**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the residents environment remained as free of accident hazards as is possible and ensure each resident received adequate supervision to prevent accidents for 1 of 6 residents (Resident #3) reviewed for accidents and hazards.The facility failed to ensure Resident #3 did not elope from the facility on 09/10/25. The noncompliance was identified as PNC (past noncompliance). The Immediate Jeopardy (IJ) began on 09/10/25 and ended on 09/15/25. The facility had corrected the noncompliance before the survey began. This deficient practice placed residents at risk for falls, injuries, and hospitalization.Based on interview and record review, the facility failed to ensure the residents environment remained as free of accident hazards as is possible and ensure each resident received adequate supervision to prevent accidents for 1 of 6 residents (Resident #3) reviewed for accidents and hazards. The facility failed to ensure Resident #3 did not elope from the facility on 09/10/25. The noncompliance was identified as PNC (past noncompliance). The Immediate Jeopardy (IJ) began on 09/10/25 and ended on 09/15/25. The facility had corrected the noncompliance before the survey began. This deficient practice placed residents at risk for falls, injuries, and hospitalization. Findings included: Record review of Resident #3's admission recorded dated 10/02/25 documented an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #3 had diagnoses including: unspecified dementia (loss of memory, language, problem solving and other thinking abilities), muscle weakness (lack of physical or muscle strength), and history of falling. Record review of Resident #3's Quarterly MDS assessment, dated 09/02/25, revealed the resident had a BIMS score of 3 indicating the resident had severe cognitive impairment. Record review of Resident #3's care plan, dated 09/29/25, revealed Resident #3 was care planned for impaired cognitive function/dementia or impaired thought processes r/t dementia, at risk for falls r/t confusion, cognitive impairment, gait/balance problems, and unaware of safety needs. Resident #3's care plan did not reflect to routinely monitor the resident. Review of an initial “Elopement Risk Assessment” dated 06/03/24, reflected Resident #3 was not at risk for elopement and care plan interventions of routinely monitor resident. Review of elopement incident report dated 09/10/25 at 6:10pm written by LVN C reflected “This nurse received a phone call that there was a possible resident of ours walking down the highway. This nurse went outside and resident was walking up with a male person. A lady in a car told me that she is bringing one of our residents back that was off the property. This nurse walked with the resident back into the facility. The resident sat down in the front lobby and was given some water to drink. Vital signs stable. Keeping the resident within sight at this time. No injuries observed at the time of the incident.” Review of Resident #3's nursing progress note dated 09/10/25 written by LVN Cat 6:17pm reflected “This nurse received a phone call of a possible resident outside. This nurse went outside and there was a male walking up the sidewalk with the resident. The lady in the car stated that our resident was walking outside and they are bringing her back. This nurse notified the ADON while we are walking back into the facility because she is here at this time. Assisted the resident back in the facility and gave her some water. VS stable 167/52(blood pressure) 98(oxygen) 97.2(temperature) 98(pulse) O2 sat. She denies any pain and said that she did not fall while she was out. States that she just wanted to get away. She has no control over anything and needed to get away. This nurse was directed to send her back to the secure until to room [ROOM NUMBER] at this time. Notified the responsible party that she would be moving back there and what room she would be in. He states that he will be calling tomorrow and speaking with management”. In an interview with the former DON on 09/29/25 at 2:59pm, she stated she had received a call from the ADON on 09/10/25 around 6:00pm and could not recall the exact time that Resident # 3 was found outside at the road to the right of the facility by someone that passed by in their car. LVN C assessed Resident #3 with no injuries and Resident #3 was placed on the secured unit. The former DON stated there was no camera footage of Resident #3 when she had exited the facility as the cameras did not work. The former DON was advised by the ADON that Resident #3 went out of the facility when a visitor was holding the door open for CNA B to come into the facility. The former DON stated that CNA B did not recognize Resident #3 because she had worked the secured unit. CNA B stated Resident #3 did not reside on the secure unit. The former DON stated CNA B thought that Resident #3 was a visitor because she was dressed like a visitor and had a purse . The former DON stated it was expected for CNA B to recognize Resident #3, and the incident could have resulted in Resident #3 possibly being hit by a car while outside the facility. The former DON stated immediately after the incident on 09/10/25 the facility was trained on the missing resident policy, what to do when a resident elope, and to prevent elopement. In an interview with LVN C on 09/29/25 at 3:14pm, she stated on 09/10/25 she had received a call around 6:00pm during shift change from a lady whom she did not know to let her know there was an elderly person out at the road. LVN C stated at the same time the ADON was on the line with another facility in the area asking if they had a resident that was missing. LVN C stated when she got off the phone she and the ADON immediately went outside the facility. LVN C stated a lady was sitting in a blue car and a young man was bringing Resident #3 to the facility door. LVN C stated Resident # 3 was not outside the facility more than five minutes. LVN C stated she asked Resident #3 where she was going, and Resident #3 told her she just needed a break. LVN C gave Resident #3 some water and assessed her for any injuries, and none were noted. Resident # 3 was placed on the secured unit. LVN C stated anything could have happened to Resident #3 that could have caused harm while outside the facility. LVN C stated inservice on preventing elopement was completed after the incident on what to do in case of elopement. In an interview with CNA B on 09/29/25 at 4:08pm, she stated on 9/10/25 after 6:00PM (the exact time could not be recalled), as she was coming in the facility, a visitor that was leaving out of the facility had held the door open as she was coming in to work. CNA B stated shortly after she was on the secured unit an unidentified staff member had stated to her that Resident #3 went out of the facility earlier. CNA B stated she asked the unidentified person what did Resident #3 look like, and the unidentified person said the resident was dressed up and had a purse. CNA B then stated to the unidentified staff member “Oh My Gosh Resident #3 was coming out of the facility as she was coming into the facility”. CNA B stated Resident #3 did not look like a facility resident. CNA B stated she did not know Resident #3 was a facility resident because she had a dressy colorful dress on, and had a purse, with big hair. CNA B stated she had never seen Resident #3 as she worked the secured unit. CNA B stated that she will take the blame for not recognizing it was Resident #3 coming out of the facility as she was coming in. CNA B expressed she was very sorry for that. CNA B received elopement training to prevent elopement after the incident over elopement procedures and the protocol to follow when there is an elopement. In an attempted interview with Resident #3 on 09/30/25 at 3:22pm, Resident #3 was sitting in the secured unit at the dining table, and she was not able to say if she was safe or not. Resident # 3 was not able to elaborate on if she had left the facility or how she got outside when she was found in the road. Resident #3 she was not able to recall the elopement incident, and she stated she was here and said she did not know. In an interview with Resident #3's RP on 10/01/25 at 9:25am he stated that he received a call on 9/10/2025 around 6:00pm that evening from a female (name unknown) at the facility advised that Resident #3 had been found outside at the road walking on the highway. Resident #3's RP stated the facility never told him how Resident #3 was let out of the facility. Resident #3's RP stated he had a problem with Resident #3 being let out of the facility and that Resident #3 was let out of the facility by staff. Resident #3's RP was very concerned because Resident #3 had dementia and that someone had let Resident #3 out and there was no way Resident #3 could have pushed that heavy door leading to the outside open. Resident #3's RP stated Resident #3 would not have known to return back to the facility if she was not found outside the facility. Resident #3's RP stated the Highway is a very busy highway and anything could have happened (possibly hit by a car) with Resident #3 being on the Highway if no one had found her. Resident #3's RP stated the problem he had was the facility door was not secured, and Resident #3 was able to get out of the facility. Resident #3's RP stated that residents could be able to walk out with employees because no staff was at the front area watching the door. Resident #3's RP stated he wanted the security to the door to be enforced for the safety of all the residents and to ensure this incident would not ever happen again. In an interview with the ADON on 10/01/25 at 11:55am she stated she was on the phone around 6:00pm (could not recall the exact time) on 09/10/25 talking with another facility in the area, and they were asking if they had a resident that was missing. The ADON stated while she was on the phone speaking with the other facility LVN C was on the line with the people that had Resident #3 outside the facility. The ADON stated once she and LVN C both got off the phone they went outside to the parking lot of the facility. The ADON stated there was a lady that was sitting in a blue car and a male gentleman was escorting Resident #3 back to the door of the facility. The ADON stated Resident #3 was back inside the facility by 6:15 pm. The ADON stated that Resident #3 may have gotten out of the facility with visitors. The ADON stated that Resident #3 dressed up every day and would not be recognized as a resident. The ADON stated when Resident # 3 was brought back inside the facility, Resident #3 sat in a chair, and was given water. The ADON stated that Resident #3 told LVN C that she just needed a break. The ADON stated Resident #3 was fully assessed by LVN C with no injuries and escorted Resident #3 to the secured unit. The ADON stated that Resident #3 was very confused and when she went out of the facility would not have known to come back into the facility. The ADON stated the speed limit in front of the facility was 55 miles per hour and the worst thing that could have happened was Resident #3 could have gotten run over by a car. The ADON stated immediately after the elopement incident elopement training was conducted on the protocol, procedure of elopement, and to monitor residents. In an interview with the ADM and interim DON on 10/01/25 at 5:30 pm they stated that when the state surveyor came in on 09/26/25 the elopement was completed. The ADM and Interim DON stated an elopement assessment was completed on all residents, the elopement book was updated and staff were in serviced on the location to find it. Inservice on the missing resident policy procedures (what to do) was completed with all staff. Care plans were updated for all residents that were elopement risks. The sign on the front door, dining area, and any door staff exit through was placed for all resident's safety. An assessment was completed on Resident #3 and the care plan was updated. Resident #3 was moved to the secure unit and staff statements and witness statements were conducted. A root cause analysis was completed by the interim DON along with a complete report of the elopement incident. An interview with the interim DON on 10/03/25 at 12:20pm reflected that Resident #3 was not recognized by CNA B when a visitor was holding the door open for her when she came to work on 9/10/25 which resulted in Resident #3 exiting the facility. The interim DON stated this could have resulted in potential harm if Resident #3 had a fall while outside the facility. The interim DON stated it was expected for staff to make sure Resident #3 was safe. An interview with the ADM on 10/03/25 at 12:40pm stated that Resident # 3 was let out by CNA B who did not recognize she was a resident on 09/10/25 around 6:00pm. The ADM stated that Resident #3 could have experienced a negative outcome with harm if she was hit by a car on the busy highway. The ADM stated it was expected Resident #3's admit assessment completed on 06/03/24 to be followed. The ADM stated Resident #3 was not an elopement risk at the initial assessment but required care plan to be routinely monitored. Review of the facility's “Safety and Supervision of Resident” policy, dated 2001, revealed “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. Policy Interpretation and Implementation Facility Oriented Approach to Safety 1. Our facility-oriented approach to safety addresses risks for groups of residents. Resident Risks and Environmental Hazards 1. 