**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the resident environment remains as free of accident hazards as is possible and each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 2 residents (Resident #1) reviewed for supervision to prevent elopement. RN A failed to ensure Resident #1's wander guard (a device designed to prevent wandering in the elderly) was functioning as required. The facility was unaware that on [DATE], Resident #1 eloped from the facility with a wander guard sometime after 8:15 p.m. (approximately) and was found on the ground at an apartment complex adjacent to the facility by EMS at approximately 10:30 p.m. Resident #1 was returned to the facility by EMS on [DATE] at approximately 10:45 p.m. An IJ was identified on [DATE] at 1:45 p.m. While the IJ was removed on [DATE] at 1:30 p.m., the facility remained out of compliance at a scope of isolated with the potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of not being properly supervised resulting in serious injury or death. Findings included: Record review of Resident #1's face sheet dated [DATE] indicated she was an [AGE] year old female, admitted on [DATE], and her diagnoses included unspecified psychosis (indicates the presence of psychotic symptoms that don't perfectly align with a specific diagnosis), lack of coordination (a condition characterized by difficulty in performing physical movements smoothly and accurately), vascular dementia (problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to the brain), and paranoid schizophrenia (mind doesn't agree with reality). Record review of quarterly MDS assessment dated [DATE] indicated she was usually able to make herself understood, usually understood others, had severe cognitive impairment (BIMS-3). Wandering was not indicated. Record review of Resident #1's care plan dated [DATE] indicated she was an elopement risk and wander guard was placed on [DATE]. Interventions included distract Resident #1 from wandering and identify pattern of wandering. Record review of Resident #1's care plan dated [DATE] indicated she was an elopement risk, the wander guard was removed. Interventions indicated Resident #1 was placed on the secure unit due to poor safety awareness and wander risk. Record review of Resident #1's physician orders dated [DATE] indicated may have wander guard due to poor cognition and poor redirection. Record review of Resident #1's physician orders dated [DATE] indicated monitor placement for function wander guard QD and pm every shift. Record review of Resident #1's physician orders dated [DATE] indicated monitor placement of wander guard bracelet at left wrist every shift. Record review of Resident #1's Elopement Risk assessment dated [DATE] indicated a score of 11 (high risk). Record review of Resident #1's Elopement Risk assessment dated [DATE] indicated a score of 17 (high risk). Record review of Nursing Progress note dated [DATE] at 2:39 a.m., completed by RN A indicated on [DATE] at 10:45 p.m. EMT F with (named service) arrived at facility and approached RN A asking, Do you have a resident named (Resident #1)? RN A confirmed this. EMT F said, Well she fell at the apartment complex across the street; a resident of the apartments saw her fall and called 911. She's on my truck right now. She told us she stays here, and that she walked out the back door. Her only complaint is that she says she got bitten by ants on one of her hands. Do you want me to transport her, and if so, to which facility? RN A asked him, Does she have ant bites on her hand? He replied, I didn't see anything, but my partner is assessing her on the truck now. RN A printed up the Resident #1's face sheet and order summary for the EMS crew and a copy for the ER staff and asked him to transport her to (named hospital) for evaluation. RN A contacted the Administrator and DON by 10:58 p.m. Made facility-wide head count = 41. At 11:51 p.m. left detailed VM with RP. At 12:56 a.m., RN A received phoned report from (named hospital RN) and CT scans were negative, fractures were ruled out, and no injuries had been noted. At 1:57 a.m., Resident #1 returned to facility via EMS. At 2:12 a.m. RN A contacted NP. Received orders as follow: Maintain Q 15 monitoring and consider admission to The Secure Unit. RN A did not address Resident #1's wander guard placement or functionality. Record review of the facility investigation dated [DATE] and completed by the Administrator, indicated the facility became aware of Resident #1 missing from the facility at 10:45 p.m. on [DATE] after she was returned to the facility by EMS. She was transported to the hospital by EMS for evaluation and treatment. The facility initiated a head count for all residents, obtained a list of all residents with wander guards, wander guards were checked for expiration dates. Resident #1 returned to the facility and had no injuries. Resident #1 was placed on 15 minute checks upon return from the ER. Resident #1's wander guard was working upon return from the hospital but it was replaced while facility obtained orders and permission from family to transfer resident number one to the secure unit. All doors and alarms were assessed and found to be in working order. The facility confirmed Resident #1 as a Missing Resident. The investigation does not include investigation of the completion or verification of wander guard placement or checks. Record review of RN A's undated statement indicated On the 6 pm to 6 am shift of [DATE] CNA B was assigned to a hall at the facility I was the charge nurse assigned to the A hall and to 1/2 of the B hall from 6 pm to 10:45 pm this night while performing my own tasks on a hall and during what time I worked at the nurses station I did observe CNA B make several trips down a hall including completing her 6 pm, 8 pm, and 10 pm rounds, as well as answering call lights. In fact she only very recently had returned from A hall to the vicinity of the nurses' station when the EMT entered the facility to inquire as to the residency of Resident #1. The statement does not include information related to Resident #1's location or to the wander guard checks for placement or functionality. Record review of CNA B's statement dated [DATE] indicated At approximately 6:00 p.m. on [DATE]nd 2025, I (CNA B) made my round checking and changing all residents. Resident #1 appeared to be sitting up in her bed watching TV. At approximately 8:15 p.m. I began my next round checking/changing and getting other residents bathed. I completed this round at approximately 10:30 (p.m.) and returned to the desk to fill out shower sheet and fill the cooler with ice to pass during my next round. Then at 10:45 p.m. EMT came into the facility stating Resident #1 made her way the apartments across the street and fallen with no apparent injuries. No alarms of any of the doors had sounded off at any point . The statement does not include information of Resident #1's location after 6:00 p.m. rounds. Record review of the facility weekly door alarm check and wander guard alarm dated [DATE] indicated all alarms were in working