would be considered, they checked for the resident's mobility. Since Resident #134 was wheelchair bound and slow to move in her condition, the wander guard was the best option for her. It depended on the resident's level of mobility and how aggressive they were when trying to leave. If they were truly exit seeking, they always looked at making sure they had a wander guard in place. The DON said to her knowledge Resident #134 did not attempt to exit seek prior to November 2024. The DON said if residents were exit seeking or attempting to elope, they conducted the elopement evaluation. The DON said the wander guard should be checked every shift to ensure it was in place, and the functionality of the wander guard was checked every night. The DON said the nurses should be documenting every shift that the wander guard was in place, one of the checks indicated the wander guard was on and the other indicated the check for the functionality of the wander guard. The DON said on 01/25/2025 Resident #134 went outside and fell at the end of the porch, and that was when they placed her in memory care (secure unit). The DON said Resident #134 was found outside by Unit Manager U. The DON said she did not think Resident #134 had her wander guard on at the time. The DON said she thought at that time was when Resident #134 was staying in the bed all the time, and they had reviewed and assessed to ensure it was no longer required. The DON said she thought she was one of the ones that had a change and did not have it on. The DON said she had asked when the last time Resident #134 was seen on 01/25/2025 and RN DDD said she had seen her 6-7 minutes prior to Unit Manager U finding her outside. The DON said she did not remember if any in-services were conducted related to this incident that she would look and provide them, if they were conducted (none were provided upon exit to the facility). The DON said the residents were not re-evaluated to see if anyone else was at risk of elopement. The DON said they evaluated the residents minute to minute if they had a change. The DON said she remembered Resident #134 had removed her wander guard the night of 01/25/2025 and placed it on her nightstand, and that was why she went to memory care (secure unit). The DON said that night, 01/25/2025, she had the staff check the residents' wander guards to ensure they were in place. During an interview on 02/04/2025 at 12:38 PM, the Administrator said she expected the staff to follow the elopement policy for the need for a wander guard or secure unit placement. The Administrator said this would be completed by the social worker or nursing that they worked together on these things. The Administrator said when Resident #134 was found outside on 01/25/2025, an incident report was completed and the DON took care of it all since she was just an interim administrator. The Administrator said the wander guards should be checked and assessed to ensure the residents did not elope and for the safety of the residents. During an observation and interview on 02/04/2025 at 12:58 PM, Unit Manager U walked outside and indicated to the state surveyor where she found Resident #134 the night of 01/25/2025. Unit Manager U said she had seen Resident #134 sitting on the curb where the handicap parking space was. Unit Manager U said it appeared like Resident #134's wheelchair had rolled down the little ramp and tilted over. The location where Resident #134 was found was approximately 40 feet from the facility's front door entrance. During an interview on 02/04/2025 at 3:48 PM, CNA HHH said the night (01/25/2025) Resident #134 got out, Resident #134 was trying to leave, and they had caught her a couple times that evening at the double doors (the front entrance of the facility). CNA HHH said they brought her back to the hall and tried to watch her. CNA HHH said she knew when Resident #134 got out she was in the shower room. CNA HHH said they kept leaving her at the nurse's desk, and the CNA she was working with tried to lay her down. CNA HHH said she notified RN DDD that Resident #134 was trying to leave, and RN DDD also saw Resident #134 was trying to leave. CNA HHH said they tried to keep an eye on Resident #134 and do one-on-one, but they were short that night. CNA HHH said it was just her and CNA KKK. CNA HHH said since she arrived for her shift Resident #134 was trying to leave. CNA HHH said when a resident was exit seeking, she tried to redirect them and bring them back in and keep them with her. CNA HHH said she tried to figure out what they were wanting so she could give it to them. CNA HHH said she believed Resident #134 was wanting to go smoke, and they were not able to take her to smoke at that moment. CNA HHH said it was important to ensure the residents did not leave the facility without their knowledge, so they did not get out and get hurt. During an interview on 02/04/2025 at 4:01 PM, RN DDD said she did not remember where in the building she was when she received the phone call from Unit Manager U that Resident #134 was outside. RN DDD said Unit Manager U had gone to the facility to relieve someone and she saw Resident #134 close to the parking lot she was sitting on the curb. Unit Manager U said Resident #134 was outside, and RN DDD ran out and Resident #134 was sitting on the curb and the wheelchair was dumped forward. RN DDD said she did not know if Resident #134 had fallen. They assessed Resident #139, and she did not have any injuries. RN DDD said Resident #134 told them she was going to smoke so they brought her back into the facility. RN DDD said she wondered why the doors did not alarm, and when they went back to Resident #134's room to see if she had any bruising, RN DDD noticed Resident #134 did not have her wander guard on. It was sitting on the bedside table like Resident #134 had slipped it off. RN DDD said she notified the DON, and they ended up taking Resident #134 to the memory care (secure) unit. RN DDD said she checked the residents' wander guards, and they were all in place. RN DDD said Resident #134 always went up and down the halls wanting to smoke even if it was not the scheduled time. RN DDD said on 01/25/2025, Resident #134 kept talking about going to smoke up and down the halls, and RN DDD told the staff, Y'all keep an eye on her. RN DDD said they had seen her at the doors exit seeking, and she wanted to go smoke. RN DDD said they just redirected her back. RN DDD said she told the CNAs to watch her until they took her to smoke. RN DDD said she was at the nurse's station the last time she saw Resident #134. RN DDD said she could not remember the timeframe between when she last saw her before Unit Manager U called her. RN DDD said, it was crazy that night. RN DDD said it was important to ensure the residents did not go outside without staff knowledge to keep the residents safe and for nothing to happen to them. During an interview on 02/05/2025 at 7:39 AM, CNA KKK said he remembered Resident #134 tried to go out of the front doors a couple times prior to being found outside the night of 01/25/2025. CNA KKK said Resident #134 kept trying to go out of the doors because she wanted to smoke. CNA KKK said they caught her, but when he went to care for his residents, he guessed at some point Resident #134 ended up getting out. CNA KKK said he was in a patient room when it happened. CNA KKK said he did not remember the timeframe from the last time he saw Resident #134 to when she was found outside. CNA KKK said RN DDD was aware Resident #134 was attempting to leave and wanted to go smoke, and they were trying to keep an eye on her. CNA KKK said he was not assigned to care for Resident #134 that day (01/25/2025), and he could not remember who the CNAs were that night. During an interview on 02/06/2025 at 4:37 PM, LVN V said on 11/18/2024 Resident #134 was exit seeking, and she thought they may have tested her for a UTI. LVN V said that was not Resident #134's normal behavior. LVN V said Resident #134 was trying to go home. LVN V said a wander guard was placed on Resident #134, they called her family member, and LVN V tried to keep Resident #134 close to her, but LVN V was doing treatments and other things. LVN V said they tried to keep Resident #134 at the nurse's station and in LVN V's line of sight, but when they turned their back Resident #134 would shoot out. LVN V said the receptionist alerted them to Resident #134 exit seeking on 11/18/20024. LVN V said she thought her family member came by later that day. LVN V said Resident #134 said if she could smoke, she would lay down. Record review of the facility's policy, Elopement, revised August 2013, indicated, To provide early identification of residents at risk for elopement and provide a secure environment. 1. Upon admission, quarterly, and with significant change, the resident will be screened for elopement risk utilizing the elopement screen form. 2. If the resident is considered to be at risk for elopement, preventative measures will be implemented: a. A care plan problem addressing the risk of elopement with a new preventative measure addressing each elopement. b. Preventative measures such as a door alarm system or other devices may be used taking into account the least restrictive measure necessary to reduce elopement risk. 3. Nursing to check placement of security bracelet each shift and function of bracelet each day. Record both in the clinical record . 5. It is the responsibility of staff members to report to a nurse if a resident attempts to leave facility. 6. Staff members will be trained on the elopement policy and procedures during orientation and ongoing . 5. The facility has an eyes on policy where residents are observed every two hours or more frequently if deemed necessary. 