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 the following: e. unsafe wandering…” Review of the facility's “Wandering and Elopements” policy, dated 2001, revealed “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.” This noncompliance was identified as Past Noncompliance (PNC). The noncompliance began on 09/10/25 and ended on 09/15/25. The facility had corrected the noncompliance before the survey began. The facility took the following actions to correct the non-compliance: - Review of Wandering/Elopement Assessment was conducted on all residents was completed on 09/10/25. - Review of Inservice on missing resident policy and protocol to follow was completed on 09/10/25. - Review of Elopement book and Inservice on where the book is located was completed on 09/10/25. - Review of Care plans updated on all residents that are an elopement risk was completed on 09/10/25. - Review of Signage on door in front door and any door staff exit through to make sure residents are not able to exit facility was observed on 09/10/25. - Review of Assessment on Resident #3, Reviewed Resident #3's updated care plan, moved to the secure unit on 09/10/25. - Review of Staff statements/witness statements about the elopement incident was completed on 09/11/25. - Review of Root cause analysis was completed on the elopement was completed by DON on 09/11/25 - Review of Complete incident report on the elopement was completed on 09/15/25

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the residents had the right to be free from abuse and neglect for three residents (Resident #1, Resident #2 and Resident #4) of seven reviewed for abuse. The facility failed to:1) Ensure Resident #1 did not engage in sexual activity with Resident #2 on 9/24/2025.2) Ensure Resident #2 did not engage in inappropriate behavior on 9/18/2025, 9/19/2025 and 9/24/2025.3) Ensure CNA D did not grab Resident #4's wrist forcefully and shake her arm in the presence of therapy staff on 9/3/2025. On 9/26/2025 at 6:40 pm an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 10/3/2025, the facility remained at a level of actual no actual harm at a scope of pattern that is not immediate jeopardy due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. These failures could place residents at risk of abuse, injury, and psychosocial harm.Findings included: 1. Review of Resident #1's face sheet, dated 9/26/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including dementia (group of brain disorders that cause progressive cognitive decline), anemia (low blood iron level), insomnia (problems falling and staying asleep), hypokalemia (low blood levels of potassium), and acute respiratory failure. Review of Resident #1's admission MDS assessment, dated 9/5/2025, reflected she had a BIMS score of 4 suggesting severe cognitive impairment. Review of Resident #1's progress notes for the date of 9/18/2025, reflected no mention of her being found in bed with Resident # 1 on 9/18/2025 Review of Resident #1 's progress note dated 9/25/2025 at 4:14 am, by LVN E reflected: CNA reported that this resident was lying in bed with female resident [Resident #1] sitting on top of him with both of their pants off. CNA told residents to stop and redirected the female resident into the dining room. Review of Resident #1's care plan dated 9/26/2025 (the only care plan in the EMR) on 9/26/2025 , reflected the focus area initiated on 9/11/2025: I reside in the Secure/ Memory unit and am at risk for injury from wandering in an un- safe environment R/T DX of dementia AEB impaired safety awareness. I am at risk for injury from others while residing in secure/ memory unit D/T altered cognition with interventions to Administer meds[ per order, monitor labs- report abnormals to MD. Ensure family/ MD aware of behaviors and/or any increase in behaviors noted, Keep environment free of possible hazards. 2. Review of Resident #2's face sheet, dated 9/26/2025, reflected an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including dementia (group of brain disorders that cause progressive cognitive decline), Parkinson's disease (progressive neurological disorder that affect movement, balance and coordination), hypotension (low blood pressure), anxiety disorder and benign prostatic hyperplasia (BPH - enlarged prostate gland). Review of Resident #2's MDS screen in the EMR on 9/26/2025 and 10/3/2025 reflected there was no MDS assessment. Review of Resident #2's progress note, dated 9/18/2025 at 2:30 pm, by LVN C, reflected: In a female room lying in bed with another female. This is not either resident room. Lying on top of the blanket and fully clothed. He had his hand on her leg. This nurse assisted him to his chair and told him that he cannot lay in the bed with anyone. Redirected this resident to his room. Review of Resident #2's progress note, dated 9/25/2025 at 4:14 am, by LVN E, reflected: CNA reported that this resident was lying in bed with female resident sitting on top of him with both of their pants off. CNA told residents to stop and redirected the female resident into the dining room. During an interview on 9/26/2025 at 2:39 pm, CNA B stated she worked Wednesday night on 9/24/25 and about 7:30 pm she discovered Resident #1 and Resident #2 in Resident #2's room. Resident #2 was sitting in his wheelchair and was naked from the waist down with Resident #1 on top of him also naked from the waist down and they were engaged in sexual activity. She stated she separated and redirected residents and took female resident across the hall to her room and helped her put her clothes back on. She called LVN E, the charge nurse, and told her what happened. She stated she had not thought it was abuse at the time because both residents had dementia and did not really know what they were doing. She had no suspicion of ANE because the residents were confused. She stated she did not call ADM because she reported it to LVN E and thought LVN E would call and report this to ADM. She stated she was trained on ANE and all incidents of ANE were to be reported immediately to the ADM. She stated- she did not do that and now she realizes it was ANE and should have been reported. She thought because they were confused it could not be ANE. During an interview on 9/26/2025 at 3:10 pm, LVN C stated she found Resident #1 and Resident #2 lying in bed together on 9/18/2025. She stated the residents were lying side by side on top of the covers, fully clothed and Resident #2 had his hand on Resident #1's leg. She stated Resident #2 wasn't trying to engage in anything. She further stated she had no suspicion of ANE because she did not see him try to grab at nothing or try to touch [Resident #1] in an inappropriate way - he did not seem malicious or vicious at that time. She stated she was easily able to redirect him from the situation and denied seeing Resident #1 and Resident #2 in bed together prior to that. She stated she did not report the incident as ANE because they weren't naked and didn't have their hands in each other pants - nothing like that going one, they were fully clothed and weren't trying to do anything. LVN C further stated she notified the DON but was not sure if she notified the ADM. During an interview on 9/26/2025 at 3:28 pm, LVN E stated she worked the evening of 9/24/2025 and received a call from CNA B around 7:30 pm or 7:45 pm about two residents found having sex. She stated she went to the memory care unit and assessed both residents and did not find any physical injuries . She stated she called the ADON around 9:20 pm and told her what happened. She said the ADON stated to do an incident report but there was no discussion about ANE or reporting to the ADM. She called the DON and told her what happened, and the DON said to complete a head-to-toe, put in a progress note in the system and notify families. She stated there was no discussion or guidance from the DON to call ADM or notify the abuse coordinator about the incident, so she was not sure how to handle it. She stated she did not have any suspicion of ANE because neither the ADON nor DON discussed it with her, so she did not think there was any ANE. She stated she had multiple in-services on ANE and they were supposed to report all incidents of ANE to the ADM who was the AC . She did not report it because no one said it was ANE. During an interview on 9/27/2025 at 12:00 pm, the ADM stated she was not aware of the incident last week on 9/18/2025 between Resident #1 and Resident #2 when they were found on the bed together. She stated it was her expectation that staff would follow the facility policy and report any ANE to her immediately. She stated she was aware of the incident on 9/24/2025; but she was not notified until the next morning when she went to work. The ADM stated she immediately began an investigation and reported it to the state agency. She stated staff should have notified her the night before right after it happened and not waited until the next day. During an interview on 9/27/2025 at 1:39 pm FM of Resident #1 stated the NF called an informed them of the incident between Resident #1 and Resident #2 on 9/24/3035. FM stated they were shocked by this behavior as it was very unlike Resident #1 to engage in behaviors like that. FM stated Resident #1's cognition is impaired and that she doesn't have the capacity for true consent. FM stated her cognition was so impaired they would have to remind her to eat and make sure she would bathe. FM stated this incident was extremely upsetting as Resident #1 does not engage in this sort of behavior. During an interview on 10/1/2025 at 12:07 pm, the ADON stated LVN E called her on 9/24/2025 between 9:22 pm and 9:25 pm and told her about the incident with Resident #1 and Resident #2. She stated she told LVN E to separate the residents, assess them and notify the DON. She stated she had not discussed the possibility of ANE or reporting to the ADM with LVN E at that time; she just told her to call the DON and get guidance. She stated she had been trained to report any ANE immediately to the ADM and was not sure why this was not reported. 3. Record review of Resident #4's admission record, dated 10/02/25, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #4's diagnoses included unspecified dementia (loss of memory, language, problem solving and other thinking abilities), muscle weakness (lack of physical or muscle strength), and major depressive disorder(feeling of sadness, hopelessness, and loss of interest or pleasure in activities). Record review of Resident #4's Quarterly MDS assessment, dated 09/01/25, revealed the resident had a BIMS score of 0 indicating severe cognitive impairment. Record review of Resident #4's care plan, dated 09/29/25, revealed Resident #4 was care planned for impaired communication r/t often just mumbled, yelled, growled, or shook head for communication and episodes of adverse behaviors physically aggressive, hitting, pinching, kicking, and throwing objects. Review of Resident #4's progress notes written by the ADON, dated 09/03/25 at 5:45 pm, reflected, RP notified by this nurse and DON of incident of abuse reported. Skin assessment and head to toe completed by this nurse all normal. No s/s of distress. An attempted interview with Resident #4 on 10/01/25 at 12:24pm, Resident #4 made a growling noise several times. The interview was not completed. Resident #4 was nonverbal. An attempted interview with Resident # 4's FM was unsuccessful. Left Resident #4's FM voice messages on 10/02/25 at 4:18pm, 10/03/25 at 9:40pm, and 10/03/25 at 6:00pm. Resident #4's FM did not return the call by facility exit on 10/03/25. During an interview on 10/01/25 at 12:39 pm, the PT stated she reported to the ADM on 09/03/25 immediately after she witnessed the incident with Resident #4 and CNA D. The PT stated she was in Resident #4's room helping her get ready for therapy. The PT stated CNA D entered Resident #4's room loudly saying she was going to change Resident #4. The PT stated CNA D moved to Resident # 4's face and repeated that she was going to change her. The PT stated Resident #4 attempted to push CNA D away and Resident #4 slapped CNA D in the face. The PT stated CNA D grabbed Resident #4's wrists forcefully down and shook Resident #4's arm. The PT stated CNA D said to Resident #4 that they were going to get this done and you are not going to be slapping me. The PT stated that she intervened to separate CNA D and Resident #4. The PT stated she told CNA D that she could not hold Resident #4's wrist down in that manner. The PT stated after the incident Resident #4 was emotional and no longer wanted to get dressed. The PT stated Resident #4 cried and did not want to go to therapy. Resident #4 did not return to her baseline until the next day 09/04/25. An interview with CNA D on 10/01/25 at 1:53pm stated on 09/3/25 she went into Resident #4's room to