condition. During an interview on [DATE] at 11:21 a.m., the Administrator said Resident #1 had a wander guard on due to her risk for elopement. She said the doors alarms were checked that night on [DATE] and the next day on [DATE] and were in working condition. She said she was informed Resident #1's wander guard was also in working condition. She said Resident #1's wander guard was discontinued, and she was placed on the secure unit effective [DATE]. She said staff were retrained from [DATE] though [DATE] on elopement risk, elopement protocols, abuse and neglect, and resident rights after Resident #1 eloped from the facility. She said the facility also ran elopement drills. She said the facility began locking the entrance and exit doors at certain times to keep the resident safe. She said the facility did not determine how Resident #1 eloped with no notice. She said it appeared Resident #1 left out the door adjacent to kitchen (back door) and walked over to the apartment complex across the street. She said Resident #1 tripped and someone saw Resident #1 trip and called 911. She said Resident #1 was placed on 1-1 until she was moved to the secure unit on [DATE]. During an observation and interview on [DATE] at 12:45 p.m., Resident #1 was laying in bed watching TV on the secure unit. She said she was fine and had no complaints. She said she did not remember leaving the facility or falling on the ground. She said she did not remember going to the hospital. She appeared calm and displayed no signs of agitation or anxiety. During an interview on [DATE] at 9:55 a.m., the DON said the wander guard scanners were locked in her office and not available for staff to use after 6:00 p.m. She said to check for wander guard functionality, the staff would assist residents to the doors with wander guard alarms to assess the functionality. She said nursing staff were expected to check the wander guards for functionality and placement. The DON said the facility exit doors were locked from 8:00 p.m. through 5:00 a.m. after Resident #1 eloped. She said the facility did not have a policy to address wander guards, placement, functionality or testing prior to the incident on [DATE]. During an interview on [DATE] at 10:00 a.m. the Administrator said Resident #2 was currently the only resident in the facility with a wander guard. She said he was not available because he was discharged to the hospital. She said Resident #2's wander guard was found to be expired and was replaced after Resident #1 eloped. She said the facility was not able to determine how Resident #1 eloped. She said wander guard checks were supposed to be completed every shift. She said it was her understanding the wander guard was working when Resident #1 returned from the hospital on [DATE]. During an observation on [DATE] from 10:15 a.m. through 10:30 a.m., conducted with the facility Administrator and Maintenance Director indicated all door alarms and wander guard alarms were in working condition. During an interview on [DATE] at 10:15 a.m., the Maintenance Director said prior to the incident on [DATE], the door alarms and wander guard door alarms were checked weekly for functionality. He said 3 doors of 6 doors had exit alarms and the other 3 doors had wander guard alarms. He said the doors with exit alarms have a code that was used to turn off the alarm. He said the front door, the dining room door and the back door had wander guard alarms. He said he did not check residents' wander guards for placement or functionality. During an interview on [DATE] at 10:49 a.m., RN A said he was the nurse assigned to Resident #1 on [DATE]. He said he did not see Resident #1 leave the facility. He said he did not hear any door alarms. He said he was on this assigned halls completing his duties. He said he was aware Resident #1 was in her room at the end of the hall. He said it was determined within 14 hours of Resident #1 leaving the facility that her wander guard battery wasn't working. He said he did not check for wander guard functionality. He said he was not going to come on his shift at 6:00 p.m. and get Resident #1 up from her bed to walk to a door with the wander guard alarm to check the battery. He said he did not know of a scanning device to check the wander guard batter for functionality. He said he marked off on the MAR that he checked Resident #1's wander guard for placement and functionality but he did not compete the task per physician orders. He said he was aware the maintenance staff checked the door alarms weekly. He said he was pretty sure Resident #1 left the facility through the back door adjacent to the facility kitchen while staff were busy with tasks because no heard the wander guard alarm go off. During an interview on [DATE] at 12:28 p.m., LVN C said she would take Resident #1 to the door on the hall closest to her room and open the door and the alarm would go off. She said she would turn the alarm off with a code. She said she was not aware the door adjacent to Resident #1's room did not have a wander guard alarm. She said she worked form 6:00 p.m. until 6:00 a.m. and did not have access to the scanner to check wander guards for functionality. During an interview on [DATE] at 6:00 p.m., CNA B said she finished her fist rounds at approximately 8:15 p.m. on [DATE] and Resident #1 was in bed watching TV. She said she finished her second rounds at approximately 10:30 p.m. She could not recall the last time she saw Resident #1. She said she was completing shower sheet documentation and getting ice ready for the next rounds when EMS arrived at the facility at approximately 10:45 p.m. There was no alarm sounds when Resident #1 left the building and there was no alarms sounding when Resident #1 returned to the facility. She said Resident #2 also had a wander guard. She said Resident #2 was woken up and taken to a door with a wander guard alarm and his wander guard was not working because the alarm did not go off. Record review of the facility's policy Safety and Supervision of Residents dated 2001 (revised [DATE]) indicated Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Individualized, Resident-Centered Approach to Safety 1. Our individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents. 2. Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment. Resident Risks and Environmental Hazards1. Due to their complexity and scope. certain resident risk factors and environmental hazards are addressed in dedicated policies and procedures. These risk factors and environmental hazards include: a. Bed Safety: b. Safe Lifting and Movement of Residents: c. Falls; d. Smoking; e. Unsafe Wandering; . Record review of the facility's Wandering and Elopements policy dated 2001 (revised [DATE]) indicated The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. An Immediate Jeopardy/Immediate Threat was identified on [DATE] at 1:45 p.m. The Administrator and the DON were notified of the Immediate Jeopardy and provided the IJ template on [DATE] at 2:00 p.m. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The facility's Plan of Removal for the Immediate Jeopardy was accepted on [DATE] at 10:24 a.m. and reflected the following: On [DATE] (named facility) completed an Elopement Risk Assessment on every resident in the facility, audit was completed by ADON. Results were reviewed and actions taken per directions below. Resident #1 was taken by EMS to the emergency room ER for evaluation and care. Resident # 1 was cleared regarding significant injuries and was placed on the secured unit on [DATE]. Resident #1 physician was notified upon transfer to the ER and upon return to the facility for orders. To remedy concerns regarding resident elopement at (named facility), the facility implemented the following changes: 1. [DATE]-Wander guards will not be utilized at (named facility) in response to this identified immediate jeopardy situation. Any resident that meets the criteria for elopement risk were placed on the secured unit. Any resident admitted or readmitted to (named facility)that meets the elopement criteria will NOT be admitted outside of the secured unit. Residents are screened on admissions/readmission and with change of condition via the elopement risk assessment to determine elopement risk and placement on the secured unit if deemed an elopement risk. 2. In-services were started on: [DATE] Wandering & Elopement by DON for all staff to include focus areas that are *What to do if you see a Resident trying to leave the facility, *What to do if a resident is missing, and *What to do if a resident is returned to the facilityXXX[DATE] Abuse & Neglect by DON for all staff to include focus areas that are *Definitions of abuse, *Assessment and Recognition of Abuse, *Cause and Identification of Abuse, *Treatment and Management, and *Monitoring/Follow up. [DATE] Emergency Procedure/Missing Resident by DON for all staff to include focus areas that are *Policy interpretation and implementation, *Emergency procedure-missing resident, *Emergency job tasks-missing resident[DATE] Elopement Policy Interpretation & Implementation by DON for all staff to include the focus area of *Elopement policy to be followed in the event of an Elopement or Elopement attempts. [DATE] Changes of Condition policy and procedure by DON for all licensed nursing staff regarding recognizing changes in condition with a special focus on exit seeking behavior changes and monitoring and follow up actions to take with physician notification. A post test will be completed with licensed nursing staff regarding recognizing changes in behavior that present an elopement risk. [DATE] Safety and Supervision of Residents policy and procedure in-service was initiated by the DON and ADON with all clinical staff. The focus of this policy will be on resident safety and supervision with emphasis on page 2 letter g-unsafe wandering with notation of nursing staff rounding every 2 hours for resident supervision. 3. An elopement drill was initiated on [DATE] by the administrator with continuation across all shifts until [DATE].4. The identified RN A is suspended at this time pending investigation results. Facility will print out an employee roster to ensure every employee is educated and will not work until in-services are completed. Agency staff-if utilized will also be educated on the in-services as set forth above prior to working by the department head or designee. The facility medical director was made aware on [DATE] for QAPI purposes and on [DATE] at 2:45 pm regarding facility action plan review. This plan was implemented on [DATE] in response to the immediate jeopardy called and will be monitored through personal observation by the administrator with verbal reports to the regional director of operations on a weekly basis. All above items will be completed before [DATE] at 3pm. Any staff that are scheduled for oncoming shifts post that date will be in-serviced prior shift acceptance. Monitoring of the Plan of Removal included the following: Record review of all residents' Elopement Risk Assessments completed on [DATE] indicated Resident #1 was placed on the secure unit. A second resident was provided a new wander guard (resident was discharged to hospital and was not present during the investigation). Record review of Resident #1's clinical record indicated she was taken by EMS to the emergency room on [DATE] for evaluation and care. Resident # 1 was cleared regarding significant injuries and was placed on the secured unit on [DATE]. Resident #1's physician was notified upon transfer to the ER and upon return to the facility for orders. Record review of the facility's IJ interventions indicated effective as of [DATE] the facility discontinued the use of wander guards. There were no residents with wander guards as of [DATE]. Record review of facility in-services conducted by the DON included:[DATE] Wandering & Elopement by DON for all staff-*What to do if you see a Resident trying to leave the facility, *What to do if a resident is missing, and *What to do if a resident is returned to the facility.There were no concerns noted. [DATE] Abuse & Neglect by DON for all staff-*Definitions of abuse, *Assessment and Recognition of Abuse, *Cause and Identification of Abuse, *Treatment and Management, and *Monitoring/Follow up. There were no concerns noted. [DATE] Emergency Procedure/Missing Resident by DON for all staff-*Policy interpretation and implementation, *Emergency procedure-missing resident, *Emergency job tasks-missing resident. There were no concerns noted. [DATE] Elopement Policy Interpretation & Implementation by DON for all staff -*Elopement policy to be followed in the event of an Elopement or Elopement attempts. There were no concerns noted. [DATE] Changes of Condition policy and procedure by DON for all licensed nursing staff regarding recognizing changes in condition with a special focus on exit seeking behavior changes and monitoring and follow up actions to take with physician notification. A posttest was completed with licensed nursing staff regarding recognizing changes in behavior that present an elopement risk. All tested nursing staff received passing scores. There were no concerns noted. [DATE] Safety and Supervision of Residents policy and procedure in-service by the DON and ADON with all clinical staff. The focus of this policy included resident safety and supervision with emphasis on page 2 letter g-unsafe wandering with notation of nursing staff rounding every 2 hours for resident supervision. There were no concerns noted. Record review of an elopement drill initiated on [DATE] though [DATE] by the Administrator for all shifts indicated all staff followed the facility procedures and protocols as required. There were no concerns noted.4. Record review of RN A's personnel record indicated RN A was suspended as of [DATE] pending facility investigation of his failure to check Resident #1's wander guard placement and functionality on [DATE] and his alleged fraudulent documentation he completed the tasks per the MAR on [DATE].Interviews conducted on [DATE] from 10:30 a.m. through 1:25 p.m. indicated the Administrator, DON, ADON, Activities Director, BOM, LVN E, MDS LVN G, CNA H, CNA I, LVN J, CNA/MA K, CNA L, CNA M, HSK N, HSK O, CNA P, and CNA Q), who represented all shifts on all days of the week (6:00 a.m.