6. The facility completes a care plan on all residents who are at risk for elopement to identify to the staff interventions to attempt to prevent elopement from the facility . This was determined to be an Immediate Jeopardy (IJ) on 02/04/2025 at 3:20 PM. The facility Administrator and the DON were notified. The Administrator was provided with the IJ template on 02/04/2025 at 3:40 PM and a Plan of Removal was requested. The facility's plan of removal was accepted on 02/05/2025 at 10:15 AM and included the following: PLAN OF REMOVAL Facility Date: 2/4/2025 Immediate action: Upon notification the resident was assisted to re-enter the facility and assessed per RN on 1/25/25 at 1948 (7:48 PM) with no injuries noted. The MD and responsible party were notified with new orders for resident to move to the secured memory care unit. The resident's care plan was updated on 2/4/2025 to include personalized interventions and potential triggers for exit seeking behavior by the Director of Nursing and/or Social Worker. The new interventions added include triggers that may cause the resident to exit seek and interventions staff can use to redirect the resident. 100% of available staff that provide care to the resident will be trained on 2/5/2025 by 10:00 a.m. and all others will be trained prior to their next scheduled shift by the Director of Nursing/Designee. 100% of all available staff will be trained on 2/4/2025 and all other staff will be trained before their next scheduled shift on elopement procedures and managing exit seeking behaviors by the Director of Nursing and/or designee. A posttest will be completed at the end of training to ensure effectiveness of training. Social Workers were educated on 2/5/2025 by the DON on resident specific care plan interventions and identifying triggers related to exit seeking behaviors. Elopement drills will be conducted on an ongoing quarterly basis to include all shift beginning with day shift on 2/5/2025 by 4 pm. Elopement Risk book will be reviewed and updated by Social Worker/Designee on 2/5/2025. This book contains identification information on residents at risk for wandering. Picture of resident as well as face sheet are included. Book is available to all staff with copy at receptionist desk and on each nursing unit. 100% of all available staff will be trained on the elopement book by Social Worker/designee on 2/5/2025 by 4 pm. All other staff will be trained before their next scheduled shift on the elopement book. If a resident exit seeks or has an elopement attempt/incident staff have been educated on what interventions to implement as part of the elopement/exit seeking training beginning on 2/4/2025. All doors with the wanderguard system will be checked to ensure proper function on 2/5/2025 by facility maintenance staff. Elopement Risk will be completed on all residents by DON/Designee by 2/5/25. Any resident identified with elopement risk will have interventions in place. These will include but not be limited to Wander Guard, Secure Unit, frequent checks and the Care Plan will be updated. These updates will reflect resident specific interventions. Residents with any risk will have interventions implemented. Elopement policy was reviewed and updated as indicated on 2/4/2025 by Regional Clinical Consultant. This was included in training being provide to staff on Elopement. As a component of the elopement policy, the Electronic Monitoring policy was updated to reflect changes made to the Elopement Risk Assessment. Medical Director was notified of IJ on 2/4/2025 at 5:47 PM. Facility QAPI meeting will be held on 2/5/2025 at 8 AM to discuss POR. This Plan of Removal will be completed by 4:00 PM on 2/5/2025. On 02/06/2025 the state surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Record review of Resident #134's care plan indicated it was revised on 02/04/2025 to include personalized interventions and triggers for exit seeking behavior. Record review completed on all residents' Elopement Risks, and reviewed the care plan of all residents who were at risk for elopement to ensure their care plans included resident specific interventions. Record review completed of the Elopement Policy and the Electronic Monitoring policy to ensure it was updated. Record review

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review, the facility failed to ensure the necessary treatment and services, in accordance with comprehensive assessment and professional standards of practice, to prevent development of pressure injuries was provided for 1 of 6 Residents (Resident #74) reviewed for pressure injuries. 1. The facility failed to provide care to prevent pressure ulcer or injury development for Resident #74. Resident #74 broke his right ankle and a soft splint was applied on 07/13/24. The facility failed to obtain a clarification order from the doctor related to Resident #74's splnt care. Resident #74 developed 4 unstageable deep tissue injuries to his right foot and possible osteomyelitis. An IJ was identified on 02/05/25. The IJ template was provided to the facility on [DATE] at 4:57 PM. While the IJ was removed on 02/06/25, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because all staff had not been trained on pressure ulcer prevention and management, cast and splint care, and turning and repositioning . This failure could potentially place residents at risk of development of pressure ulcers, worsening pressure ulcers, and infections. The findings included: Record review of the face sheet, dated 02/07/25, reflected Resident #74 was an [AGE] year-old male who initially admitted to the facility on [DATE] with diagnoses of dementia (memory loss) and diabetes mellitus (high blood sugar). The face sheet further revealed two stage 3 pressure ulcers to the right heel and left heel (wound caused from pressure with full-thickness skin loss) developed after admission and a stage 4 pressure ulcer to other site (wound caused from pressure with exposed muscle, tendon, or bone) developed after admission. Record review of the quarterly MDS assessment, dated 01/08/25, reflected Resident #74 had clear speech and was understood by others. The MDS reflected Resident #74 was able to understand others. The MDS reflected Resident #11 had a BIMS score of 11, which indicated moderately impaired cognition. The MDS reflected Resident #74 had no behaviors or refusal of care. The MDS reflected Resident #74 normally used a wheelchair and had impairment to both lower extremities. The MDS reflected Resident #74 required substantial/maximal assistance to partial/moderate assistance with bed mobility and transfers. The MDS reflected Resident #74 had one or more unhealed pressure ulcers/injuries and was receiving treatments that included: pressure reducing device for chair, nutrition or hydration interventions to manage skin problems, pressure ulcer/injury care, and applications of ointments/medications other than to feet. Record review of the comprehensive care plan, initiated on 04/17/24, reflected Resident #74 was at risk for complications related to edema to bilateral lower extremities. The interventions included: encourage elevation of bilateral lower extremities as tolerated. Record review of the comprehensive care plan, revised on 07/16/24, reflected Resident #74 had impaired mobility related to weakness. The interventions included: assist with positioning, transfers and ambulation as necessary and no weight bearing to right lower extremity. Record review of the comprehensive care plan, revised 07/16/24, reflected Resident #74 was at risk for complications related to fracture of right lower leg. The interventions included: no weight bearing to right lower extremity, consult with orthopedic doctor, follow up with orthopedic as ordered/needed, notify physician as needed, observe extremities every shift for signs of complications (redness, swelling, fever, poor circulation, pain) and intervene as appropriate, and provide proper body alignment and safety as possible. An intervention was added on 07/29/24 for right tall CAM boot on at all times; off only for showers. Record review of the discontinued and completed orders, between 04/29/24 and 7/26/24, reflected Resident #74 had no orders for the care of his soft splint that was placed on 07/13/24. Record review of the MAR/TAR, dated July 2024, reflected Resident #74 had no treatment or orders for splint care. The TAR reflected orders were started on 07/26/24 for pressure ulcer wound care. Record review of the body audit form, dated 07/12/25, reflected Resident #74 had redness and discoloration to his right knee, left ear lobe, left upper elbow, left lower forearm and hand, upper elbow, left inner elbow discoloration, left index knuckle, right inner forearm discoloration, and right small discoloration to hip after a fall that occurred on 07/12/24. The body audit form did not reveal any pressure ulcers. Record review of the emergency room records, dated 07/13/24, reflected Resident #74 had an ankle fracture and a soft splint was applied. The care instructions included: do not put weight on the splint, keep leg raised when sitting or lying down, keep cast or splint dry at all times, and place an ice pack over the injured area for no more than 15 to 20 minutes. The follow-up care instructions included: follow up with healthcare provider in 1 week, or as advised, if you were given a splint, it may be changed to a cast or boot after the swelling goes down. The instructions did not specify do not remove. Record review of the body audit form, dated 07/14/24, reflected Resident #74 had skin issues (such as redness, broken areas, darkened or bruised areas) to ears, elbows, lower arms, hands/fingers, and hips. The additional comments section reflected acute mildly displaced distal fibula fracture to right leg. (broken right leg at the ankle) The body audit form did not reveal any pressure ulcers. Record review of the total body skin assessment, dated 07/15/24, reflected Resident #74 had good elasticity, normal skin color, warm skin, normal moisture, and normal condition. The assessment reflected Resident #74 had no new wounds. Record review of the body audit form, dated 07/20/24, reflected Resident #74 had skin issues (such as redness, broken areas, darkened or bruised areas) to lower legs. The additional comments section reflected acute mildly displaced distal fibula fracture (broken right ankle) to the right leg. Cast remains on leg. Record review of the Braden Scale for Predicting Pressure Sore Risk assessment, dated 07/26/24, reflected Resident #74 had a score of 15, which indicated he was at risk for pressure ulcer development. Record review of Resident #74's progress notes from 07/04/24 to 08/03/24, reflected the following: 07/13/24 at 3:20 PM Resident #74 was hurting bad and screaming with pain to his ankle, he was sent to the emergency room. 07/13/24 7:40 PM Resident #74 returned from the hospital with a diagnosis of right ankle fracture. The note did not reflect any orders or care orders for a soft splint. 