change her. CNA D stated the PT was at the foot of Resident #4's bed and told her to back off and leave Resident #4 alone while she was agitated. CNA D stated she was trying to get Resident #4 changed. CNA D stated she was eye level with Resident #4 sitting Indian style in her bed and asked Resident #4 what was wrong and Resident #4 slapped her in the face and she placed her right hand over Resident #4's left hand to prevent Resident #4 from further slapping her. CNA D stated Resident #4 acted like she was going to slap her again, so she placed her left hand on Resident #4's right hand. CNA D stated she did not hold Resident #4's wrists back or shake her arm. CNA D stated she did her job and was not disrespectful to any of the residents. CNA D stated immediately after the incident the ADM told her to clock out due to the investigation and the ADM called her by phone could not recall the date and was told her they had to let her go due to the incident. An interview with the SW[ on 10/03/25 at 12:06 pm stated she was not aware of the incident with Resident #4 and CNA D when it occurred on 09/03/25. The SW stated she was made aware of the incident after it occurred and the ADM conducted the investigation on. An interview with the interim DON on 10/03/25 at 12:20pm stated the PT reported the incident with Resident #4 and CNA D immediately to the ADM after the incident occurred. The interim DON stated the ADM made her aware of the incident on 9/03/25. The interim DON stated she did not notice a difference with Resident #4's behavior after the incident. The interim DON stated Resident #4 was nonverbal and it was expected for her to be free from any abuse. An interview with the ADM on 10/03/25 at 12:40pm stated the PT notified her on 09/03/25 after the incident occurred with Resident #4 and CNA D. The ADM stated the PT stated CNA D pinned Resident #4's wrists back to prevent Resident #4 from slapping her. The ADM stated Resident #4 was nonverbal and it was expected for CNA D not to have pinned Resident's #4's wrist back. Review of CNA D's personnel file reflected that she was terminated on 09/03/25. Review of the facility's investigation, dated 09/03/25, reflected a thorough investigation was completed, and the allegation of physical abuse was confirmed. Review of the facility's policy, dated April 2021, titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program reflected:Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes 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 program consists of a facility-wide commitment and resource allocation to support the following objectives:1.Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to:a. facility staff.b. other residents.C. consultants.d. volunteers.e. staff from other agencies.f. family members.g. legal representatives.h. friends.i. visitors; and/orj. any other individual. Ensure adequate staffing and oversight/support to prevent burnout, stressful working situations and high turnover rates.Establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral, cognitive or emotional problems. This was determined to be an Immediate Jeopardy (IJ) on 10/01/2025 at 4:53 pm. The Administrator was notified. The ADM was provided with the IJ template on 10/01/2025 at 4:53 pm .The following Plan of Removal submitted by the facility was accepted on 10/02/25 at 4:54pm Immediate Jeopardy (IJ) states as follows: 1--The facility failed to keep Resident #1 and Resident #2 from abuse and neglect when both residents were observed engaging in sexual activity on the memory care unit on 9/24/2025 about 7:30 pm.2-- Resident #5 free from misappropriation when the Business Office Manager took his benefits card and spent $3,700. The facility immediately implemented the following plans: F600- Free from Abuse/Neglect Action (Immediate): 1--Resident 1 and Resident 2 were immediately separated from each other. Residents 1 and 2 received head to toe assessments performed by charge nurse and an emotional assessment performed by social worker. The social worker performed trauma informed care assessment. No adverse findings noted. Medical Director was notified, and orders obtained for psychiatric services.Residents 1 and 2 were evaluated by Psychiatric services and medication changes were implemented. Resident 1 and 2 care plans and Kardex were updated to reflect the resident's history of resident-to-resident sexual activity. 2-The Business Office Manager was immediately terminated from employment at the facility, and the local police department was notified of the misappropriation of resident funds. The BOM was terminated on 09/17/25. The resident's funds were replaced by the facility on 9/18/25. Person(s) Responsible: Administrator and/or Director of Nursing Completion Date: 10/1/2025 Action (Identification): 1--All residents with behaviors documented as an incident report and/or in the progress notes for the previous 90 days will be reviewed to identify any other residents that may exhibit sexually inappropriate behaviors. If any behavioral events are identified the resident care plan and Kardex will be reviewed and updated, and interventions will be placed immediately. Zero out of 60 incident reports reviewed showed no adverse/inappropriate behavior. Daily audit of resident behaviors and interventions will be reviewed and noted in resident chart. Daily audits will be conducted for behavioral events for 14 days, then weekly X30 days. 2. The Regional Business Office Director completed an audit for 70 residents trust funds with no discrepancies noted. This was completed at the corporate level by the Regional Business Office, as the facility BOM was terminated. There were no discrepancies noted from this audit. Person(s) Responsible: Administrator and/or Director of NursingCompletion Date: 10/1/2025 Action (Identification): Staff assigned to the secured unit, in which there are consistent staff members, other facility staff including PRN staff and agency staff will be interviewed for any additional incidents or residents that may have been affected by resident-to-resident abuse. Person(s) Responsible Administrator and/or Designee Completion Date: 10/1/2025 Action (Prevention): 1--Education provided to Administrator and Director of Nursing on the abuse policy, investigating and reporting abuse per HHS and CMS regulations. Testing and discussion were utilized to assess the knowledge retention of the Administrator and the Director of Nursing.2-One-time weekly audits over the next 30 days by the Regional Business Office Manager. Resident Fund Management Service will be audited weekly for the next 30 days. Person(s) Responsible: Regional Nurse ConsultantCompletion Date: 10/1/2025 Action (Prevention): Education provided to all staff by the Administrator:1. Abuse and Neglect: Types of abuse, including sexual abuse and when/who to report to (immediately & the administrator- abuse coordinator)1. Resident to Resident: Recognizing behaviors, triggers, and how to effectively intervene. Staff will be educated to immediately separate the residents and implement 1:1 observation until instructed otherwise by the Administrator and/or Director of Nursing. All Facility staff will complete prior to working their next shift. New employees and agency staff will be educated upon hire and/or prior to working a shift. Knowledge will be verified via test and verbal discussion with affirmative feedback2. Staff that handle resident funds, Business Office and Human Resources Director will undergo retraining on financial policies, ethical standards, and proper fund management procedures. This training was completed on 9/18/25 by the Regional Business Office Director, with the Human Resources Director. Person(s) Responsible: Administrator and/or Designee Completion Date: 10/01/25 Action (Prevention): Education provided to Nursing Staff by the Director of Nursing on:1. Resident Kardex that will contain the updated care plans and interventions following behavioral events. Staff will be notified of behavioral events through shift-to-shift report and/or the Director of Nursing and/or Assistant Director of Nursing. 2. Testing and verbal confirmation are utilized to assess knowledge retention.3. Annual training via Relias regarding resident's rights, theft, misappropriation and abuse. All Facility staff, new hire and agency will complete prior to working their next shift. Knowledge will be verified via test and verbal discussion with affirmative feedback. Person(s) Responsible: Administrator and/or Designee Completion Date: 10/1/25 Action (Monitoring): 1--During daily meeting, Director of Nursing, Assistant Director of Nursing, and/or Designee will review all progress notes and event reports to ensure effective care plans/interventions are in place following any resident-to-resident or other inappropriate behavior. Will be reviewed during daily meeting x 30 days and then weekly thereafter. 2-Weekly and as needed reconciliation of resident trust fund by the Business Office Manager/Regional Business Office Manager. This will be ongoing. Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, and/or Designee Completion Date: 10/1/2025Action (QAPI): Medical Director informed of this plan at the Ad Hoc QAPI. At this time no other recommendations have been made. Person(s) Responsible: Administrator Completion Date: 10/1/2025 The surveyor monitored the POR as follows: Record Review of abuse, neglect, exploitation Inservice completed by 10/03/25 Record Review of copy of cashier's check totaling in the amount of $3700 paid out to Resident #5's RP. An interview with CNA F on 10/03/25 at 12:00pm stated she completed her abuse, neglect, exploitation inservice this morning and was giving a test after completion. CNA F was able to provide types of abuse physical, sexual, financial, and gave examples such as stealing a resident's money. CNA F knew to report immediately if ever witnessed to the ADM. An interview with RN G on 10/03/25 at 12:15pm stated she was given in-service this morning over abuse, neglect, and exploitation. RN G knew to contact the ADM immediately if ever witnessed. RN G knew types of abuse such as taking funds, sexual abuse, and talking bad to residents. RN G knew the signs of abuse/neglect, gave examples of not changing the residents and not caring for them. An interview with CNA H on 10/03/25 at 1:42pm stated as soon as she walked in the door this morning she was provided the abuse, neglect, exploitation training along with a test. CNA H gave examples of abuse /neglect such as yelling at a resident, ignoring call light, sexual, mental, and stealing money from a resident. CNA H stated she was aware last week sometime that a resident had something stolen. An interview with MA I on 10/03/25 at 2:03pm stated she received her in-service on by 10/3/25 over abuse, neglect, and exploitation. MA I was able to give the types of abuse such as physical, mental, and financial. MA I was able to give an example of financial abuse by stealing or borrowing. MA I was able to give signs of abuse/neglect examples such as not changing residents, not feeding, or caring for them. An interview with HK J on 10/03/25 at 2:36pm stated that she received the in-service over abuse, neglect, and exploitation today. HK J knows to report to the ADM if she ever witnessed any abuse or neglect. HK J was able to give examples of abuse /neglect such as resident-to-resident aggression, verbal abuse, not wanting to help a resident, exploitation (stealing money). An interview with the DM on 10/02/25 at 2:53pm stated that she just had her in-service over exploitation in the DON's office. The DM stated taking a resident's magazine would be exploitation. The DM know to report immediately to the AM if she witnessed any abuse or neglect. An interview with the DA on 10/02/25 at 3:07pm stated she was in the DON's office just a while ago for in-service. The DA know who to report abuse, neglect, and exploitation to the ADM immediately. While the IJ was removed on 10/03/25 at 5:12pm, the facility remained out of compliance at a level of no actual harm at a scope of pattern because the facility's need to 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 ensure the residents had the right to be free from abuse and neglect for three residents (Resident #1, Resident #2 and Resident #4) of seven reviewed for abuse. The facility failed to:1) Ensure Resident #1 did not engage in sexual activity with Resident #2 on 9/24/2025.2) Ensure Resident #2 did not engage in inappropriate behavior on 9/18/2025, 9/19/2025 and 9/24/2025.3) Ensure CNA D did not grab Resident #4's wrist forcefully and shake her arm in the presence of therapy staff on 9/3/2025. On 9/26/2025 at 6:40 pm an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 10/3/2025, the facility remained at a level of actual no actual harm at a scope of pattern that is not immediate jeopardy due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. These failures could place residents at risk of abuse, injury, and psychosocial harm. Findings included: 1. Review of Resident #1's face sheet, dated 9/26/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including dementia (group of brain disorders that cause progressive cognitive decline), anemia (low blood iron level), insomnia (problems falling and staying asleep), hypokalemia (low blood levels of potassium), and acute respiratory failure. Review of Resident #1's admission MDS assessment, dated 9/5/2025, reflected she had a BIMS score of 4 suggesting severe cognitive impairment. Review of Resident #1's progress notes for the date of 9/18/2025, reflected no mention of her being found in bed with Resident #1 on 9/18/2025 Review of Resident #1 's progress note dated 9/25/2025 at 4:14 am, by LVN E reflected: CNA reported that this resident was lying in bed with female resident [Resident #1] sitting on top of him with both of their pants off. CNA told residents to stop and redirected the female resident into the dining room. Review of Resident #1's care plan dated 9/26/2025 (the only care plan in the EMR) on 9/26/2025, reflected the focus area initiated on 9/11/2025: I reside in the Secure/ Memory unit and am at risk for injury from wandering in an un- safe environment R/T DX of dementia AEB impaired safety awareness. I am at risk for injury from others while residing in secure/ memory unit D/T altered cognition with interventions to Administer meds per order, monitor labs- report abnormals to MD. Ensure family/ MD aware of behaviors and/or any increase in behaviors noted, Keep environment free of possible hazards. 