-6:00 p.m., 6:00 p.m.-6:00 a.m., 7:00 a.m.-1:00 p.m., and 1:00 p.m. - 5:30 p.m.) indicated they were retrained and aware of the facility's policy and protocols for Wandering and Elopement, Abuse/Neglect Prevention and Reporting, Emergency Procedures/Missing Resident, Elopement Policy and Interpretation, and Safety and Supervision of Residents. All staff were able to give examples elopement risk and interventions, elopement policy and protocols, who to call when a resident is discovered missing and were able to identify wandering and exit seeking behaviors in residents. They were able to verbalize the appropriate interventions with residents who were elopement risk and to monitor all exits to ensure they were in good working order. Staff were aware all facility entrance and exit doors would be locked from 8:00 p.m. through 5:00 a.m. for resident safety. Nursing staff was aware resident census would be confirmed at the beginning and end of each shift. During an interview on [DATE] at 11:15 a.m., the DON said she, the ADON, and the Administrator would monitor risk assessments weekly. She confirmed all facility entrance and exit doors would be locked from 8:00 p.m. through 5:00 a.m. for resident safety. She said resident census would be confirmed at the beginning and end of each shift. During an interview on [DATE] at 11:25 a.m., the ADON said she, the DON, and the Administrator will monitor risk assessments weekly. She said resident census would be confirmed at the beginning and end of each shift. During an interview on [DATE] at 11:30 a.m., the Administrator said she would be monitoring all risk assessments weekly to ensure residents were appropriately placed. She confirmed the facility no longer utilized wander guards to prevent eloping and all residents assessed at risk of eloping would be placed on the secure unit. An Immediate Jeopardy (IJ) was identified on [DATE] at 1:45 p.m. The IJ template was provided to the facility on [DATE] at 2:00 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents were free from abuse for 1 of 5 residents (Resident #1) reviewed for abuse. The facility failed to prevent Resident #1 from grabbing, hitting and slapping Resident #2 on 11/03/23 . The noncompliance was identified as PNC. The immediate jeopardy (IJ) began on 11/03/23 and ended on 11/08/23. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of physical harm, mental anguish, emotional distress, or death. Findings included: Record review of Resident #1's face sheet indicated she was a [AGE] year old female admitted on [DATE] and her diagnoses included Alzheimer's (a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) with behavioral disturbance, psychotic disorder (serious illness that affect the mind) with delusions (a belief that is clearly false and that indicates an abnormality in the affected person's content of thought), and anxiety (a feeling of fear, dread, and uneasiness). Record review of Resident #1's MDS dated [DATE] indicated she was usually able to make herself understood and usually understood others. She had severe cognitive impairment (BIMS score of 3). She had physical behaviors directed at others. Record review of Resident #1's care plan dated 07/12/23 (revised 08/29/23) indicated Resident #1 has attempted and hit other residents. Interventions included assess and anticipate Resident #1's needs. Record review of Resident #2's face sheet indicated she was an [AGE] year old female, admitted on [DATE], and her diagnoses included Alzheimer's, schizoaffective disorder (a mental illness that can affect your thoughts, mood and behavior) depressive type, and cognitive communication deficit (difficulty with thinking and how someone uses language). Record review of Resident #2's MDS dated [DATE] indicated she was usually understood and sometimes understands others. She had severe cognitive impairment (BIMS score of 5). She had hallucinations and delusions. There were no behaviors directed at others. Record review of progress note dated 10/31/23 at 1:50 p.m., completed by LVN E (MDS) indicated Resident #1 was on secure unit. She was hitting, slapping, and pinching staff. LVN E spoke with staff at behavior hospital who said Resident #1 was at base line of needing one on one care with aggressive behaviors. The physician was notified and waiting for orders. Record review of a progress noted dated 11/03/23 at 7:29 p.m., completed by LVN A indicated Resident #1 attempted to pull walker away from Resident #2. Resident #1 hit Resident #2 on the top of her left hand, on her left wrist, and on the left side of her face. Resident #1 separated from Resident #2 and monitored one on one. Record review of a progress note dated 11/03/23 at 11:45 p.m., completed by LVN B indicated Resident #1's family member was notified of Resident #1's behaviors. Resident #1 was transported by the facility and discharged home at approximately 11:30 p.m. Record review of Resident #1's incident report dated 11/03/23 at 11:00 p.m. , completed by LVN A indicated Resident #1 attempted to pull Resident #2's walker away from her. When Resident #1 was not able to pull the walker away from Resident #2, Resident #1 hit Resident #2 on the top of her left hand, on her left wrist, and on the left side of her face. CNA C walked into the dining room while Resident #1 and Resident #2 were standing close together with arms locked. CNA C separated Resident #1 and Resident #2. Resident #2 hit CNA C. Residents #1 and Resident #2 were separated. Resident #1 placed on one to one monitoring. The DON, Administrator, RP, and MD were notified. Hospice was notified. There were no observed injuries. Record review of Resident #2's incident report dated 11/11/23 at 11:00 p.m., completed by LVN A indicated Resident #2 was hit on her left hand, left wrist, and left side of her face. Resident #2 said, She hit me. Did you see her? Resident #2 was grabbed on her left wrist by Resident #1. Unable to determine how hard Resident #2 was grabbed. Resident #1 had both hands wrapped around Resident #1's wrist and was twisting Resident #2's hands back and forth while grabbing Resident #1's left wrist. Resident #1 and Resident #2 were separated. Resident #2 denied any pain. No distress noted. No bruising, [NAME], discoloration, or anything abnormal noted to Resident #2's left hand, wrist or face. No signs of pain noted upon passive ROM to LUE. Physician, DON, Administrator, and guardian notified. Record review of CNA C's statement dated 11/08/23 indicated she was returning to the dayroom of the secure unit when she saw Resident #1 gripping Resident #2's arm. CNA C intervened and pried Resident #1's hand off of Resident #2. Resident #2 proceeded to attack CNA C. One on One was implemented on the other side of the day room. CNA C reported the incident to the charge nurse immediately. The surveyor requested to observe the video of the incident on 11/03/23. The facility was not able to provide access to the video because the system did not retain a