07/13/24 9:09 PM The NP was notified of Resident #74's return to facility. Verbal orders were obtained for pain medications. The note did not reflect any orders or care orders for a soft splint. The note did not reflect the NP was notified of the soft splint to his ankle. 07/14/24 2:57 PM The note did not mention a soft splint or care to Resident #74's right ankle. 07/14/24 9:39 PM The note did not mention a soft splint or care to Resident #74's right ankle. 07/15/24 3:23 PM Resident #74 was resting in bed with splint in place to right lower leg extremity. No neurovascular assessment was documented. 07/16/24 12:10 AM Resident #74 was lying in bed with splint in place to right leg. No neurovascular assessment was documented. 07/16/24 12:47 PM Resident #74's splint was intact. No neurovascular assessment was documented. 07/16/8:56 PM Resident #74 was in bed, required assistance of 2 person to reposition. The note stated soft cast was noted to right lower leg. No neurovascular assessment was documented. 07/18/24 11:31 PM The responsible party notified facility of the orthopedic doctor attempting to cancel Resident #74's appointment related to insurance information. Unit Manager voiced concerns of pain, resident begin non weight bearing, skin concerns, diet and quality of life with responsible party. 07/19/24 11:05 AM Resident #74 lying in bed with soft cast to right lower extremity. Resident #74 required Hoyer lift for transfers. No neurovascular assessment was documented. 07/19/24 7:16 PM Resident #74 was non-weight bearing to right leg and Resident #74 required a Hoyer lift for all transfers. The note did not mention the soft splint or a neurovascular assessment. 07/20/24 1:57 PM Resident #74 was non-weight bearing to right leg and Resident #74 required a Hoyer lift for all transfers. The note did not mention the soft splint or a neurovascular assessment. 07/21/24 2:26 AM Resident #74 was non-weight bearing to right leg and Resident #74 required a Hoyer lift for all transfers. The note did not mention the soft splint or a neurovascular assessment. 07/23/24 1:20 AM Resident #74 was non-weight bearing and awaiting a walking boot. The note did not mention the soft splint or a neurovascular assessment. 07/25/24 4:59 PM Resident #74's right leg in cast and required a mechanical lift for transfers to wheelchair. No neurovascular assessment was documented. 07/26/24 11:46 AM The director of rehab received clarification for the right lower extremity as non-weight bearing and wear right tall CAM boot at all times, remove only for showers; remove soft splint. 07/26/24 12:45 PM The Treatment Nurse documented the following unstageable wounds: 1. Unstageable deep tissue injury to right mid dorsal foot (top of right foot), which measured 5.5 cm x 2 cm. Unable to determine depth. (Later identified as a stage 4 pressure ulcer.) 2. Unstageable deep tissue injury to right plantar 5th metatarsal area (side of foot near 5th toe) which measured 1 cm x 1.5 cm. Unable to determine depth. (Later healed.) 3. Unstageable deep tissue injury to right heel which measured 1.5 cm x 2 cm. Unable to determine depth. (Later identified as a stage 3 pressure ulcer.) 4. Unstageable deep tissue injury to left heel which measured 2.5 cm x 3 cm. Unable to determine depth. (Later identified as a stage 3 pressure ulcer.) Record review of the Orthopedic progress note, dated 07/22/24, reflected Resident #74 was seen by the doctor with new orders for a right tall CAM walker boot x 99 months . The progress note did not specify do not remove the soft splint. Record review of the nursing progress note, dated 02/04/25, reflected Resident #74 had a vascular appointment in which they were concerned for osteomyelitis (bone infection) and ordered several x-rays to his right foot. Record review of the radiology results report, dated 02/05/25, showed Resident #74 had potential osteomyelitis to the distal second and third metatarsal (bones of the foot). Record review of the e-mailed statement, dated 02/05/25 at 9:22 PM, reflected the NP stated Resident #74 returned to the facility after a short acute hospital stay for a right ankle fracture. The NP stated the staff notified her of his return and were concerned there was no instructions on care for the splinted leg. The NP stated she instructed the staff to follow up with orthopedist for instructions on care, when she was asked about removal of the splint, she instructed them to leave it in place until guidance was received on care from orthopedist. During an interview on 02/03/25 beginning at 11:32 AM, Resident #74 stated he had developed wounds after he broke his leg at the facility. Resident #74 was unable to remember details of the incident as it happened in July 2024. During an observation and interview on 02/05/25 beginning at 8:54 AM, the Treatment Nurse performed wound care on Resident #74 in 3 locations, his left heel, top of his right foot, and his right heel. The Treatment Nurse explained the wound to his left heel started out as unstageable and was later staged at a stage 3 pressure wound. The Treatment Nurse stated the wound to his right heel was also started out as unstageable and was later identified as a stage 3 pressure wound. The Treatment Nurse stated the wound to the top of his right foot was unstageable at first and was later staged at a stage 4 because he had exposed tendon. The wound observed. It was open and tendon was observed. During an interview on 02/05/25 beginning at 2:33 PM, Unit Manager T stated Resident #74 moved to the C wing after he had already developed the pressure ulcers. Unit Manager T stated Unit Manager O would have been the one overseeing Resident #74's care during the month of July 2024. During an interview on 02/05/25 beginning at 2:38 PM, Unit Manager O said she did not remember Resident #74's care back in July 2024. Unit Manger O stated she was unsure she was even the one overseeing his care during that time. Unit Manager O said she was unsure what type of care Resident #74 needed prior to the fall on 07/12/24. Unit Manager O stated if a resident had a splint/cast the nurses should have been assessing the area every shift. Unit Manager O stated the site should have been assessed for redness, warmth, pain, or any rubbing or tightness. Unit Manager O stated it would have depended on the doctors' orders if it was removed or remained in place. Unit Manager O stated if orders were not obtained then the physician should have been contacted and order clarifications received. During an interview on 02/05/25 beginning at 2:43 PM, the Orthopedic doctor stated Resident #74 was seen at the facility after a right ankle fracture. The Orthopedic doctor stated Resident #74 had a soft splint at the appointment. The Orthopedic doctor stated he instructed Resident #74 and the people who accompanied him to the appointment that he was able to remove the splint for showers, therapy, and assessments. The Orthopedic doctor stated if he did not want the splint removed, he would have specified in his notes. During an interview on 02/05/25 beginning at 2:48 PM, LVN XX stated she was unable to remember Resident #74 receiving pressure ulcers or breaking his ankle. LVN XX stated she remembered he was always happy and required help with transfers. LVN XX stated if a resident was at risk for developing pressure ulcers, wound care should have been consulted and involved in the care. LVN XX stated if a resident had a soft splint, it should have been assessed for skin breakdown or redness. LVN XX stated a resident should have been turned and repositioned every 2 hours if they were immobile. LVN XX stated the nurse of the floor should have clarified orders with the physician if it did not specify removal of the splint for showers or assessment. During an interview on 02/05/25 beginning at 3:24 PM, CNA KK stated she remembered Resident #74 when he was on her hallway. CNA KK stated Resident #74 required a one person assistance with his ADLs including dressing, bathing, transfers, and personal hygiene. CNA KK stated when Resident #74 broke his leg, then he required a two person assistance with transfers and use of mechanical lift. CNA KK stated the nurses let them know he had a change of condition and she noticed he stayed in the bed more often. CNA KK stated the staff floated the leg that was hurt and changed his position when he asked. CNA KK stated she remembered he complained of pain to his leg. During an interview on 02/05/25 beginning at 3:56 PM, the Treatment Nurse stated she did not take