2. Review of Resident #2's face sheet, dated 9/26/2025, reflected an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including dementia (group of brain disorders that cause progressive cognitive decline), Parkison's disease (progressive neurological disorder that affect movement, balance and coordination), hypotension (low blood pressure), anxiety disorder and benign prostatic hyperplasia (BPH - enlarged prostate gland). Review of Resident #2's MDS screen in the EMR on 9/26/2025 and 10/3/2025 reflected there was no MDS assessment. Review of Resident #2's progress note, dated 9/18/2025 at 2:30 pm, by LVN C, reflected: In a female room lying in bed with another female. This is not either resident room. Lying on top of the blanket and fully clothed. He had his hand on her leg. This nurse assisted him to his chair and told him that he cannot lay in the bed with anyone. Redirected this resident to his room. Review of Resident #2's progress note, dated 9/25/2025 at 4:14 am, by LVN E, reflected: CNA reported that this resident was lying in bed with female resident sitting on top of him with both of their pants off. CNA told residents to stop and redirected the female resident into the dining room. During an interview on 9/26/2025 at 2:39 pm, CNA B stated she worked Wednesday night on 9/24/25 and about 7:30 pm she discovered Resident #1 and Resident #2 in Resident #2's room. Resident #2 was sitting in his wheelchair and was naked from the waist down with Resident #1 on top of him also naked from the waist down and they were engaged in sexual activity. She stated she separated and redirected residents and took female resident across the hall to her room and helped her put her clothes back on. She called LVN E, the charge nurse, and told her what happened. She stated she had not thought it was abuse at the time because both residents had dementia and did not really know what they were doing. She had no suspicion of ANE because the residents were confused. She stated she did not call ADM because she reported it to LVN E and thought LVN E would call and report this to ADM. She stated she was trained on ANE and all incidents of ANE were to be reported immediately to the ADM. She stated- she did not do that and now she realizes it was ANE and should have been reported. She thought because they were confused it could not be ANE. During an interview on 9/26/2025 at 3:10 pm, LVN C stated she found Resident #1 and Resident #2 lying in bed together on 9/18/2025. She stated the residents were lying side by side on top of the covers, fully clothed and Resident #2 had his hand on Resident #1's leg. She stated Resident #2 wasn't trying to engage in anything. She further stated she had no suspicion of ANE because she did not see him try to grab at nothing or try to touch [Resident #1] in an inappropriate way - he did not seem malicious or vicious at that time. She stated she was easily able to redirect him from the situation and denied seeing Resident #1 and Resident #2 in bed together prior to that. She stated she did not report the incident as ANE because they weren't naked and didn't have their hands in each other pants - nothing like that going one, they were fully clothed and weren't trying to do anything. LVN C further stated she notified the DON but was not sure if she notified the ADM. During an interview on 9/26/2025 at 3:28 pm, LVN E stated she worked the evening of 9/24/2025 and received a call from CNA B around 7:30 pm or 7:45 pm about two residents found having sex. She stated she went to the memory care unit and assessed both residents and did not find any physical injuries[. She stated she called the ADON around 9:20 pm and told her what happened. She said the ADON stated to do an incident report but there was no discussion about ANE or reporting to the ADM. She called the DON and told her what happened, and the DON said to complete a head-to-toe, put in a progress note in the system and notify families. She stated there was no discussion or guidance from the DON to call ADM or notify the abuse coordinator about the incident, so she was not sure how to handle it. She stated she did not have any suspicion of ANE because neither the ADON nor DON discussed it with her, so she did not think there was any ANE. She stated she had multiple in-services on ANE and they were supposed to report all incidents of ANE to the ADM who was the AC. She did not report it because no one said it was ANE. During an interview on 9/27/2025 at 12:00 pm, the ADM stated she was not aware of the incident last week on 9/18/2025 between Resident #1 and Resident #2 when they were found on the bed together. She stated it was her expectation that staff would follow the facility policy and report any ANE to her immediately. She stated she was aware of the incident on 9/24/2025; but she was not notified until the next morning when she went to work. The ADM stated she immediately began an investigation and reported it to the state agency. She stated staff should have notified her the night before right after it happened and not waited until the next day. During an interview on 10/1/2025 at 12:07 pm, the ADON stated LVN E called her on 9/24/2025 between 9:22 pm and 9:25 pm and told her about the incident with Resident #1 and Resident #2. She stated she told LVN E to separate the residents, assess them and notify the DON. She stated she had not discussed the possibility of ANE or reporting to the ADM with LVN E at that time; she just told her to call the DON and get guidance. She stated she had been trained to report any ANE immediately to the ADM and was not sure why this was not reported. 3. Record review of Resident #4's admission record, dated 10/02/25, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #4's diagnoses included unspecified dementia (loss of memory, language, problem solving and other thinking abilities), muscle weakness (lack of physical or muscle strength), and major depressive disorder(feeling of sadness, hopelessness, and loss of interest or pleasure in activities). Record review of Resident #4's Quarterly MDS assessment, dated 09/01/25, revealed the resident had a BIMS score of 0 indicating severe cognitive impairment. Record review of Resident #4's care plan, dated 09/29/25, revealed Resident #4 was care planned for impaired communication r/t often just mumbled, yelled, growled, or shook head for communication and episodes of adverse behaviors physically aggressive, hitting, pinching, kicking, and throwing objects. Review of Resident #4's progress notes written by the ADON, dated 09/03/25 at 5:45 pm, reflected, RP notified by this nurse and DON of incident of abuse reported. Skin assessment and head to toe completed by this nurse all normal. No s/s of distress. An attempted interview with Resident #4 on 10/01/25 at 12:24pm, Resident #4 made a growling noise several times. The interview was not completed. Resident #4 was nonverbal. An attempted interview with Resident # 4's FM was unsuccessful. Left Resident #4's FM voice messages on 10/02/25 at 4:18pm, 10/03/25 at 9:40pm, and 10/03/25 at 6:00pm. Resident #4's FM did not return the call by facility exit on 10/03/25. During an interview on 10/01/25 at 12:39 pm, the PT stated she reported to the ADM on 09/03/25 immediately after she witnessed the incident with Resident #4 and CNA D. The PT stated she was in Resident #4's room helping her get ready for therapy. The PT stated CNA D entered Resident #4's room loudly saying she was going to change Resident #4. The PT stated CNA D moved to Resident # 4's face and repeated that she was going to change her. The PT stated Resident #4 attempted to push CNA D away and Resident #4 slapped CNA D in the face. The PT stated CNA D grabbed Resident #4's wrists forcefully down and shook Resident #4's arm. The PT stated CNA D said to Resident #4 that they were going to get this done and you are not going to be slapping me. The PT stated that she intervened to separate CNA D and Resident #4. The PT stated she told CNA D that she could not hold Resident #4's wrist down in that manner. The PT stated after the incident Resident #4 was emotional and no longer wanted to get dressed. The PT stated Resident #4 cried and did not want to go to therapy. Resident #4 did not return to her baseline until the next day 09/04/25. An interview with CNA D on 10/01/25 at 1:53pm stated on 09/3/25 she went into Resident #4's room to change her. CNA D stated the PT was at the foot of Resident #4's bed and told her to back off and leave Resident #4 alone while she was agitated. CNA D stated she was trying to get Resident #4 changed. CNA D stated she was eye level with Resident #4 sitting Indian style in her bed and asked Resident #4 what was wrong and Resident #4 slapped her in the face and she placed her right hand over Resident #4's left hand to prevent Resident #4 from further slapping her. CNA D stated Resident #4 acted like she was going to slap her again, so she placed her left hand on Resident #4's right hand. CNA D stated she did not hold Resident #4's wrists back or shake her arm. CNA D stated she did her job and was not disrespectful to any of the residents. CNA D stated immediately after the incident the ADM told her to clock out due to the investigation and the ADM called her by phone could not recall the date and was told her they had to let her go due to the incident. An interview with the SW on 10/03/25 at 12:06 pm stated she was not aware of the incident with Resident #4 and CNA D when it occurred on 09/03/25. The SW stated she was made aware of the incident after it occurred and the ADM conducted the investigation on. An interview with the interim DON on 10/03/25 at 12:20pm stated the PT reported the incident with Resident #4 and CNA D immediately to the ADM after the incident occurred. The interim DON stated the ADM made her aware of the incident on 9/03/25. The interim DON stated she did not notice a difference with Resident #4's behavior after the incident. The interim DON stated Resident #4 was nonverbal and it was expected for her to be free from any abuse. An interview with the ADM on 10/03/25 at 12:40pm stated the PT notified her on 09/03/25 after the incident occurred with Resident #4 and CNA D. The ADM stated the PT stated CNA D pinned Resident #4's wrists back to prevent Resident #4 from slapping her. The ADM stated Resident #4 was nonverbal and it was expected for CNA D not to have pinned Resident's #4's wrist back. Review of CNA D's personnel file reflected that she was terminated on 09/03/25. Review of the facility's investigation, dated 09/03/25, reflected a thorough investigation was completed, and the allegation of physical abuse was confirmed. Review of the facility's policy, dated April 2021, titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program reflected:Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes 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 program consists of a facility-wide commitment and resource allocation to support the following objectives:1.Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to:a. facility staff.b. other residents.C. consultants.d. volunteers.e. staff from other agencies.f. family members.g. legal representatives.h. friends.i. visitors; and/orj. any other individual. Ensure adequate staffing and oversight/support to prevent burnout, stressful working situations and high turnover rates.Establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral, cognitive or emotional problems. This was determined to be an Immediate Jeopardy (IJ) on 10/01/2025 at 4:53 pm. The Administrator was notified. The ADM was provided with the IJ template on 10/01/2025 at 4:53 pm .The following Plan of Removal submitted by the facility was accepted on 10/02/25 at 4:54pm Immediate Jeopardy (IJ) states as follows: 1--The facility failed to keep Resident #1 and Resident #2 from abuse and neglect when both residents were observed engaging in sexual activity on the memory care unit on 9/24/2025 about 7:30 pm.2-- Resident #5 free from misappropriation when the Business Office Manager took his benefits card and spent $3,700. The facility immediately implemented the following plans: F600- Free from Abuse/Neglect Action (Immediate): 1--Resident 1 and Resident 2 were immediately separated from each other. Residents 1 and 2 received head to toe assessments performed by charge nurse and an emotional assessment performed by social worker. The social worker performed trauma informed care assessment. No adverse findings noted. Medical Director was notified, and orders obtained for psychiatric services.Residents 1 and 2 were evaluated by Psychiatric services and medication changes were implemented. Resident 1 and 2 care plans and Kardex were updated to reflect the resident's history of resident-to-resident sexual activity. 2-The Business Office Manager was immediately terminated from employment at the facility, and the local police department was notified of the misappropriation of resident funds. The BOM was terminated on 09/17/25. The resident's funds were replaced by the facility on 9/18/25. Person(s) Responsible: Administrator and/or Director of Nursing Completion Date: 10/1/2025 Action (Identification): 1--All residents with behaviors documented as an incident report and/or in the progress notes for the previous 90 days will be reviewed to identify any other residents that may exhibit sexually inappropriate behaviors. If any behavioral events are identified the resident care plan and Kardex will be reviewed and updated, and interventions will be placed immediately. Zero out of 60 incident reports reviewed showed no adverse/inappropriate behavior. Daily audit of resident behaviors and interventions will be reviewed and noted in resident chart. Daily audits will be conducted for behavioral events for 14 days, then weekly X30 days. 2. The Regional Business Office Director completed an audit for 70 residents trust funds with no discrepancies noted. This was completed at the corporate level by the Regional Business Office, as the facility BOM was terminated. There were no discrepancies noted from this audit. Person(s) Responsible: Administrator and/or Director of NursingCompletion Date: 10/1/2025 Action (Identification): Staff assigned to the secured unit, in which there are consistent staff members, other facility staff including PRN staff and agency staff will be interviewed for any additional incidents or residents that may have been affected by resident-to-resident abuse. Person(s) Responsible Administrator and/or Designee Completion Date: 10/1/2025 Action (Prevention): 1--Education provided to Administrator and Director of Nursing on the abuse policy, investigating and reporting abuse per HHS and CMS regulations. Testing and discussion were utilized to assess the knowledge retention of the Administrator and the Director of Nursing.2-One-time weekly audits over the next 30 days by the Regional Business Office Manager. Resident Fund Management Service will be audited weekly for the next 30 days. Person(s) Responsible: Regional Nurse ConsultantCompletion Date: 10/1/2025 Action (Prevention): Education provided to all staff by the Administrator:1. Abuse and Neglect: Types of abuse, including sexual abuse and when/who to report to (immediately & the administrator- abuse coordinator)1. Resident to Resident: Recognizing behaviors, triggers, and how to effectively intervene. Staff will be educated to immediately separate the residents and implement 1:1 observation until instructed otherwise by the Administrator and/or Director of Nursing. All Facility staff will complete prior to working their next shift. New employees and agency staff will be educated upon hire and/or prior to working a shift. Knowledge will be verified via test and verbal discussion with affirmative feedback2. Staff that handle resident funds, Business Office and Human Resources Director will undergo retraining on financial policies, ethical standards, and proper fund management procedures. This training was completed on 9/18/25 by the Regional Business Office Director, with the Human Resources Director. Person(s) Responsible: Administrator and/or Designee Completion Date: 10/01/25 Action (Prevention): Education provided to Nursing Staff by the Director of Nursing on:1. Resident Kardex that will contain the updated care plans and interventions following behavioral events. Staff will be notified of behavioral events through shift-to-shift report and/or the Director of Nursing and/or Assistant Director of Nursing. 2. Testing and verbal confirmation are utilized to assess knowledge retention.3. Annual training via Relias regarding resident's rights, theft, misappropriation and abuse. All Facility staff, new hire and agency will complete prior to working their next shift. Knowledge will be verified via test and verbal discussion with affirmative feedback. Person(s) Responsible: Administrator and/or Designee Completion Date: 10/1/25 Action (Monitoring): 1--During daily meeting, Director of Nursing, Assistant Director of Nursing, and/or Designee will review all progress notes and event reports to ensure effective care plans/interventions are in place following any resident-to-resident or other inappropriate behavior. Will be reviewed during daily meeting x 30 days and then weekly thereafter. 2-Weekly and as needed reconciliation of resident trust fund by the Business Office Manager/Regional Business Office Manager. This will be ongoing. Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, and/or Designee Completion Date: 10/1/25 Action (QAPI): Medical Director informed of this plan at the Ad Hoc QAPI. At this time no other recommendations have been made. Person(s) Responsible: Administrator Completion Date: 10/1/2025 The surveyor monitored the POR as follows: Record Review of abuse, neglect, exploitation Inservice completed by 10/03/25 Record Review of copy of cashier's check totaling in the amount of $3700 paid out to Resident #5's RP. An interview with CNA F on 10/03/25 at 12:00pm stated she completed her abuse, neglect, exploitation inservice this morning and was giving a test after completion. CNA F was able to provide types of abuse physical, sexual, financial, and gave examples such as stealing a resident's money. CNA F knew to report immediately if ever witnessed to the ADM. An interview with RN G on 10/03/25 at 12:15pm stated she was given in-service this morning over abuse, neglect, and exploitation. RN G knew to contact the ADM immediately if ever witnessed. RN G knew types of abuse such as taking funds, sexual abuse, and talking bad to residents. RN G knew the signs of abuse/neglect, gave examples of not changing the residents and not caring for them. An interview with CNA H on 10/03/25 at 1:42pm stated as soon as she walked in the door this morning she was provided the abuse, neglect, exploitation training along with a test. CNA H gave examples of abuse /neglect such as yelling at a resident, ignoring call light, sexual, mental, and stealing money from a resident. CNA H stated she was aware last week sometime that a resident had something stolen. An interview with I on 10/03/25 at 2:03pm stated she received her in-service on by 10/3/25 over abuse, neglect, and exploitation. MA I was able to give the types of abuse such as physical, mental, and financial. MA I was able to give an example of financial abuse by stealing or borrowing. MA I was able to give signs of abuse/neglect examples such as not changing residents, not feeding, or caring for them. An interview with HK J on 10/03/25 at 2:36pm stated that she received the in-service over abuse, neglect, and exploitation today. HK J knows to report to the ADM if she ever witnessed any abuse or neglect. HK J was able to give examples of abuse /neglect such as resident-to-resident aggression, verbal abuse, not wanting to help a resident, exploitation (stealing money). An interview with the DM on 10/02/25 at 2:53pm stated that she just had her inservice over exploitation in the DON's office. The DM stated taking a resident's magazine would be exploitation. The DM know to report immediately to the AM if she witnessed any abuse or neglect. An interview with the DA on 10/02/25 at 3:07pm stated she was in the DON's office just a while ago for in-service. The DA know who to report abuse, neglect, and exploitation to the ADM immediately. While the IJ was removed on 10/03/25 at 5:12pm, the facility remained out of compliance at a level of no actual harm at a scope of pattern because the facility's need to evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately but not later than 2 hours after the allegation is made if the events that cause the allegation involve abuse or not later than 24 hours if the events that cause the allegation do not involve abuse to the Administrator for 3 of 7 residents (Resident #1, Resident #2, Resident #5) reviewed for Abuse and Neglect.[KS1] [LP2] The facility staff failed to immediately report abuse and neglect to the Administrator when: 1) Resident #1 was observed engaging in sexual activity with Resident #2 on 9/24/2025.2) Resident #2 was observed engaging in inappropriate behavior with Resident #1 on 9/18/2025 and 9/24/2025.An Immediate Jeopardy (IJ) was identified on 9/29/2025. The IJ template was provided to the facility on 9/29/2025 at 2:00 pm. While the IJ was removed on 10/3/2025, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not IJ and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems.3) The BOM confessed to the Marketing Director that she had taken Resident #5's credit card and spent $3700 for personal useThis failure placed residents at risk of not being protected from abuse, neglect, or exploitation.Findings included: 1.) Resident #1 Review of Resident #1's face sheet dated 9/26/2025 reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including Dementia (group of brain disorders that cause progressive cognitive decline), Anemia (low blood iron level), Insomnia (problems falling and staying asleep), Hypokalemia (low blood levels of potassium), and acute respiratory failure. Review of Resident #1's admission MDS assessment dated [DATE] reflected she had a BIMS score of 4 suggesting severe cognitive impairment. Review of the behavior section revealed no behaviors were noted. Review of Resident #1's progress notes on 9/18/2025, reflected no mention of her being found in bed with Resident #2 on 9/18/2025. Review of Resident #1's progress notes dated 9/25/2025 at 4:14 am by LVN E reflected: CNA reported that this resident was lying in bed with female resident [Resident #1] sitting on top of him with both of their pants off. CNA told residents to stop and redirected the female resident into the dining room. Review of Resident #1's care plan (the only care plan in the EMR) on 9/26/2025, reflected the focus area initiated on 9/11/2025:I reside in the Secure/ Memory unit and am at risk for injury from wandering in an un- safe environment R/T DX of dementia AEB impaired safety awareness. I am at risk for injury from others while residing in secure/ memory unit D/T altered cognition.with interventions Administer meds per order, monitor labs- report abnormals to MD. Ensure family/ MD aware of behaviors and/or any increase in behaviors noted, Keep environment free of possible hazards. 