copy. During an interview on 11/11/23 at 9:35 a.m., the Administrator said she was the abuse coordinator. She said Resident #1 resided on the secure unit. She said Resident #1 had a history of aggression towards staff and residents. She said the other residents were afraid of Resident #1. She said there were two CNAs on the secure unit when the incident occurred. She said staff were supposed to supervise and monitor Resident #1 but left her alone to provide care for another resident. Staff should have called for the nurse to provide the supervision when they were not able to supervise Resident #1. She said all staff were at risk of abuse from Resident #1 when there was no supervision. She said after the incident with Resident #1 on 11/03/23, the facility held a QAPI on 11/08/23 and developed PIPs related to preventing, identifying, and reporting resident abuse and neglect, physician orders, resident to resident altercations, resident rights, and dealing with residents with aggressive behaviors. She said the facility started retraining nursing staff on 11/03/23. She said all nursing staff were retrained on preventing, identifying, and reporting resident abuse and neglect, physician orders, resident to resident altercations, resident rights, and dealing with residents with aggressive behaviors. She said all new staff and any staff not trained were trained by the DON or ADON prior to working their scheduled shift. She said there were no other residents in the facility who were abusive to other residents. She said she (the Administrator) and the DON were responsible to ensure all staff were trained and to monitor to ensure compliance with the QAPI plan/PIP. During observation and interview on 11/11/23 at 10:25 a.m., Resident #2 sat at a dining table watching TV with other residents. When asked if she remembered anyone grabbing her walker or hurting her she smiled and replied with unintelligible words. There was no signs of anxiety or distress. During an interview on 11/11/23 at 11:57 a.m., LVN A said CNA C came off the secure unit and reported Resident #1 hit Resident #2. She said she went on to the secure unit and Resident #1 and Resident #2 were separated. She assessed Resident #1 and Resident #2 and there was no injuries. She said she reviewed the video and noted Resident #2 was hit on her left hand, left wrist, and left side of her face. Resident #2 was grabbed on her left wrist by Resident #1. She said she was not able to determine how hard Resident #2 was grabbed. Resident #1 had both hands wrapped around Resident #1's wrist and was twisting Resident #2's hands back and forth while grabbing Resident #1's left wrist. Resident #1 and Resident #2 were separated. She said there was no assigned 1 to 1 staff on the secure unit. She said the staff should have called for help when they were providing care to any resident that required two staff. She said all residents were at risk of abuse from Resident #1 when there was no supervision. She said she was retrained on preventing, identifying, and reporting resident abuse and neglect, physician orders, resident to resident altercations, resident rights, and dealing with residents with aggressive behaviors During an interview on 11/11/23 at 12:56 p.m., LVN E said she was the MDS nurse. She said she admitted Resident #1 back to the facility from a behavior hospital on [DATE]. She said Resident #1 was combative with the transport driver. She said she did not want to readmit her to the facility and wanted to send her back to the behavior hospital. She said Resident #1 was sent back to the facility without report. She said the transport driver directed her to call the behavior hospital. She said the behavior hospital said Resident #1's combative and aggressive behavior was her baseline and if she required 1-1 staff then that is what the facility would have to implement. She said she argued with the behavior hospital and said it was not appropriate to send Resident #1 back to the facility. She said she called the NP and was told to send Resident #1 back to the behavior hospital but she could not because it was across state lines. She said she did not assign 1 to 1 staff. She said she did not get a physician order for one to one staff and was waiting for an order. She said other residents were at risk of abuse from Resident #1 if there was not adequate supervision. She said she was retrained on preventing, identifying, and reporting resident abuse and neglect, physician orders, resident to resident altercations, resident rights, and dealing with residents with aggressive behaviors. During an interview on 11/11/23 at 1:15 p.m., the RDO said after the incident with Resident #1 on 11/03/23, the facility held a QAPI on 11/08/23 and developed PIPs related to preventing, identifying, and reporting resident abuse and neglect, physician orders, resident to resident altercations, resident rights, and dealing with residents with aggressive behaviors. He said the facility started retraining nursing staff on 11/03/23. He said all nursing staff were retrained on preventing, identifying, and reporting resident abuse and neglect, physician orders, resident to resident altercations, resident rights, and dealing with residents with aggressive behaviors. He said all new staff and any staff not trained would be trained by the DON or ADON prior to working their scheduled shift. He said there were no other residents in the facility who were abusive to other residents. During an interview on 11/11/23 at 2:55 p.m., the ADON said Resident #1 was re-admitted to the facility from a behavior hospital. She said Resident #1 was more combative with care and not usually aggressive towards other residents. She said Resident #1 should have been placed on 1-1 when she returned. She said all residents were supposed to be protected from abuse. She said after the incident with Resident #1 on 11/03/23, the facility held a QAPI on 11/08/23 and developed PIPs related to preventing, identifying, and reporting resident abuse and neglect, physician orders, resident to resident altercations, resident rights, and dealing with residents with aggressive behaviors. She said the facility started retraining nursing staff on 11/03/23. She said all staff were retrained on preventing, identifying, and reporting resident abuse and neglect, physician orders, resident to resident altercations, resident rights, and dealing with residents with aggressive behaviors. She said all new staff and any staff not trained would trained by the DON or ADON prior to working their scheduled shift. She said there were no other residents in the facility who were abusive to other residents. During an interview on 11/11/23 at 3:11 p.m. the DON said when Resident #1 was re-admitted to the facility from the behavior hospital on [DATE], the facility should have implemented one to one. She said after the incident with Resident #1 on 11/03/23, the facility held a QAPI on 11/08/23 and developed PIPs related to preventing, identifying, and reporting resident abuse and neglect, physician orders, resident to resident altercations, resident