over Resident #74's care until he developed the wounds. The Treatment Nurse said Resident #74 had a soft cast placed from the hospital and she was told by the nurse not to remove the splint until he followed up with the orthopedic doctor. The Treatment Nurse stated she assumed orders were in place by the nurse who received the orders. The Treatment Nurse stated once the wounds developed, she immediately assessed the wounds, notified the doctor, implemented treatment orders, and updated his care plan. During an interview on 02/05/25 beginning at 5:34 PM, Escort CNA OO stated she remembered taking Resident #74 to his orthopedic appointment on 07/22/24. Escort CNA OO stated the orthopedic doctor did not remove the dressing or splint to his right lower leg because it was fresh. Escort CNA OO said the orthopedic doctor said not to remove the splint until the CAM boot was received by the facility. Escort CNA OO stated she reported the information to LVN XX on the day of the appointment. Escort CNA OO stated LVN XX and the DOR asked for the orders from the orthopedic doctor on 07/26/24 and she told them again. Escort CNA OO stated the DOR then called the orthopedic office for clarification orders. Escort CNA OO stated Resident #74's family member was at the appointment with him and heard the same orders. During an interview on 02/05/25 beginning at 5:44 PM, the DON stated the NP gave the verbal order after Resident #74 returned from the emergency room with the soft splint to not remove it. The DON stated the orders should have been placed in the computer and documented. The DON stated she was looking for the orders. During an interview on 02/07/25 beginning at 12:52 PM, the DON stated she expected the nursing staff to ensure preventable measures were in place to prevent pressure ulcer development. The DON stated she expected orders to have been clarified if they were unclear. The DON stated interventions and order clarifications should have been documented to prove that things were completed and promote continuity of care. During an interview on 02/07/25 beginning at 1:15 PM, the Administrator stated she was not at the facility in July 2024. The Administrator stated she expected pressure ulcers to have been reviewed daily during the clinical stand up meetings. The Administrator stated if actions were needed, she expected the actions to have been completed immediately. The Administrator stated she expected the doctors' orders to have been followed and documented in the clinical record. The Administrator stated if it wasn't documented, it was not done. The Administrator stated it was important to ensure pressure ulcer prevention was implemented because it could affect the outcome of the health of the residents. Record review of the Wound Intervention and Prevention policy, dated 12/2023, reflected identify residents being at risk for alteration in skin integrity .limited transfer and bed mobility; bed/chair bound; unable to reposition self .assure proper tissue load management .reposition resident when in bed or in chair .use proper position technique and positioning device . Record review of the Cast Care policy, dated June 2024, reflected protect from moisture, position the cast to prevent the edge from pinching or pressing into the skin .observe for persistent pain/swelling .circulation checks - observe for warmth, color, edema, and adequate capillary refill to effected extremity every shift .elevate if needed . This was determined to be an Immediate Jeopardy (IJ) on 02/05/25 at 4:45 PM. The Administration and the DON were notified. The Administrator was provided the IJ template on 02/05/25 at 4:57 PM and a plan of removal was requested. The following plan of removal submitted by the facility was accepted on 02/06/25 at 8:26 AM and included the following: Immediate action: On 07/26/24, PT and Charge Nurse removed the soft cast and observed skin impairments. The Treatment Nurse was notified, the areas were evaluated, and the physician was notified. New orders for wound care were initiated. The soft cast remained off and a CAM boot was applied that could be removed for showers allowing skin checks. Care plans were initiated for the skin impairments. 100% of all available direct care staff will be trained on 02/05/25 by the DON or designee and all other direct care staff will be trained before their next scheduled shift on skin check procedures for residents with a splint or cast and wound care prevention. A post-test will be completed at the end of training to ensure effectiveness of training. 100% of all available licensed nurses will be trained on 02/05/25 by the DON/Designee on following physician's orders. All others will be trained before their next scheduled shift. The Wound Nurse received 1:1 (one on one) education on caring for a resident with a cast/splint, following physician's orders and wound care prevention per the Regional Nurse Consultant on 02/05/25. Skin audits were completed on all residents by the DON/Designees on 02/05/25. No new pressure injuries were identified during the audit. Care plans were audited for all residents with pressure ulcers and/or risk for pressure ulcers to ensure interventions were accurate and in place by the DON/Designee on 02/05/25. On 02/05/25, The DON/Designee reviewed current resident care needs for any resident with a device that is not/cannot be removed. No residents currently reside in the facility with devices that cannot be removed. On 02/05/25 100% audit of all residents was completed to ensure weekly skin checks are ordered. No issues identified. Pressure Ulcer QA tool will be completed on 02/06/25 by 11:00 AM, weekly X 4 weeks, the monthly X 2 months, and then quarterly. The results will be presented to the QAPI committee, and any areas of deficiency will be immediately addressed through education. Wound Care Prevention policy was reviewed, and no updates were indicated on 02/05/25 by Director of Clinical Operations. This policy was included in the above noted training. Medical Director was notified of IJ on 02/05/25 at 5:27 PM. Facility QAPI meeting will be held on 02/06/25 at 8AM to discuss POR. This Plan of Removal will be completed by 4PM on 02/06/25. On 02/06/25 the survey team confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: 1. During an interview on 02/06/2025 at 9:25 AM, the Medical Director said he had been notified of the immediate jeopardy. The Medical Director said the facility had sent him the reports to review and the facility was working on monitoring to prevent further issues. 2. Record review of Resident #74's nursing progress notes, dated 07/26/24, reflected the nurse removed the soft splint and noted skin impairments. The Treatment Nurse was notified, and the skin was assessed. 4 new pressure injuries were identified, and the doctor was notified. 3. Record review of Resident #74's TAR, dated July 2024, reflected new treatment orders were initiated and completed for the 4 new pressure injuries. The TAR also revealed a CAM boot was applied after the soft splint was removed . 4. Record review of the comprehensive care plan, dated 07/26/24, reflected Resident #74 had care plans in place for the 4 pressure areas identified after the soft splint was removed. 5. Record review of the shower/bath sheet used for the skin audit, dated 02/05/25, reflected all residents received a skin assessment with no new skin areas identified. 6. Record review of the care plan detail report used for the care plan audit, dated 02/05/25 - 02/06/25 reflected all residents with pressure ulcers or residents at risk for pressure ulcers were reviewed and updated. 7. Record review of the order summary report, dated 02/05/25, reflected all residents had an order for weekly skin reviews. 8. Record review of the Pressure Ulcer QA tool, dated 02/06/25, reflected each resident identified with pressure ulcers, including Resident #74, had no identified issues. 9. Record review of the QAPI sign-in sheet, dated 02/06/25 at 8 AM, reflected the meeting was held with multiple department heads in attendance. 10. Record review of the in-service training on wound intervention, prevention, and turning and repositioning, un-dated, reflected education was provided to the facility staff. There were 64 signatures. 11. Record review of the pressure ulcer prevention post-test, dated 02/05/25 to 02/06/25, reflected CNA X, CNA DD, CNA EE, CNA FF, CNA GG, CNA F, CNA HH, CNA KK, CNA LL, CNA MM, CNA NN, CNA PP, CNA QQ, CNA RR, CNA SS, CNA UU, CNA VV, CNA WW, Escort CNA OO, Escort CNA TT, MA Y, MA Z, MA W, MA BB, MMA CC, LVN H, LVN K, LVN G, LVN L, LVN M, LVN N, LVN P, LVN Q, LVN V, RN AA, Unit Manager O, Unit Manager R, Unit Manager T, Unit Manager U, Unit Manager A, Treatment Nurse, MDS Coordinator D, Quality Assurance Nurse, and ADON S were able to answer all questions appropriately including turning and repositioning residents at risk for pressure ulcers at least every 2 hours, factors that could increase the risk for pressure ulcers, and the purpose of using pressure-reliving devices. 12. Record review of the in-service training on cast care, undated, reflected education was provided to facility staff. There were 64 signatures. 13. Record review of the cast care post-test, dated 02/05/25 to 02/06/25, reflected CNA X, CNA DD, CNA EE, CNA FF, CNA GG, CNA F, CNA HH, CNA KK, CNA LL, CNA MM, CNA NN, CNA PP, CNA QQ, CNA RR, CNA SS, CNA UU, CNA VV, CNA WW, Escort CNA OO, Escort CNA TT, MA Y, MA Z, MA W, MA BB, MMA CC, LVN H, LVN K, LVN G, LVN L, LVN M, LVN N, LVN P, LVN Q, LVN V, RN AA, Unit Manager O, Unit Manager R, Unit Manager T, Unit Manager U, Unit Manager A, Treatment Nurse, MDS Coordinator D, Quality Assurance Nurse, and ADON S were able to answer all questions appropriately including monitoring warmth, color, adequate capillary refill every shift, and notifying the physician or nurse if resident is complaining of severe pain. 14. Record review of the in-service training on physician orders, dated 02/05/25, reflected the nurses were provided education on ensuring clear communication of orders, documentation of orders, verifying orders with care team, implementing orders timely, monitoring, and evaluating outcomes and engaging the family and resident. There were 26 signatures. 