2.) Resident #2 Review of Resident #2's face sheet dated 9/26/2025 reflected an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including Dementia (group of brain disorders that cause progressive cognitive decline), Parkinson's disease (progressive neurological disorder that affects movement, balance and coordination), hypotension (low blood pressure), anxiety disorder and Benign Prostatic Hyperplasia (BPH - enlarged prostate gland). Review of Resident #2's MDS screen in the EMR on 9/26/2025 and 10/3/2025 reflected there was no MDS assessment. Review of Resident #2's progress note dated 9/18/2025 at 2:30 pm by LVN C reflected: In a female room lying in bed with another female. This is not either resident room. Lying on top of the blanket and fully clothed. He had his hand on her leg. This nurse assisted him to his chair and told him that he cannot lay in the bed with anyone. Redirected this resident to his room. Review of Resident #2's progress note dated 9/25/2025 at 4:14 am by LVN E reflected: CNA reported that this resident was lying in bed with female resident sitting on top of him with both of their pants off. CNA told residents to stop and redirected the female resident into the dining room. During an interview on 9/26/2025 at 2:39 pm, CNA B stated she was working Wednesday night on 9/24/25 and about 7:30 pm she discovered Resident #1 and Resident #2 in Resident #2's room. Resident #2 was sitting in his wheelchair and was naked from the waist down with Resident #1 on top of him also naked from the waist down and they were engaged in sexual activity. She stated she separated and redirected residents and took the female resident across the hall to her room and helped her put her clothes back on. She called LVN E, the charge nurse, and told her what happened. She stated she had not thought it was abuse at the time because both residents had dementia and did not really know what they were doing. She had no suspicion of ANE because the residents were confused. She stated she did not call the ADM because she reported it to LVN E and thought she would. She stated she has had training on ANE and all incidents of ANE are to be reported immediately to the ADM. She did not do that and now she realizes it was ANE and should have been reported. She thought because they were confused it could not be ANE. During an interview on 9/26/2025 at 3:10 pm, LVN C stated she found Resident #1 and Resident #2 lying in bed together on 9/18/2025. She stated the residents were lying side by side on top of the covers, fully clothed and Resident #2 had his hand on Resident #1's leg. She stated Resident #2 wasn't trying to engage in anything. She further stated she had no suspicion of ANE because she did not see him try to grab at nothing try to touch [Resident #1] in an inappropriate way - he did not seem malicious or vicious at that time. She stated she was easily able to redirect him from the situation and denied seeing Resident #1 and Resident #2 in bed together prior to that. She stated she did not report the incident as ANE because they weren't naked and didn't have their hands in each other pants - nothing like that going on, they were fully clothed and weren't trying to do anything. LVN C further stated she notified the DON but was not sure if the DON notified the ADM. During an interview on 9/26/2025 at 3:28 pm, LVN E stated she had been working the evening of 9/24/2025 and received a call from CNA B around 7:30 - 7:45 pm about two residents found having sex. She stated she went to the memory care unit and assessed both residents and did not find any physical injuries. She stated she called the ADON around 9:20 pm and told her what happened. The ADON told her to do an incident report. There was no discussion about ANE or reporting to the ADM. She referred to the DON. She called the DON and told her what happened, and the DON told her to complete a head to toe assessment, put a progress note in the system and notify families. She stated there was no discussion or guidance from the DON to call the ADM or notify the abuse coordinator about the incident, so she was not sure how to handle it. She stated she did not have any suspicion of ANE because neither the ADON nor DON discussed it with her, so she did not think there was any ANE. She stated she has had multiple in-services on ANE and they were supposed to report all incidents of ANE to the ADM who is the AC. She did not report it because no one said it was ANE. During an interview on 9/27/2025 at 12:00 pm, the ADM stated she was not aware of the incident last week on 9/18/2025 between Resident #1 and Resident #2 when they were found on the bed together. She stated it was her expectation that staff would follow the facility policy and report any ANE to her immediately. She stated she was aware of the incident on 9/24/2025; but she had not been notified until the next morning when she came into work and immediately began an investigation and reported it to the state agency. She stated staff should have notified her the night before right after it happened and not waited until the next day. During an interview on 10/1/2025 at 12:07 pm, the ADON stated LVN E called her on 9/24/2025 about 9:22-9:25 pm and told her about the incident with Resident #1 and Resident #2. She stated she told LVN E to separate the residents, assess them and notify the DON. She stated she had not discussed the possibility of ANE or reporting to the ADM with LVN E at that time; she just told her to call the DON and get guidance. She stated she had been trained to report any ANE immediately to the ADM and is not sure why this was not reported. The ADM was notified on 10/01/25 at 4:53 pm, that an Immediate Jeopardy had been identified due to the above failures and an IJ template was provided. The following POR was accepted on 10/02/25 at 4:53 pm. Plan of Removal Immediate Jeopardy F609On 09/26/2025 an abbreviated survey was initiated. On 09/26/202the surveyor provided an Immediate Jeopardy (IJ) notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate jeopardy to resident health and safety. The notification of Immediate Jeopardy states as follows: 1-F609 The facility staff failed to immediately report suspicion of abuse and neglect to the Abuse Coordinator for Resident #1 and Resident #2 when both residents had been observed engaging in sexual activity on the memory care unit on 9/24/2025 at about 7:30 pm.2-- Resident #5 free from misappropriation when the Business Office Manager took his benefits card and spent $3,700.Action (Immediate): 1-Resident 1 and Resident 2 were immediately separated from each other. Residents 1 and 2 received head to toe assessments performed by charge nurse and an emotional assessment performed by social worker. The social worker performed trauma informed care assessment. No adverse findings noted. Medical Director was notified, and orders obtained for psychiatric services. Residents 1 and 2 were evaluated by Psychiatric services and medication changes were implemented. Resident 1 and 2 care plans and Kardex were updated to reflect the resident's history of resident-to-resident sexual activity. 2- The Business Office Manager was immediately terminated from employment at the facility on 9/17/25, and the local police department was notified on 9/17/25 of the misappropriation of resident funds.Completion Date: 10/1/2025Responsible: Administrator and/or Director of Nursing Action: (Identification) 1--All residents with behaviors documented as an incident report and/or in the progress notes for the previous 90 days will be reviewed to identify any other residents that may exhibit sexually inappropriate behaviors. If any behavioral events are identified the resident care plan and Kardex will be reviewed and updated, and interventions will be placed immediately. Zero out of 60 incident reports reviewed showed no adverse/inappropriate behavior. Daily audit of resident behaviors and interventions will be reviewed and noted in resident chart. Daily audits will be conducted for behavioral events for 14 days, then weekly x 30 days.2-- 2- On 9/18/25 The Regional Business Office director completed an audit for 70 residents' trust funds based on the immediate jeopardy, with no discrepancies noted. Start Date: 9/26/2025Completion Date: 10/1/2025Responsible: Administrator and/or Director of Nursing Action: (Prevention) 1--Education provided to Administrator and Director of Nursing on the abuse policy, investigating and reporting abuse per HHS and CMS regulations. Testing and discussion were utilized to assess the knowledge retention of the Administrator and the Director of Nursing.2--One-time weekly audits over the next 30 days by the Regional Business Office Manager. --One-time weekly Resident Funds Management Service audits over the next 30 days by the Regional Business Office Manager. If a discrepancy is found, it will be investigated by the regional business office manager, facility administrator, and Regional VP of Operations. This began on 9/19/25. Start Date: 9/26/2025 Completion Date: 10/1/2025Responsible: Administrator and/or Director of Nursing Action: (Prevention) 1. Abuse and Neglect: Types of abuse, including sexual abuse and when/who to report to (immediately & the administrator- abuse coordinator) 2. Resident to Resident: Recognizing behaviors, triggers, and how to effectively intervene. Staff will be educated to immediately separate the residents and implement 1:1 observation until instructed otherwise by the Administrator and/or Director of Nursing. All Facility staff will complete them prior to working their next shift. New employees and agency staff will be educated upon hire and/or prior to working a shift. Knowledge will be verified via test and verbal discussion with affirmative feedback. 2-- Staff that handle resident funds will undergo retraining on financial policies, ethical standards, and proper fund management procedures. Start Date: 9/26/2025 Completion Date: 10/1//2025Responsible: Administrator and/or Director of Nursing Action: (Monitoring) 1--The resident will be monitored for aggressive/inappropriate behaviors. When no longer exhibiting aggressive/inappropriate behavior that warranted the 1:1 observation the Interdisciplinary Team and Physician will collaborate for the discontinuation of 1:1 observation. 2--Weekly and as needed reconciliation of resident trust fund by the Business Office Manager/Regional Business Office Manager. Start Date: 9/26/2025Completion Date: 10/1/2025Responsible: Administrator and/or Director of Nursing/IDT/Physician The surveyor monitored the POR as follows: Record Review of abuse, neglect, exploitation Inservice completed by 10/03/25In an interview with CNA F on 10/03/25 at 12:00pm she stated she completed her abuse, neglect, exploitation in-service this morning and was given a test after completion. CNA F was able to provide types of abuse including physical, sexual, financial, and gave examples such as stealing a resident's money. CNA F Knew to report immediately if ever witnessed to the ADM.In an interview with RN G on 10/03/25 at 12:15pm she stated she was given in-service this morning over abuse, neglect, and exploitation. RN G knew to contact the ADM immediately if she ever witnessed and ANE. RN G knew types of abuse such as taking funds, sexual abuse, and talking bad to residents. RN G knew the signs of abuse/neglect and gave examples of not changing the residents and not caring for them.In an interview with CNA H on 10/03/25 at 1:42pm she stated as soon as she walked in the door this morning she was provided the abuse, neglect, exploitation training along with a test. CNA H gave examples of abuse /neglect such as yelling at a resident, ignoring call lights, sexual, mental, and stealing money from a resident. CNA H stated she was aware last week sometime that a resident had something stolen. CNA H stated she was aware she needed to report any ANE immediately to her Administrator.In an interview with MA I on 10/03/25 at 2:03pm she stated she received her in-service on 10/3/25 over abuse, neglect, and exploitation. MA I was able to give the types of abuse such as physical, mental, and financial. MA I was able to give an example of financial abuse by stealing or borrowing. MA I was able to give signs of abuse/neglect examples such as not changing residents, not feeding, or caring for them. MA stated she knew to report and ANE immediately to the ADM.In an interview with HK J on 10/03/25 at 2:36pm she stated that she received the in-service over abuse, neglect, and exploitation today. HK J knew to report to the ADM if she ever witnessed any abuse or neglect. HK J was able to give examples of abuse /neglect such as resident-to-resident aggression, verbal abuse, not wanting to help a resident, exploitation (stealing money).In an interview with the DM on 10/02/25 at 2:53pm she stated that she just had her inservice over exploitation in the DON's office. The DM stated taking a resident's magazine would be exploitation. The DM knew to report immediately to the ADM if she witnessed any abuse or neglect.In an interview with the DA on 10/02/25 at 3:07pm she stated she was in the DON's office just a while ago for in-service. The DA knew to report abuse, neglect, and exploitation to the ADM immediately. The DA gave an example of exploitation such as stealing money from a resident. While the IJ was removed on 10/03/25 at 5:12pm, the facility remained out of compliance at a level of no actual harm at a scope of pattern because the facility's need to evaluate the effectiveness of the corrective systems.Additional Findings included:3.) Resident #5Record review of Resident #5's admission record dated 10/02/25 documented a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #5 had diagnoses including: major depressive disorder (sadness), cognitive communication deficit (inability to communicate effective), and hypertension (high blood pressure).Record review of Resident #5's Quarterly MDS assessment, dated 09/23/25, revealed the resident had a BIMS score of 0 indicating the resident had severe cognitive impairment. Record review of Resident #5's care plan, dated 09/29/25, revealed Resident #5 was care planned for visually impaired and requires secure storage of personal items/medications in a lock box to ensure safety and prevent misuse or loss.An attempted interview with the BOM was made 10/02/25 at 4:30pm, 10/03/25 at 11:49am, and 10/03/25 at 3:37pm. Voice message was left and the BOM did not return call prior to facility exit 10/03/25.In an interview with the Marketing Director on 10/01/25 at 10:44am she stated that the BOM confessed to her on 9/16/25 around 6:00 PM that she took Resident #5's credit card and used it for her personal use. The Marketing Director stated the BOM stated that she had used $2000 and then stated $3000. The Marketing Director told the BOM that once she used the card she could not stop. The Marketing Director stated the BOM gave her the office key and stated she was not coming back to work because the police would be there. The Marketing Director stated she did not immediately report the incident to the ADM because she was still trying to process what the BOM just told her. The Marketing Director stated she reported to the ADM around 9:00am on 9/17/25. The Marketing Director stated it was expected for her to report to the abuse coordinator immediately after the BOM told her.In an interview with the ADM on 10/03/25 at 12:40pm she stated the Marketing Director did not contact her until the next day (could not recall the exact time, around 10:30am), after the BOM told her that she took Resident #5's credit card and used it for her personal use. The ADM stated it was expected for the Marketing Director to report to her immediately once she found out about the incident and not the next day.Review of facility policy Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, revised September 2022, reflected: Reporting Allegations to the Administrator and Authorities1. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law and HHSC reporting guidelines.2. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies:a. The state licensing/certification agency responsible for surveying/licensing the facility;b. The local/state ombudsman;c. The resident's representative;d. Adult protective services (where state law provides jurisdiction in long-term care);e. Law enforcement officials;f. The resident's attending physician; andg. The facility medical director.3. Immediately is defined as:a. within 2 hours of an allegation involving abuse or result in serious bodily injury; orb. within 24 hours of an allegation that does not involve abuse or result in serious bodily injury.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the residents environment remained as free of accident hazards as is possible and ensure each resident received adequate supervision for 2 of 8 residents (Resident #1 and Resident #2) reviewed for accidents and hazards. The facility failed to ensure Resident #1 did not elope from the facility on [DATE]. The facility failed to ensure Resident #2 did not elope from the facility [DATE]. An Immediate Jeopardy (IJ) existed from [DATE] - [DATE]. The IJ was determined to be at past noncompliance as the facility had implemented actions that corrected the deficient practice prior to the beginning of the investigation. This deficient practice placed residents at risk for falls, injuries, dehydration, and hospitalization. Findings included: Record review of Resident #1's admission recorded dated [DATE] documented a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses included: unspecified dementia (loss of memory, language, problem solving and other thinking abilities), mild protein-calorie malnutrition (protein intake that is insufficient to meet bodily demands for protein synthesis and tissue repair) and muscle weakness (lack of physical or muscle strength). Record review of Resident #1's Quarterly MDS assessment, dated [DATE], revealed the resident had a BIMS score of 06 indicating the resident had severe cognitive impairment. Record review of Resident #1's care plan, dated [DATE], revealed Resident #1 was care planned for neurocognitive disorder with Lewy bodies, risk for injury from wandering in an unsafe environment, cognitive loss/dementia, and falls. Review of Resident #1's nursing progress note dated [DATE], reflected resident told staff he wanted the manager to know he was not eating anything anymore and he hated living here. Review of an Elopement Risk Assessment date [DATE], reflected Resident #1 was a risk for elopement. No interview could be conducted with Resident #1 due to the Resident #1 being discharged to the VA hospital for behavioral support and elopement risks. Record review of Resident #2's admission recorded dated [DATE] documented a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #2 had diagnoses included: vascular dementia (chronic condition that affects the brain's ability to function by damaging blood vessels and reducing blood flow and oxygen supply), memory deficit (issue with forming, storing, or recalling memories), and anxiety (feeling of fear, dread, and uneasiness that can be a normal reaction of stress). Record review of Resident #2's Quarterly MDS assessment, dated [DATE], revealed the resident had a BIMS score of 05 indicating the resident had severe cognitive impairment. Record review of Resident #2's care plan, dated [DATE], revealed Resident #2 was care planned for episodes of anxiety, psychotropic drug use, dehydration/fluid maintenance, communication, visual function, cognitive loss/dementia, delirium, and elopement. Review of Resident #2's nursing progress note dated [DATE], reflected spoke Resident #2's and she said his worked at the hospital and that is probably why he went over there. Review of an Elopement Risk Assessment dated [DATE], reflected Resident #2 was a risk for elopement. During an interview with Resident #2 on [DATE] at 12:45pm, Resident #2 stated that he climbed over the fence with the chairs. Resident #2 did not state why he eloped but stated he felt safe and was ok. An interview with RN A on [DATE] at 10:00am, revealed RN A stated Resident #2 was outside in the courtyard a few minutes before smoke time. RN A stated that Resident #2 liked to go sit in the gazebo. RN A stated that Resident #2 was only outside for about 10-15 minutes. RN A stated that she was giving resident on the secure unit fluids when LVN A brought Resident #2 back in the secure unit and stated that he was found in the hospital parking lot across the street by a prn facility staff. RN A stated that Resident #2 did not let her assess lower body but only his upper body. RN A stated Resident #2 did not have any injuries from the elopement. RN A stated that since the incident no resident was allowed in the courtyard alone. RN A stated that Resident #2 was placed on 15-minute check. RN A stated when resident was allowed in the courtyard alone staff checked on the resident every 15-30 minutes while outside. RN A stated round inside the secure unit were done at least every two hours. RN A stated that Resident #2 could have been hit by a car, died from heat exhaustion, been injured or been abducted due to his elopement. An interview with the CNA A on [DATE] at 12:55pm, revealed she was an agency staff, and she was in-serviced on the visual check log, missing person policy, rounds and supervision. CNA A stated no resident can be left alone in the courtyard, elopement drill will be performed twice a week for the next five weeks, window alarms were installed on the windows in the secure unit, and window and window alarms checks will be done twice a week for the next five weeks. An interview with the DON on [DATE] at 1:55pm, revealed the DON stated that the facility in-serviced facility staff as well as agency staff on the visual check log, missing person policy, rounds and supervision. DON stated no resident could be left alone in the courtyard, elopement drill will be performed twice a week for the next five weeks, window alarms were installed on the windows in the secure unit, and window and window alarms check will be done twice a week for the next five weeks. DON stated that both Resident #1 and Resident #2 two used objects to get over the fence around the secure unit. DON stated that both residents could have been hit by cars, passed out, or gotten injured during the elopement incidents. An interview with ADM on [DATE] at 4:10pm, revealed that ADM stated in-services were done on visual check log, missing person policy, rounds, and supervision. ADM stated facility staff and agency were in-serviced on those topics of concern. ADM stated no resident can be left alone in the courtyard, elopement drill will be performed twice a week for the next five weeks, window alarms were installed on the windows in the secure unit, and window and window alarms check would be done twice a week for the next five weeks. ADM stated that both Resident #1 and Resident #2 two used objects to get over the fence around the secure unit. ADM stated that both residents could have been dehydrated, picked up by a stranger, fallen and gotten injured or hit by a car due to the elopement incidents. ADM stated she expected for staff to follow through with the invention put in place to ensure all residents were present and safe. Review of the facility's Safety and Supervision of Resident policy, dated 2001, revealed 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. Policy Interpretation and Implementation Facility Oriented Approach to Safety 1. Our facility-oriented approach to safety addresses risks for groups of residents. Resident Risks and Environmental Hazards 1. 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 the following: e. unsafe wandering . This noncompliance was identified as Past Noncompliance (PNC). The noncompliance began on [DATE] and ended on [DATE]. The facility had corrected the noncompliance before the survey began. The facility took the following actions to correct the non-compliance: - A Wandering/Elopement Assessment was conducted on all residents. - Resident #1 received 1:1 supervision until he was discharged to the VA hospital on [DATE]. - Observation on [DATE] at 12:45pm of window alarms were installed to all windows and were working properly on the secure unit. - On [DATE] Resident #1 was sent to the VA Hospital for elopement risk and behavioral support. - All staff were in-serviced on their Missing Person Policy, Rounds, and 1:1 supervision. - On [DATE] at 2:55pm reviewed Elopement Drills were conducted ([DATE] and [DATE]). Elopement drills are being conducted twice a week for the next five weeks. - On [DATE] reviewed the facility head count sheet. The facility was conducting a head count on all residents daily. - Visual check logs were being completed on residents in secure unit by the Nurse at the being of each shift and turned in to the DON daily. - On [DATE] at 3:00pm reviewed the window and window alarm checklist. The window and window alarm checks were being conducted five times a week (conducted by maintenance and weekend supervisor) - Resident #2 received 15-minute supervision checks implemented on [DATE]. The 15-minute checks were completed for 72 hours. Observed the 15-minute checks documentation on [DATE] at 11:15am. - Both Resident #1 and Resident #2 care planned were updated with elopement risk interventions. - Resident #1 and Resident #2 received nursing assessments no injuries noted from elopements. Resident #2 was seen by the NP, no med changes and had a follow up visit in two weeks. - On [DATE] QAPI meeting was conducted. - The facility and VA hospital will coordinate a safe placement for Resident #1.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure the resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 2 of 6 residents (Residents #1 and #4) reviewed for abuse. 1. The facility failed to ensure Resident #1 was protected from verbal and physical abuse by MA C. 2. The facility failed to ensure Resident #4 was protected from verbal abuse which included verbally aggressive behavior, such as screaming, cursing, bossing around/demanding, insulting to race or ethnic group and intimidating from CNA A. An Immediate Jeopardy (IJ) situation was identified on 04/23/23. While the IJ was removed on 04/25/23 at 4:40 PM, the facility remained out of compliance at a scope of pattern with actual harm, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed residents at risk for physical harm and severe negative psychosocial outcomes which could prevent them from achieving their highest practicable physical, mental, and psychosocial well-being. Findings include: 1. Record review of Resident #1's, undated, face sheet indicated a [AGE] year-old female who was last admitted to the facility on [DATE]. Her diagnoses included epilepsy (recurrent seizures), Parkinson's (a progressive disorder that affects the nervous system), Depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), Bipolar (a mental health condition that causes extreme mood swings that include emotional highs known as mania or hypomania and lows such as depression, Anxiety (a group of mental illnesses that cause constant fear and worry), and mixed receptive-expressive disorder (a communication disorder in which both the receptive and expressive areas of communication may be affected in any degree, from mild to severe). Record review of a Resident #1's quarterly MDS, dated [DATE], indicated a BIMS of 4, which indicated a severe cognitive impairment. Her bed mobility, transfer, dressing, eating, and personal hygiene functional status was 01, which indicated she required supervision for self-performance and support level for each was 01, which indicated setup help only. Record review of Resident #1's care plan, last reviewed/revised on 04/17/23, indicated she had a behavior of yelling and cussing at staff that started 04/13/23 and the approach was staff to calm and redirect resident when she became agitated. Record review of the facility event report, created 04/13/23, at 6:40 PM, by LVN I, stated Resident #1 attacked Medication Aide C. Record review of Resident #1's progress notes, printed 04/19/23, reflected no progress