rights, and dealing with residents with aggressive behaviors. She said the facility started retraining nursing staff on 11/03/23. She said all staff were retrained on preventing, identifying, and reporting resident abuse and neglect, physician orders, resident to resident altercations, resident rights, and dealing with residents with aggressive behaviors. She said she (the DON) and the Administrator were responsible to ensure all staff were trained and to monitor to ensure compliance with the QAPI plan/PIP. She said all new staff and any staff not trained would be trained by the DON or ADON prior to working their scheduled shift. She said there were no other residents in the facility who were abusive to other residents. During an interview on 11/14/23 at 2:12 p.m., LVN D said Resident #1 was re-admitted to the facility from a behavior hospital. She said Resident #1 was very combative. She said after CNA C reported Resident #1 hit Resident #2, she went on the secure unit and saw the aides had separated the residents. She said she viewed the incident on the video and saw Resident #2 was hit on her left hand, left wrist, and left side of her face. Resident #2 was grabbed on her left wrist by Resident #1. Unable to determine how hard Resident #2 was grabbed. Resident #1 had both hands wrapped around Resident #1's wrist and was twisting Resident #2's hands back and forth while grabbing Resident #1's left wrist. Resident #1 and Resident #2 were separated. She said she notified the Administrator, the DON, the physician and Resident #1's family member. She said the residents were assessed and had no injuries. She said she was retrained on preventing, identifying, and reporting resident abuse and neglect, physician orders, resident to resident altercations, resident rights, and dealing with residents with aggressive behaviors. Record review of facility policy Preventing Resident Abuse dated 2001 indicated 1. The facility's goal is to achieve and maintain an abuse-free environment. 2. Our abuse prevention/intervention program includes but is not limited to, the following: . g. Training staff to understand and manage a resident's verbal or physical aggression; . j. Assessing, care planning and monitoring residents with needs and behaviors that may lead to conflict or neglect; k. Assessing residents with signs and symptoms of behavior problems and developing and implementing care plans to address behavioral issues; . striving to maintain adequate staffing on all shifts to ensure that needs of each resident are met; . Record review of the facility's Abuse, Neglect, Exploitation and Misappropriation Prevention Program dated 2001 indicated Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This included but is not limited to freedom from corporal punishment, involuntary seclusion verbal, mental, sexual, or physical abuse and physical or chemical restraint not required to treat the resident's symptoms. The resident abuse, neglect and exploitation prevention or misappropriation of property by anyone including, but not necessarily limited to: a. facility staff; other residents; . On 11/14/23, the surveyor confirmed the facility implemented appropriate measures to ensure the safety of residents after the incident on 11/03/23 involving Resident #1 and Resident #2 by: Review of QAPI notes dated 11/08/23 showed a meeting was held to discuss the incident with Resident #1 and Resident #2 on 11/03/23. Members present included the Administrator, DON, Medical Director, MDS Coordinator, and ADON. The interventions and plan for correction included : -obtaining emergency physician orders -resident to resident altercations -resident rights -discharge and IDT communication -abuse and neglect prevention and staff training Record review of the staff in-services dated 11/03/23 through 11/11/23 included: -obtaining emergency physician orders, -resident to resident altercations, -resident rights, -discharge and IDT communication, and -abuse and neglect prevention and staff training. During interviews on 11/11/23 9:30 a.m. through 4:00 p.m., and 11/14/23 from 9:30 a.m. through 2:20 p.m., 5 LVN's (on all shifts) 10 CNA's (on all shifts) and the ADON said they received training prior to the incident and after the incident on 11/03/23 from the Administrator or the DON regarding resident abuse, neglect, rights, dealing with residents with aggressive behaviors and resident supervision levels. The nursing staff verbalized understanding of the trainings and were able to give examples of dealing with behaviors and preventing abuse. The noncompliance was identified as PNC. The immediate jeopardy (IJ) began on 11/03/23 and ended on 11/08/23. The facility had corrected the noncompliance before the survey began.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to implement policy to ensure the rights of residents to be free from abuse for 1 of 6 residents (Resident #2) reviewed for abuse. The facility failed to prevent Resident #1 from grabbing, hitting and slapping Resident #2 on 11/03/23. The noncompliance was identified as PNC. The immediate jeopardy (IJ) began on 11/03/23 and ended on 11/08/23. The facility had corrected the noncompliance before the survey began. The failure could place residents at risk for abuse, intimidation, fear, agitation, and decreased quality of life. Findings included: Record review of the facility's Abuse, Neglect, Exploitation and Misappropriation Prevention Program dated 2001 indicated Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This included but is not limited to freedom from corporal punishment, involuntary seclusion verbal, mental, sexual, or physical abuse and physical or chemical restraint not required to treat the resident's symptoms. The resident abuse, neglect and exploitation prevention or misappropriation of property by anyone including, but not necessarily limited to: a. facility staff; other residents; . Record review of facility policy Preventing Resident Abuse dated 2001 indicated 1. The facility's goal is to achieve and maintain an abuse-free environment. 