15. Record review of the employee counseling form, dated 02/05/25, reflected the Treatment Nurse was provided a verbal warning. The employer statement was a resident returned to the facility on [DATE] with a soft splint. The treatment nurse did not ensure that appropriate treatment orders were in place for splint care to ensure the resident was free from complications. 16. During an interview on 02/06/25 between 1:30 PM and 3:41 PM, CNA X, CNA DD, CNA EE, CNA FF, CNA GG, CNA F, CNA HH, CNA KK, CNA LL, CNA MM, CNA NN, CNA PP, CNA QQ, CNA RR, CNA SS, CNA UU, CNA VV, CNA WW, Escort CNA OO, Escort CNA TT, MA Y, MA Z, MA W, MA BB, MMA CC, LVN H, LVN K, LVN G, LVN L, LVN M, LVN N, LVN P, LVN Q, LVN V, RN AA, Unit Manager O, Unit Manager R, Unit Manager T, Unit Manager U, Unit Manager A, Treatment Nurse, MDS Coordinator D, Quality Assurance Nurse, and ADON S were able to verbalize residents at risk for pressure ulcers, interventions for pressure ulcer preventions, procedure for turning and repositioning, and procedures for cast/splint care. 17. During an interview on 02/06/25 between 1:30 PM and 3:41 PM, LVN H, LVN K, LVN G, LVN L, LVN M, LVN N, LVN P, LVN Q, LVN V, RN AA, Unit Manager O, Unit Manager R, Unit Manager T, Unit Manager U, Unit Manager A, Treatment Nurse, MDS Coordinator D, Quality Assurance Nurse, and ADON S were able to verbalize the correct procedure for obtaining physician orders including when to clarify orders and documentation of the orders. The Administrator and DON were informed the IJ was removed on 02/06/25 at 3:51 PM. The facility remained out of compliance at a scope of pattern and a severity level of no actual harm with a potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the resident had the right to be free from abuse for 1 of 10 (Resident #1) residents reviewed for abuse. The facility failed to protect Resident #1 from physical abuse by CNA A on 5/14/2023.CNA A had a history of a physical abuse allegation in December 2022 towards Resident #2. The facility failed to implement measures to protect residents from further abuse. The facility failed to train staff on how to manage residents with behaviors that could lead to abusive behaviors. These failures resulted in an identification of an Immediate Jeopardy (IJ) on 11/15/23 at 4:25 p.m. While the IJ was removed on 11/18/23, the facility remained out of compliance at no actual harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could place residents at risk for physical and verbal abuse, psychosocial harm, and decreased quality of life. Findings Include: 1. Record review of the Provider Investigation Report dated 12/6/22 indicated Housekeeper CCC witnessed CNA A slap Resident #2 on the back. The Provider Investigation Report indicated Housekeeper CCC also witnessed Resident #2 hit CNA A in the throat. The Provider Investigation Report indicated CNA denied slapping Resident #2 in the back. The Provider Investigation Report indicated CNA admitted to pushing Resident #2 due to Resident #2's aggression. The Provider Investigation Report indicated CNA A was suspended pending investigation. The Provider Investigation report indicated the facility determined the event to be unfounded. Record review of a written statement dated 12/6/22 by CNA A indicated Resident #2 was pulling on the computer wires at the nurse's station. The written statement indicated CNA A tried to take the computer wires from Resident #2. The written statement indicated Resident #2 grabbed CNA A by the throat and then Resident #2 hit CNA A in the throat with his fist. The written statement indicated CNA A pushed Resident #2 to get him off her. Record review of an Investigation Statement/Interview dated 12/6/22 with Housekeeper CCC indicated on 12/5/22 Housekeeper CCC witnessed Resident #2 punch CNA A in the throat. The Investigation Statement/Interview indicated Housekeeper CCC then witnessed CNA A hit Resident #2 on the back with an open hand. The Investigation Statement/Interview indicated Resident #2 became more aggressive with CNA after CNA hit Resident #2. 2. Record review of the face sheet dated 11/22/23 indicated Resident #1 was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses including Alzheimer's, hypertension (elevated blood pressure), repeated falls, delusional disorder, and anxiety disorder. Record review of the MDS dated [DATE] indicated Resident # 1 understood others and was understood by others. The MDS indicated Resident #1 had a BIMS of 03 and was severely cognitively impaired. The MDS indicated Resident #1 required extensive assistance with bed mobility, transfers, dressing, eating, and personal hygiene. The MDS indicated Resident #1 used a wheelchair for mobility. Record review of the care plan last revised 8/18/23 indicated Resident #1 had anticipatory grief and anxiety secondary to expected decline of resident. The care plan indicated Resident #1 required hospice care. The care plan indicated Resident #1 had impaired cognitive function/dementia or impaired thought process related to Alzheimer's. Record review of the Provider Investigation Report dated 5/15/23 indicated on 5/14/23 at 11:20 p.m. a fellow CNA alleged that CNA A hit Resident #1 in the back of the head with an opened hand. The Provider Investigation Report indicated CNA A was witnessed pushing Resident #1 in his wheelchair aggressively down the hall. The Provider Investigation Report indicated Resident #1 swung his arm back and knocked CNA A's glasses off. The Provider Investigation Report indicated CNA was observed hitting Resident #1 in the back of the head with an open hand and then pushed him to his room. The Provider Investigation Report indicated CNA A denied the allegation and was suspended pending investigation. The Provider Investigation Report indicated on 5/15/23 CNA A notified the facility she would not be returning to work and requested her employment be terminated. The Provider Investigation Report indicated the allegation was unconfirmed due to having no other witnesses and Resident #1 was unable to recall the event. The Provider Investigation Report indicated upon conclusion of this investigation, there were no other witnesses to this event. The Provider Investigation Report indicated Resident (#1) was unable to recall the event and was noted to have no injuries. The Provider Investigation Report indicated with no collaborating evidence this allegation is unconfirmed. The Provider Investigation Report indicated the Provider Action Taken Post investigation was social services would follow for distress and staff education regarding timely reporting. The Provider Action Taken Post investigation did not indicate any other education to staff as a response to the incident. Record review of the nursing progress note dated 5/14/23 at 11:45 p.m. indicated a head-to-toe assessment was completed on Resident #1 with no injuries noted. The nursing progress note indicated Resident #1 did not demonstrate any distress and had no recall of the alleged staff related event. Record review of the social services progress note dated 5/16/23 at 10:34 a.m. indicated the social worker went down to visit with Resident #1 regarding the staff incident. The social services progress note indicated Resident #1 did not recall the event and showed no signs of distress. Record review of CNA A's schedules indicated she had worked on the secured unit on 12/01/22, 12/05/22, 1/25/23, 3/11/23, 3/12/23, and 5/12/23. Record review of CNA A's time sheet for 5/14/23 indicated she clocked in at 6:00 p.m. and clocked out at 11:50 p.m. Record review of CNA A's Notice of Termination dated 5/19/23 indicated her effective date of termination was 5/15/23, The Notice of Termination indicated the reason for termination was due to CNA A quitting. The Notice of Termination indicated CNA A was eligible for rehire. During an interview on 11/15/23 at 11:55 a.m. the DON said CNA A had been involved in an altercation with Resident #1 and asked to leave the facility. The DON said the facility did a telephone interview with CNA A and the DON was going to terminate CNA A. The DON said CNA A did not return to the facility and said during the phone interview CNA A said she was tired of them. During an interview on 11/15/23 at 12:54 p.m. the DON said CNA A's alleged physical abuse towards Resident #1 was unconfirmed due to being she said, she said and the facility not being able to prove the abuse occurred. The DON said prior to CNA A's resignation the facility had planned on terminating CNA A for this incident even though they were unable to prove the allegation. The DON said it did not sit well with her and CNA A had a previous allegation of physical abuse on 12/5/22 against Resident #2. During an interview on 11/15/23 at 2:05 p.m. the DON said she sat CNA A down in her office and spoke with her after the incident on 12/5/22 with Resident #2. The DON said she did not have any documentation of a formal one-on-one in-service or counseling with CNA A due to the allegation being unconfirmed by the facility and unsubstantiated by the state agency. The DON said the allegation of abuse from 12/22/22 was unconfirmed due to the witness changing his story. During an interview on 11/15/23 at 3:11 p.m. Housekeeper CCC said he remembered the incident between CNA A and Resident #2. Housekeeper CCC said Resident #2 punched CNA A in the throat and CNA A got mad. Housekeeper CCC said CNA A and Resident #2 got into a scuffle. Housekeeper CCC said Resident #2 was bent over, and CNA A slapped Resident #2 in the back to get him off her. Housekeeper CCC said Resident #2 was bent over trying to fight with CNA A. During an interview on 11/16/23 at 9:00 a.m. the DON said CNA A denied both allegations of abuse. The DON said the witness to the first allegation changed his story on how the CNA hit Resident #2. The DON said they felt if Resident #2 had been hit as hard as what was alleged, he would have had some kind of mark on his body. Record review of the facility's Abuse policy dated October 2022 indicated, Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to facility staff, other residents, consultants or volunteers, staff of other agencies serving the residents, family members, resident representatives, friends, and other individuals. The resident(s) will be protected from any identified offender during the course of the investigation by removing the alleged perpetrator from the facility. Record review of the facility's Abuse Prevention policy dated October 2022 indicated, .The facility will identify resident whose personal histories, aggressive behaviors, dependency for daily care, and/or communication needs render them at risk for abuse and/or abusing other residents .Supervisory staff will be responsible for identifying and intervening in situations of inappropriate staff/resident behaviors .The facility will provide ongoing oversight and supervision of staff to assure policies are implemented as written to include education and periodic drills. The DON was notified on 11/15/23 at 4:40 p.m. that an Immediate Jeopardy situation was identified due to the above failure. The DON was provided the Immediate Jeopardy template on 11/15/23 at 4:50 p.m. The facility's Plan of Removal was accepted on 11/17/23 at 4:04 p.m. and included: Identification of Residents Affected or Likely to be Affected: The facility took the following actions to address the citation and prevent any additional residents from suffering an adverse outcome. In-services on Abuse have been held in facility 11/15/2023 to train on the following process. Upon an allegation of abuse, Resident will be immediately evaluated for any physical, emotional, cognitive changes or signs of injury. Resident will be interviewed. A written statement and interview will be completed by person alleging abuse. The alleged person will also be interviewed and asked to write a statement. The alleged person will be suspended and directed to immediately leave the facility and not return until asked to do so by administration. Other residents will be interviewed related to quality of care provided by alleged person. Any staff assigned to area during time of incident will be interviewed and statements obtained regarding incident. At conclusion of investigation Administrator, DON, and other designated staff will review the evidence and reach a conclusion if abuse has been substantiated. CNA A attended trainings on Abuse and Managing Resident Behaviors 12/14/2022, 1/26/2023, 3/24/2023, and 4/3/2023. CNA A was reassigned from Memory Support Unit to D Unit upon return to work 12/14/2022. D Unit was her primary assignment until suspension 5/14/2023. On 5/14/2023 she did assist with mealtime on MSU and went to D Unit at 6PM. Incident occurred on D Wing at 11:15 PM. On 12/14/2022 CNA A received the training provided to other staff, after the incident, regarding abuse and the incident was reenacted with CNA A and DON. Incident was discussed regarding any potential triggers. Due to allegation being unfounded no additional disciplinary action was warranted. CNA A was immediately suspended from the facility following allegations of abuse on 5/14/2023. CNA A called facility to state she would not be returning on 5/15/2023 during the facility allegation of abuse investigation. All staff is being trained on the de-escalation of aggressive behaviors. This training includes having no physical contact with resident. Regardless of whether it is a reflex reaction or a defensive action on the part of the staff member it is considered abuse. Staff should remove themselves from the Resident and have no contact. This training is being currently completed for all staff at the facility and will be completed by 4:30 PM on 11/17/2023. Training will be ongoing until all staff have attended. Staff will not be permitted to work unless education has been completed. DON did initial training to all administrative staff and department supervisors. Department Supervisors are subsequently training their staff. DON and designees educated all staff on facility Abuse policies, Resident Aggression including Management and Prevention. This training commenced on 11/15/2023 and continues 11/16/2023. Training will be ongoing until all staff have attended. Staff will not be permitted to work unless education has been completed. DON has been educated by Regional Nurse on 11/17/2023 that following any staff to resident incidents, staff are to receive 1:1 training and disciplinary action prior to returning to their shift should they be reinstated. Residents with a BIMS score of 10 or greater are being interviewed by facility social workers to identify if they feel safe and if they experienced abuse while living at facility. These interviews will be completed by 5:00PM 11/16/2023. RN House supervisors and LVN Unit Managers are completing physical assessments/ body audits on residents with BIMS score less than 10 to identify any injuries of unknown origin and/or evidence of abuse. These physical assessments/ body audits will be completed by 5:00 PM 11/16/2023. 0. Actions to Prevent Occurrence/Recurrence: The facility took the following actions to prevent an adverse outcome from reoccurring. 1. CNA A resigned from facility on May 15, 2023, while on suspension. 2. Allegation of Abuse/Neglect Checklist has been implemented 11/15/2023. This includes step by step tasks that are required, including any training that was done with alleged perpetrator and staff. Checklist and file will then be reviewed and signed off by administrator, DON and HR prior to closing file within five days of incident. 3. Staff is being monitored by RN House Supervisors and Unit Managers beginning 11/16/2023 for any signs of potential burnout that could lead to low tolerance. Nurse leadership have received education from Regional Nurse on 11/16/2023 on Nurse Burnout and how to prevent it. A burnout self-test was provided with this training to assist in identifying burnout. 4. Burnout can result not only from working long hours but also caring for demanding and confused residents. Staff is being educated to discuss any concerns regarding a change in their tolerance, becoming easily agitated, feeling overwhelmed with Nurse managers. This training is being currently completed for all staff at the facility and will be completed by 4:30 PM on 11/17/2023. Training will be ongoing until all staff have attended. Staff will not be permitted to work unless education has been completed. 5. Staffing coordinator will not schedule staff for multiple days without time off. The staffing coordinator was re-educated on 11/16/2023 by DON. 6. In the absence of Administrator, Abuse Coordinator is DON. Date Facility Asserts Likelihood for Serious Harm No Longer Exists: 11/17/2023. On 11/18/23 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Record review of a random sample of Safe Surveys dated 11/15/23 through 11/17/23 indicated residents felt comfortable asking staff for assistance, felt they were treated with dignity and respect, felt safe in the facility, felt comfortable telling staff about concerns, felt staff were willing to listen to their concerns and resolve them, and had not ever had staff physically harm them. Record review of a random sample of body audits dated 11/15/23 through 11/16/23 indicated residents assessed did not have an injury of unknown origin or evidence of abuse. Staff interviewed on 11/18/23 between 12:25 PM - 4:52 PM: Medical Records F Administrative Assistant G RN H LVN K Director of Human Resources ADON Housekeeper L Floor Tech M BOM Cook N Dietary Aide P Dietary Aide Q MDS Coordinator Housekeeper R Housekeeper S Housekeeper T Housekeeper V LVN W Laundry Aide X LVN Y CNA Z LVN AA RN BB LVN CC NAIT DD Social Worker EE admission Coordinator RN FF Director of Rehabilitation Assistant Maintenance Director Housekeeping Supervisor LVN GG Quality Assurance Treatment Nurse Activities Assistant CNA HH AD CNA KK CNA LL Transportation Supervisor LVN MM CNA NN LVN PP Were able to verbalize the different types of abuse, identify the abuse coordinator, and when to report abuse. They were able to verbalize different approaches at de-escalating combative or aggressive residents. They stated if they were unable to de-escalate the situation, they would make sure the resident was safe and walk away. They stated reflexively or defensively hitting a resident was still considered abuse. They were able to identify triggers that may indicate burnout, and all stated if they were feeling that way, they should report it to their immediate supervisor. During an interview with the Staffing Coordinator on 11/18/23 at 1:48 PM she was able to answer all above questions and was also in-serviced on looking at the schedule to identify potential for burnout and try not to schedule multiple days in a row. The Staffing Coordinator stated she always checks on staff and asks if they are doing okay if they exhibit signs of burnout. The Staffing Coordinator stated if they are experiences signs of burnout, she tries to look at the schedule to see what can be