2. Our abuse prevention/intervention program includes but is not limited to, the following: . g. Training staff to understand and manage a resident's verbal or physical aggression; . j. Assessing, care planning and monitoring residents with needs and behaviors that may lead to conflict or neglect; k. Assessing residents with signs and symptoms of behavior problems and developing and implementing care plans to address behavioral issues; . striving to maintain adequate staffing on all shifts to ensure that needs of each resident are met; . Record review of Resident #1's face sheet indicated she was a [AGE] year old female admitted on [DATE] and her diagnoses included Alzheimer's (a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) with behavioral disturbance, psychotic disorder (serious illness that affect the mind) with delusions (a belief that is clearly false and that indicates an abnormality in the affected person's content of thought), and anxiety (a feeling of fear, dread, and uneasiness). Record review of Resident #1's MDS dated [DATE] indicated she was usually able to make herself understood and usually understood others. She had severe cognitive impairment (BIMS score of 3). She had physical behaviors directed at others. Record review of Resident #1's care plan dated 07/12/23 (revised 08/29/23) indicated Resident #1 has attempted and hit other residents. Interventions included assess and anticipate Resident #1's needs. Record review of Resident #2's face sheet indicated she was an [AGE] year old female, admitted on [DATE], and her diagnoses included Alzheimer's, schizoaffective disorder (a mental illness that can affect your thoughts, mood and behavior) depressive type, and cognitive communication deficit (difficulty with thinking and how someone uses language). Record review of Resident #2's MDS dated [DATE] indicated she was usually understood and sometimes understands others. She had severe cognitive impairment (BIMS score of 5). She had hallucinations and delusions. There were no behaviors directed at others. Record review of progress note dated 10/31/23 at 1:50 p.m., completed by LVN E (MDS) indicated Resident #1 was on secure unit. She was hitting, slapping, and pinching staff. LVN E spoke with staff at behavior hospital who said Resident #1 was at base line of needing one on one care with aggressive behaviors. The physician was notified and waiting for orders. Record review of a progress noted dated 11/03/23 at 7:29 p.m., completed by LVN A indicated Resident #1 attempted to pull walker away from Resident #2. Resident #1 hit Resident #2 on the top of her left hand, on her left wrist, and on the left side of her face. Resident #1 separated from Resident #2 and monitored one on one. Record review of a progress note dated 11/03/23 at 11:45 p.m., completed by LVN B indicated Resident #1's family member was notified of Resident #1's behaviors. Resident #1 was transported by the facility and discharged home at approximately 11:30 p.m. Record review of Resident #1's incident report dated 11/03/23 at 11:00 p.m. , completed by LVN A indicated Resident #1 attempted to pull Resident #2's walker away from her. When Resident #1 was not able to pull the walker away from Resident #2, Resident #1 hit Resident #2 on the top of her left hand, on her left wrist, and on the left side of her face. CNA C walked into the dining room while Resident #1 and Resident #2 were standing close together with arms locked. CNA C separated Resident #1 and Resident #2. Resident #2 hit CNA C. Residents #1 and Resident #2 were separated. Resident #1 placed on one to one monitoring. The DON, Administrator, RP, and MD were notified. Hospice was notified. There were no observed injuries. Record review of Resident #2's incident report dated 11/11/23 at 11:00 p.m., completed by LVN A indicated Resident #2 was hit on her left hand, left wrist, and left side of her face. Resident #2 said, She hit me. Did you see her? Resident #2 was grabbed on her left wrist by Resident #1. Unable to determine how hard Resident #2 was grabbed. Resident #1 had both hands wrapped around Resident #1's wrist and was twisting Resident #2's hands back and forth while grabbing Resident #1's left wrist. Resident #1 and Resident #2 were separated. Resident #2 denied any pain. No distress noted. No bruising, [NAME], discoloration, or anything abnormal noted to Resident #2's left hand, wrist or face. No signs of pain noted upon passive ROM to LUE. Physician, DON, Administrator, and guardian notified. The surveyor requested to observe the video of the incident on 11/03/23. The facility was not able to provide access to the video because the system did not retain a copy. During an interview on 11/11/23 at 9:35 a.m., the Administrator said she was the abuse coordinator. She said Resident #1 resided on the secure unit. She said Resident #1 had a history of aggression towards staff and residents. She said the other residents were afraid of Resident #1. She said there were two CNAs on the secure unit when the incident occurred. She said staff were supposed to supervise and monitor Resident #1 but left her alone to provide care for another resident. Staff should have called for the nurse to provide the supervision when they were not able to supervise Resident #1. She said all staff were at risk of abuse from Resident #1 when there was no supervision. She said after the incident with Resident #1 on 11/03/23, the facility held a QAPI on 11/08/23 and developed PIPs related to preventing, identifying, and reporting resident abuse and neglect, physician orders, resident to resident altercations, resident rights, and dealing with residents with aggressive behaviors. She said the facility started retraining nursing staff on 11/03/23. She said all nursing staff were retrained on preventing, identifying, and reporting resident abuse and neglect, physician orders, resident to resident altercations, resident rights, and dealing with residents with aggressive behaviors. She said all new staff and any staff not trained would be trained by the DON or ADON prior to working their scheduled shift. She said there were no other residents in the facility who were abusive to other residents. She said she (the Administrator) and the DON were responsible to ensure all staff were trained and to monitor to ensure compliance with the QAPI plan/PIP. During observation and interview on 11/11/23 at 10:25 a.m., Resident #2 sat at a dining table watching TV with other residents. When asked if she remembered anyone grabbing her walker or hurting her she smiled and replied with unintelligible words. There was no signs of anxiety or distress. During an interview on 11/11/23 at 11:57 a.m., LVN A said CNA C came off the secure unit and reported Resident #1 hit Resident #2. She said she went on to the secure unit and Resident #1 and Resident #2 were separated. She assessed Resident #1 and Resident #2 and there was no injuries. She said she reviewed the video and noted Resident #2 was hit on her left hand, left wrist, and left side of her face. Resident #2 was grabbed on her left wrist by Resident #1. She said she was not able to determine how hard Resident #2 was grabbed. Resident #1 had both hands wrapped around Resident #1's wrist and was twisting Resident #2's hands back and forth while grabbing Resident #1's left wrist. Resident #1 and Resident #2 were separated. She said there was no assigned 1 to 1 staff on the secure unit. She said the staff should have called for help when they were providing care to any resident that required two staff. She said all residents were at risk of abuse from Resident #1 when there was no supervision. She said she was retrained on preventing, identifying, and reporting resident abuse and neglect, physician orders, resident to resident altercations, resident rights, and dealing with residents with aggressive behaviors During an interview on 11/11/23 at 12:56 p.m., LVN E said she was the MDS nurse. She said she admitted Resident #1 back to the facility from a behavior hospital on [DATE]. She said Resident #1 was combative with the transport driver. She said she did not want to readmit her