done. During an interview with the DON on 11/18/23 at 12:53 p.m. she was able to answer all above questions and was also in-serviced on the abuse allegation and investigation process to include assess resident/interview residents (ensure safety) - obtain statement from the alleged perpetrator and suspend them pending investigation. Notify the state agency and start an investigation. The DON said if any type of abuse was substantiated, she would terminate the employee. The DON said if it was required coming back from suspension, she would provide disciplinary action. The DON said she instructed all managers to monitor for signs of burnout and instructed all employees to notify the manager if they were experiencing burnout. The DON said reflexively or defensively hitting a resident was still considered abuse. While the IJ was removed on 11/18/23, the facility remained out of compliance at no actual harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement written policies to prevent abuse, neglect, and exploitation for 1 of 10 (Resident #1) residents reviewed for abuse. The facility failed to follow facility policy of each resident having the right to be free from abuse, corporal punishment, and involuntary seclusion by not protecting Resident #1 from physical abuse by a staff member. The facility failed to implement their policy by providing training to manage residents with behaviors that could lead to abusive behaviors. These failures resulted in an identification of an Immediate Jeopardy (IJ) on 11/15/23 at 4:25 p.m. While the IJ was removed on 11/18/23, the facility remained out of compliance at no actual harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could place the resident at risk for abuse, neglect, and injuries of unknown origin. Findings include: 1. Record review of the facility's Abuse policy dated October 2022 indicated, Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to facility staff, other residents, consultants or volunteers, staff of other agencies serving the residents, family members, resident representatives, friends, and other individuals. The resident(s) will be protected from any identified offender during the course of the investigation by removing the alleged perpetrator from the facility. Record review of the facility's Abuse Prevention policy dated October 2022 indicated, .The facility will identify resident whose personal histories, aggressive behaviors, dependency for daily care, and/or communication needs render them at risk for abuse and/or abusing other residents .Supervisory staff will be responsible for identifying and intervening in situations of inappropriate staff/resident behaviors .The facility will provide ongoing oversight and supervision of staff to assure policies are implemented as written to include education and periodic drills. Record review of the Provider Investigation Report dated 12/6/22 indicated Housekeeper CCC witnessed CNA A slap Resident #2 on the back. The Provider Investigation Report indicated Housekeeper CCC also witnessed Resident #2 hit CNA A in the throat. The Provider Investigation Report indicated CNA denied slapping Resident #1 in the back. The Provider Investigation Report indicated CNA admitted to pushing Resident #1 due to Resident #2's aggression. The Provider Investigation Report indicated CNA A was suspended pending investigation. The Provider Investigation report indicated the facility determined the event to be unfounded. Record review of a written statement dated 12/6/22 by CNA A indicated Resident #2 was pulling on the computer wires at the nurse's station. The written statement indicated CNA A tried to take the computer wires from Resident #2. The written statement indicated Resident #2 grabbed CNA A by the throat and then Resident #2 hit CNA A in the throat with his fist. The written statement indicated CNA A pushed Resident #2 to get him off her. Record review of an Investigation Statement/Interview dated 12/6/22 with Housekeeper CCC indicated on 12/5/22 Housekeeper CCC witnessed Resident #2 punch CNA A in the throat. The Investigation Statement/Interview indicated Housekeeper CCC then witnessed CNA A hit Resident #2 on the back with an open hand. The Investigation Statement/Interview indicated Resident #2 became more aggressive with CNA after CNA hit Resident #2. 2. Record review of the face sheet dated 11/22/23 indicated Resident #1 was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses including Alzheimer's, hypertension (elevated blood pressure), repeated falls, delusional disorder, and anxiety disorder. Record review of the MDS dated [DATE] indicated Resident # 1 understood others and was understood by others. The MDS indicated Resident #1 had a BIMS of 03 and was severely cognitively impaired. The MDS indicated Resident #1 required extensive assistance with bed mobility, transfers, dressing, eating, and personal hygiene. The MDS indicated Resident #1 used a wheelchair for mobility. Record review of the care plan last revised 8/18/23 indicated Resident #1 had anticipatory grief and anxiety secondary to expected decline of resident. The MDS indicated Resident #1 required hospice care. The care plan indicated Resident #1 had impaired cognitive function/dementia or impaired thought process related to Alzheimer's. Record review of the nursing progress note dated 5/14/23 at 11:45 p.m. indicated a head-to-toe assessment was completed on Resident #1 with no injuries noted. The nursing progress note indicated Resident #1 did not demonstrate any distress and had no recall of the alleged staff related event. Record review of the Provider Investigation Report dated 5/15/23 indicated on 5/14/23 at 11:20 p.m. a fellow CNA alleged that CNA A hit Resident #1 in the back of the head with an opened hand. The Provider Investigation Report indicated CNA A was witnessed pushing Resident #1 in his wheelchair aggressively down the hall. The Provider Investigation Report indicated Resident #1 swung his arm back and knocked CNA A's glasses off. The Provider Investigation Report indicated CNA was observed hitting Resident #1 in the back of the head with an open hand and then pushed him to his room. The Provider Investigation Report indicated CNA A denied the allegation and was suspended pending investigation. The Provider Investigation Report indicated on 5/15/23 CNA A notified the facility she would not be returning to work and requested her employment be terminated. The Provider Investigation Report indicated the allegation was unconfirmed due to having no other witnesses and Resident #1 was unable to recall the event. The Provider Investigation Report indicated upon conclusion of this investigation, there were no other witnesses to this event. The Provider Investigation Report indicated Resident (#1) was unable to recall the event and was noted to have no injuries. The Provider Investigation Report indicated with no collaborating evidence this allegation is unconfirmed. The Provider Investigation Report indicated the Provider Action Taken Post investigation was social services would follow for distress and staff education regarding timely reporting. The Provider Action Taken Post investigation did not indicate any other education to staff as a response to the incident. Record review of the nursing progress note dated 5/14/23 at 11:45 p.m. indicated a head-to-toe assessment was completed on Resident #1 with no injuries noted. The nursing progress note indicated Resident #1 did not demonstrate any distress and had no recall of the alleged staff related event. Record revie of the social services progress note dated 5/16/23 at 10:34 a.m. indicated the social worker went down to visit with Resident #1 regarding the staff incident. The social services progress note indicated Resident #1 did not recall the event and showed no signs of distress. Record review of CNA A's schedules indicated she had worked on the secured unit on 12/01/22, 12/05/22, 1/25/23, 3/11/23, 3/12/23, and 5/12/23. Record review of CNA A's time sheet for 5/14/23 indicated she clocked in at 6:00 p.m. and clocked out at 11:50 p.m. Record review of CNA A's Notice of Termination dated 5/19/23 indicated her effective date of termination was 5/15/23, The Notice of Termination indicated the reason for termination was due to CNA A quitting. The Notice of Termination indicated CNA A was eligible for rehire. During an interview on 11/15/23 at 11:55 a.m. the DON said CNA A had been involved in an altercation with Resident #1 and asked to leave the facility. The DON said the facility did a telephone interview with CNA A and the DON was going to terminate CNA A. The DON said CNA A did not return to the facility and said during the phone interview CNA A said she was tired of them. During an interview on 11/15/23 at 12:54 p.m. the DON said CNA A's alleged physical abuse towards Resident #1 was unconfirmed due to being she said, she said and the facility not being able to prove the abuse occurred. The DON said prior to CNA A's resignation the facility had planned on terminating CNA A for this incident because even though they were unable to prove the allegation. The DON said it did not sit well with her and CNA A had a previous allegation of physical abuse on 12/5/22 against Resident #2. During an interview on 11/15/23 at 2:05 p.m. the DON said she sat CNA A down in her office and spoke with her after the incident on 12/5/22 with Resident #2. The DON said she did not have any documentation of a formal one-on-one in-service or counseling with CNA A due to the allegation being unconfirmed by the facility and unsubstantiated by the state agency. The DON said the allegation of abuse from 12/5/22 was unconfirmed due to the witness changing his story. During an interview on 11/15/23 at 3:11 p.m. Housekeeper CCC said he remembered the incident between CNA A and Resident #2. Housekeeper CCC said Resident #2 punched CNA A in the throat and CNA A got mad. Housekeeper CCC said CNA A and Resident #2 got into a scuffle. Housekeeper CCC said Resident #2 was bent over, and CNA A slapped Resident #2 in the back to get him off of her. Housekeeper CCC said Resident #2 was bent over trying to fight with CNA A. During an interview on 11/16/23 at 9:00 a.m. the DON said CNA A denied both allegations of abuse. The DON said the witness to the first allegation changed his story on how the CNA hit Resident #2. The DON said they felt if Resident #2 had been hit as hard as what was alleged, he would have had some kind of mark on his body. The DON was notified on 11/15/23 at 4:40 p.m. that an Immediate Jeopardy situation was identified due to the above failure. The DON was provided the Immediate Jeopardy template on 11/15/23 at 4:50 p.m. The facility's Plan of Removal was accepted on 11/17/23 at 4:04 p.m. and included: Identification of Residents Affected or Likely to be Affected: The facility took the following actions to address the citation and prevent any additional residents from suffering an adverse outcome. In-services on Abuse have been held in facility 11/15/2023 to train on the following process. Upon an allegation of abuse, Resident will be immediately evaluated for any physical, emotional, cognitive changes or signs of injury. Resident will be interviewed. A written statement and interview will be completed by person alleging abuse. The alleged person will also be interviewed and asked to write a statement. The alleged person will be suspended and directed to immediately leave the facility and not return until asked to do so by administration. Other residents will be interviewed related to quality of care provided by alleged person. Any staff assigned to area during time of incident will be interviewed and statements obtained regarding incident. At conclusion of investigation Administrator, DON, and other designated staff will review the evidence and reach a conclusion if abuse has been substantiated. CNA A attended trainings on Abuse and Managing Resident Behaviors 12/14/2022, 1/26/2023, 3/24/2023, and 4/3/2023. CNA A was reassigned from Memory Support Unit to D Unit upon return to work 12/14/2022. D Unit was her primary assignment until suspension 5/14/2023. On 5/14/2023 she did assist with mealtime on MSU and went to D Unit at 6PM. Incident occurred on D Wing at 11:15 PM. On 12/14/2022 CNA A received the training provided to other staff, after the incident, regarding abuse and the incident was reenacted with C. N. A. A and DON. Incident was discussed regarding any potential triggers. Due to allegation being unfounded no additional disciplinary action was warranted. CNA A was immediately suspended from the facility following allegations of abuse on 5/14/2023. CNA A called facility to state she would not be returning on 5/15/2023 during the facility allegation of abuse investigation. All staff is being trained on the de-escalation of aggressive behaviors. This training includes having no physical contact with resident. Regardless of whether it is a reflex reaction or a defensive action on the part of the staff member it is considered abuse. Staff should remove themselves from the Resident and have no contact. This training is being currently completed for all staff at the facility and will be completed by 4:30 PM on 11/17/2023. Training will be ongoing until all staff have attended. Staff will not be permitted to work unless education has been completed. DON did initial training to all administrative staff and department supervisors on 11/17/2023. Department Supervisors are subsequently training their staff. DON and designees educated all staff on facility Abuse policies, Resident Aggression including Management and Prevention. This training commenced on 11/15/2023 and continues 11/16/2023. Training will be ongoing until all staff have attended. Staff will not be permitted to work unless education has been completed. DON has been educated by Regional Nurse on 11/17/2023 that following any staff to resident incidents, staff are to receive 1:1 training and disciplinary action prior to returning to their shift should they be reinstated. Residents with a BIMS score of 10 or greater are being interviewed by facility social workers to identify if they feel safe and if they experienced abuse while living at facility. These interviews will be completed by 5:00PM 11/16/2023. RN House supervisors and LVN Unit Managers are completing physical assessments/ body audits on residents with BIMS score less than 10 to identify any injuries of unknown origin and/or evidence of abuse. These physical assessments/ body audits will be completed by 5:00 PM 11/16/2023. 0. Actions to Prevent Occurrence/Recurrence: The facility took the following actions to prevent an adverse outcome from reoccurring. 1. CNA A resigned from facility on May 15, 2023, while on suspension. 2. Allegation of Abuse/Neglect Checklist has been implemented 11/15/2023. This includes step by step tasks that are required, including any training that was done with alleged perpetrator and staff. Checklist and file will then be reviewed and signed off by administrator, DON and HR prior to closing file within five days of incident. 3. Staff is being monitored by RN House Supervisors and Unit Managers beginning 11/16/2023 for any signs of potential burnout that could lead to low tolerance. Nurse leadership have received education from Regional Nurse on 11/16/2023 on Nurse Burnout and how to prevent it. A burnout self-test was provided with this training to assist in identifying burnout. 4. Burnout can result not only from working long hours but also caring for demanding and confused residents. Staff is being educated to discuss any concerns regarding a change in their tolerance, becoming easily agitated, feeling overwhelmed with Nurse managers. This training is being currently completed for all staff at the facility and will be completed by 4:30 PM on 11/17/2023. Training will be ongoing until all staff have attended. Staff will not be permitted to work unless education has been completed. 5. Staffing coordinator will not schedule staff for multiple days without time off. The staffing coordinator was re-educated on 11/16/2023 by DON. 6. In the absence of Administrator, Abuse Coordinator is DON. Date Facility Asserts Likelihood for Serious Harm No Longer Exists: 11/17/2023. On 11/18/23 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Record review of a random sample of Safe Surveys dated 11/15/23 through 11/17/23 indicated residents felt comfortable asking staff for assistance, felt they were treated with dignity and respect, felt safe in the facility, felt comfortable telling staff about concerns, felt staff were willing to listen to their concerns and resolve them, and had not ever had staff physically harm them. Record review of a random sample of body audits dated 11/15/23 through 11/16/23 indicated residents assessed did not have an injury of unknown origin or evidence of abuse. Staff interviewed on 11/18/23 between 12:25 PM - 4:52: Medical Records F Administrative Assistant G RN H LVN K Director of Human Resources ADON Housekeeper L Floor Tech M BOM Cook N Dietary Aide P Dietary Aide Q MDS Coordinator Housekeeper R Housekeeper S Housekeeper T Housekeeper V LVN W Laundry Aide X LVN Y CNA Z LVN AA RN BB LVN CC NAIT DD Social Worker EE admission Coordinator RN FF Director of Rehab Assistant Maintenance Director Housekeeping Supervisor LVN GG Quality Assurance Treatment Nurse Activities Assistant CNA HH AD CNA KK CNA LL Transportation Supervisor LVN MM CNA NN LVN PP Were able to verbalize the different types of abuse, identify the abuse coordinator, and when to report abuse. There were able to verbalize different approaches at de-escalating combative or aggressive residents. They stated if they were unable to de-escalate the situation, they would make sure the resident was safe and walk away. They stated reflexively or defensively hitting a resident was still considered abuse. They were able to identify triggers that may indicate burnout, and all stated if they were feeling that way, they should report it to their immediate supervisor. During an interview with the Staffing Coordinator on 11/18/23 at 1:48 PM she was able to answer all above questions and was also in-serviced on looking at the schedule to identify potential for burnout and try not to schedule multiple days in a row. The Staffing Coordinator stated she always checks on staff and asks if they are doing okay if they exhibit signs of burnout. The Staffing Coordinator stated if they are experiences signs of burnout, she tries to look at the schedule to see what can be done. During an interview with the DON on 11/18/23 at 12:53 p.m. she was able to answer all above questions and was also in-serviced on the abuse allegation and investigation process to include assess resident/interview residents (ensure safety) - obtain statement from the alleged perpetrator and suspend them pending investigation. Notify the state agency and start an investigation. The DON said if any type of abuse was substantiated, she would terminate the employee. The DON said if it was required coming back from suspension, she would provide disciplinary action. The DON said she instructed all managers to monitor for signs of burnout and instructed all employees to notify the manager if there were experiencing burnout. The DON said reflexively or defensively hitting a resident was still considered abuse. While the IJ was removed on 11/18/23, the facility remained out of compliance at no actual harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.