to the facility and wanted to send her back to the behavior hospital. She said Resident #1 was sent back to the facility without report. She said the transport driver directed her to call the behavior hospital. She said the behavior hospital said Resident #1's combative and aggressive behavior was her baseline and if she required 1-1 staff then that is what the facility would have to implement. She said she argued with the behavior hospital and said it was not appropriate to send Resident #1 back to the facility. She said she called the NP and was told to send Resident #1 back to the behavior hospital but she could not because it was across state lines. She said she did not assign 1 to 1 staff. She said she did not get a physician order for one to one staff and was waiting for an order. She said other residents were at risk of abuse from Resident #1 if there was not adequate supervision. She said she was retrained on preventing, identifying, and reporting resident abuse and neglect, physician orders, resident to resident altercations, resident rights, and dealing with residents with aggressive behaviors. During an interview on 11/11/23 at 1:15 p.m., the RDO said after the incident with Resident #1 on 11/03/23, the facility held a QAPI on 11/08/23 and developed PIPs related to preventing, identifying, and reporting resident abuse and neglect, physician orders, resident to resident altercations, resident rights, and dealing with residents with aggressive behaviors. He said the facility started retraining nursing staff on 11/03/23. He said all nursing staff were retrained on preventing, identifying, and reporting resident abuse and neglect, physician orders, resident to resident altercations, resident rights, and dealing with residents with aggressive behaviors. He said all new staff and any staff not trained would be trained by the DON or ADON prior to working their scheduled shift. He said there were no other residents in the facility who were abusive to other residents. During an interview on 11/11/23 at 2:55 p.m., the ADON said Resident #1 was re-admitted to the facility from a behavior hospital. She said Resident #1 was more combative with care and not usually aggressive towards other residents. She said Resident #1 should have been placed on 1-1 when she returned. She said all residents were supposed to be protected from abuse. She said after the incident with Resident #1 on 11/03/23, the facility held a QAPI on 11/08/23 and developed PIPs related to preventing, identifying, and reporting resident abuse and neglect, physician orders, resident to resident altercations, resident rights, and dealing with residents with aggressive behaviors. She said the facility started retraining nursing staff on 11/03/23. She said all staff were retrained on preventing, identifying, and reporting resident abuse and neglect, physician orders, resident to resident altercations, resident rights, and dealing with residents with aggressive behaviors. She said all new staff and any staff not trained would trained by the DON or ADON prior to working their scheduled shift. She said there were no other residents in the facility who were abusive to other residents. During an interview on 11/11/23 at 3:11 p.m. the DON said when Resident #1 was re-admitted to the facility from the behavior hospital on [DATE], the facility should have implemented one to one. She said after the incident with Resident #1 on 11/03/23, the facility held a QAPI on 11/08/23 and developed PIPs related to preventing, identifying, and reporting resident abuse and neglect, physician orders, resident to resident altercations, resident rights, and dealing with residents with aggressive behaviors. She said the facility started retraining nursing staff on 11/03/23. She said all staff were retrained on preventing, identifying, and reporting resident abuse and neglect, physician orders, resident to resident altercations, resident rights, and dealing with residents with aggressive behaviors. She said she (the DON) and the Administrator were responsible to ensure all staff were trained and to monitor to ensure compliance with the QAPI plan/PIP. She said all new staff and any staff not trained would be trained by the DON or ADON prior to working their scheduled shift. She said there were no other residents in the facility who were abusive to other residents. During an interview on 11/14/23 at 2:12 p.m., LVN D said Resident #1 was re-admitted to the facility from a behavior hospital. She said Resident #1 was very combative. She said after CNA C reported Resident #1 hit Resident #2, she went on the secure unit and saw the aides had separated the residents. She said she viewed the incident on the video and saw Resident #2 was hit on her left hand, left wrist, and left side of her face. Resident #2 was grabbed on her left wrist by Resident #1. Unable to determine how hard Resident #2 was grabbed. Resident #1 had both hands wrapped around Resident #1's wrist and was twisting Resident #2's hands back and forth while grabbing Resident #1's left wrist. Resident #1 and Resident #2 were separated. She said she notified the Administrator, the DON, the physician and Resident #1's family member. She said the residents were assessed and had no injuries. She said she was retrained on preventing, identifying, and reporting resident abuse and neglect, physician orders, resident to resident altercations, resident rights, and dealing with residents with aggressive behaviors. On 11/14/23, the surveyor confirmed the facility implemented appropriate measures to ensure the safety of residents after the incident on 11/03/23 involving Resident #1 and Resident #2 by: Review of QAPI notes dated 11/08/23 showed a meeting was held to discuss the incident with Resident #1 and Resident #2 on 11/03/23. Members present included the Administrator, DON, Medical Director, MDS Coordinator, and ADON. The interventions and plan for correction included : -obtaining emergency physician orders -resident to resident altercations -resident rights -discharge and IDT communication -abuse and neglect prevention and staff training Record review of the staff in-services dated 11/03/23 through 11/11/23 included: -obtaining emergency physician orders, -resident to resident altercations, -resident rights, -discharge and IDT communication, and -abuse and neglect prevention and staff training. During interviews on 11/11/23 9:30 a.m. through 4:00 p.m., and 11/14/23 from 9:30 a.m. through 2:20 p.m., 5 LVN's (on all shifts) 10 CNA's (on all shifts) and the ADON said they received training prior to the incident and after the incident on 11/03/23 from the Administrator or the DON regarding resident abuse, neglect, rights, dealing with residents with aggressive behaviors and resident supervision levels. The nursing staff verbalized understanding of the trainings and were able to give examples of dealing with behaviors and preventing abuse. The noncompliance was identified as PNC. The immediate jeopardy (IJ) began on 11/03/23 and ended on 11/08/23. The facility had corrected the noncompliance before the survey began.