note, dated 04/13/23; no progress note documented the incident between Resident #1 and MA C Record review of Resident #2, undated, face sheet revealed a [AGE] year-old-male who was admitted to the facility on [DATE] with diagnoses which included fracture of the spine, and back pain. Record review of Resident #2 quarterly MDS, dated [DATE], revealed a BIMs of 15, which indicated the resident was cognitively intact. Record review of Resident #2's undated progress notes revealed no progress notes on 04/13/23 and no incident reports. During an interview on 04/19/23 at 4:00 pm with Resident #1 she began sobbing immediately and the DON arrived to comfort the resident, she was not interviewable. During an interview on 04/20/23 at 1:00 PM, MAINT B stated on 04/13/23 during a normal smoke break at 3:30 PM, Resident #1 was out of cigarettes and only had cigars. The resident got upset, stood up to staff and called her a fat bitch, Resident #1 was down the ramp a bit, he went to back her away the from road. MA C came in, numerous times Resident #1 stood up and MA C grabbed her by the pants and pulled her down. MA C grabbed Resident #1 by the head. MAINT B stated he froze up and walked away from situation, it diffused then he turned and saw the wheelchair at an angle with resident in it, almost tilted so Maint B went to Resident #1 and stabilized her wheelchair. MAINT B stated MA C said she could have used that rod in his hand a little while ago (during incident). Maint B told the ADON and DON immediately that Maint B witnessed MA C in a confrontation with Resident #1 because he was uncomfortable. MA C was sent home that day. He stated MA C went in and claimed Resident #1 scratched her and the Administrator leaned towards self defense. MA C said Resident #1 tried to burn her with a cigarette, Resident #1 was highly upset after the incident, asked them to call the cops and was crying. Even after the incident when everyone was back in the building, Resident #1 was screaming and hollering at MA C to get out. Resident #2, was very upset by the situation and told MAINT B that he needed to report it. During an interview on 04/20/23 at 1:30 PM with the DON, she stated MA C worked Saturday in the kitchen (after the incident with Resident #1 on Thursday (04/13/23) without contact with residents, then worked with residents on Monday as a medication aid, but due to new information MA C was then re-suspended Monday (04/17/23) evening at the end of her shift; she was originally suspended Thursday afternoon after the event (MA C abusing Resident #1) during the 3:30 PM smoke break. During an interview and observation on 04/20/23 at 1:55 PM with Resident #2, he stated Resident #1 was trying to go down the ramp in the smoking area and MA C grabbed her by the arm and they grappled. MA C grabbed Resident #1 by the head and twisted Resident #1's hair. Resident #1 hit her head on the bar by the ramp because she was upset with the situation. MA C made the MAINT B, who was out there at the time, leave (by upsetting him). Resident #1 was trying to go down the ramp. Resident #2 said he felt terrible about it (MA C abusing Resident #1), I couldn't do anything about it. He stated staff could put their hands on residents when they wanted and nothing happened (referring to staff being allowed to hit and grab residents abusively), he understood the resident had no choice when staff provided care. He stated Resident #1 was often crying constantly and no staff tried to comfort her or intervene with her (Resident #1 has behaviors of verbally crying and calling out, often tied to smoking). He stated the Adm won't listen to residents and always took the staff member's side (believed what staff said and ignored resident concerns). He was visibly upset when recounting the abuse of Resident #1 by MA C; his voice trembled and he got loud when he conveyed his frustration at not being able to intervene on behalf of Resident #1. He stated he felt helpless when he witnessed the abuse. During an interview on 04/20/23 at 2:22 PM, CNA K stated she did not witness the incident on Thursday (04/13/23), but was assigned to Resident #1's hall that day. Resident #1 was very upset and acted out a lot on Thursday (04/13/23) after the incident. She stated Resident #1 was upset, rocking back and forth and stated she wanted a cigarette and had other behaviors (crying often, hollering out) throughout the evening. During an interview on 04/20/23 at 2:24 PM with the DON, she stated MAINT B reported, around 3:45 PM, on Thursday (04/13/23), MA C tried to get Resident #1 to sit, and MA C could have had Resident #1 by the hair (DON said MANT B was not certain at that moment). The DON took MAINT B to the ADM. The ADM talked to MA C and got the DON, she said Resident #1 tried to burn MA C with a cigarette, was clawing at MA C, and MA C's ring may have caught in Resident #1's hair when she was defending herself from being burned by Resident #1. MA C was sent home at that time and ADM was investigating. During an interview on 04/20/23 at 3:00 PM with the ADM, she stated she talked to Maint B more about it on Monday which was when he said some things he did not mention on Thursday (04/13/23). MAINT B said Resident #1 was outside, upset, and went down the slope of the sidewalk. MA C grabbed Resident #1 by the pants and put her back in the chair, Resident #1 had got combative. MA C said to ADM that she tried to get Resident #1 to stop her from walking down the ramp. It was said Resident #1's hair was pulled, MA C denied pulling Resident #1's hair, MA C stated her ring may have gotten caught in it. The ADM stated she talked to Resident #1 on Thursday (04/13/23) around supper time, before 5 PM. There were no marks on Resident #1. MA C said she pulled the resident by the pants to get her to sit and not walk down the ramp. Resident #1 was fighting MA C; Resident #1 was angry that day. On Monday (04/17/23) MAINT B mentioned hair pulling, he wasn't sure what happened. CNA G came in and said something Monday (04/17/23), MA C was suspended in evening time. Staff were not trained to pull pants to get residents to sit down. The ADM said MA C had scratches on her and got them when she was trying to get Resident #1 to sit back down. MA C told her she did it because he did not want the resident to fall and it was the only way to keep her from falling. Resident #1 tried to burn her with her cigarette and the resident clawed MA C until she drew blood and almost knocked them both over. MA C was sent home Thursday, I thought it was the right thing to do at the time but she did not feel it was reportable at the time but she was investigating. In a confidential staff interview, staff stated one of the housekeepers came in and asked who they should report something to. Confidential Staff said Adm was in kitchen, notify DON. Confidential Staff member stated she went out smoke, a few residents were still outside, Resident #1 was upset and crying, Resident #1 was saying Mama that bitch pulled my hair, mama that bitch snatched me and she was telling that to LVN H. MA C said, she was tired of bringing them out to smoke because every time there was an issue with Resident #1. She was telling LVN H that, LVN H was trying to calm Resident #1. MA C said she was tired of it (Resident #1's behavior). Resident #1 said I'm tired of it too (MA C's arguing); arguing back and forth. MA C went closer to Resident #1. Resident #1 said again Mama she pulled my hair. MA C stated Resident #1 tried to burn her with a cigarette. Resident #1 jumped up from her wheelchair Resident #1 said Mama move I am going to whip that Bitch. The Confidential Staff member got between Resident #1 and MA C. MA C stated, yeah you scratched me, you had a hold of my arm, I bet you let go of my arm then Resident #1 got more upset. MA C said she was not going to allow the resident to hit her, and she was going to defend herself. The DON and ADON came out and grabbed Resident #1. Maint B had a stick in his hand, MA C said next time you need to let me have that (rod), Maint B said he had nothing to do with that and went back inside. MA C continued inflaming the other residents. Another resident offered her a cigarette (menthol), but MA C would not let the resident give Resident #1 a cigarette. MA C said she tried to burn her with a cigar. Confidential Staff stated what she witnessed verbal abuse of Resident #1 and mental abuse of Resident #1. She stated Resident #2 said that's wrong, she didn't have to do her like that, she was pulling her hair and everything. In a confidential staff interview staff stated she did not witness the incident but residents were upset and talked about it. After the incident on 04/13/23, staff was at the nurse's station and MA C sat down and said I am tired of this shit (said at the nurses station in front of staff and referring to Resident #1 having behaviors that revolved around smoking and MA C did not like taking Resident #1 out to smoke). Resident #1 arrived at the nurses station while that comment was said and Resident #1 tried to come into nursing station and said she (Resident #1) was going to get that bitch because she (MA C) pulled her hair. MAINT B calmed the resident down and took Resident #1 to the break room, got Resident #1 a soda, and Maint B pushed Resident #1 back to her room in her wheelchair. Confidential Staff stated that Maint B was supportive of Resident #1 and Resident #1 had a trusting relationship with Maint B; Maint B was often able to calm Resident #1. In a confidential resident interview of a resident stated resident was late to smoke on Thursday at the 3:30 PM smoke time, so they did not witness what occurred. However, they saw Resident #1 had MA C's arm behind her head. MA C was above Resident #1 and Resident #1 was in her wheelchair. She said she saw MA C put her hands on Resident #1's neck. In an interview on 04/21/23 at 4:35 PM, HK D via phone stated, she was out the entire time in the smoking area and Resident #1 was throwing a fit because she had no cigarettes, which was odd and it seemed her cigarettes were going missing, but there was a pack of donated cigars that were the size of cigarettes so Resident #1 was given one of those. Resident #1 called MA C a Fat Bitch and Resident #1 was going down the ramp (standing) and MA C moved several feet to where Resident #1 was and grabbed Resident #1 by her pants and pulled her down into her wheelchair twice. Resident #1 was upset and cussing, MA C pulled Resident #1's hair. MA C held Resident #1 in the chair for about 1 minute against Resident #1's will and was pulling the chair with Resident #1 in it toward the trash cans, still holding her down by the pant loop. Resident #1 was yelling you pulled my hair. She heard Resident #1 say she was going to call the police on MA C and MA C said they would take you (Resident #1) to jail. HK D went and told the ADON. She stated the ADM told HK D she should not say that she saw MA C pull Resident #1's hair if she spoke to the state. In an interview on 04/23/23 at 12:30 PM with MA C, she stated Resident #1 was upset there were no menthol cigarettes, in the can there were free cigars so she gave Resident #1 a cigar and lit it. Resident #1 started to cuss rant and [NAME] and she wanted another resident to give her a cigarette because she had menthol like Resident #1 liked. MA C stated she did not approve of a resident giving a cigarette to another resident. Resident #1 called her names we went further in the smoking area down the ramp she said no don't go further Resident #1 turned and slapped MA C. Resident #1 started to stand up he told her she had to sit because she had seizures and was not wearing her helmet. She grabbed her side to sit her down she had MA C's arm and was punching then reached out with the other hand to burn MA C. MA C stated she had a ring on her finger that was heart-shaped and it grabbed in the residents hair when she reached out so she didn't burn her with the cigar in her hand she got caught in the residents hair while she was trying to get her in her chair. A staff member from housekeeping got her up the ramp Resident #1 grabbed the rail to the ramp and dumped the trash can over. Resident #1 then calmed down and was fine it was all over a cigarette. A nurse came out, the DON or the ADON got her and took her back in she washed blood and stuff off of my arm. She was trying to stop her from burning herself. She did not want her disappearing She went inside and told the DON, and the administrator what happened. She took the residents out for the 11:00 AM smoke break on Monday. Resident #1 came up and apologized, said Mama, she am sorry and she told her she needed to control her temper. When the residents went out at 1:00 pm on Monday someone bought menthol cigarettes for Resident #1. MA C stated her last training on abuse was one month ago the facility did not train staff to touch residents or hold residents down by their pants. Resident #1 had fallen and hit her head in the past when she walked away when she got mad so she was protecting Resident #1. Around 6:55 PM, the DON went and said she was suspended again. She had my arm around her waist for 10 seconds each time and it happened twice during the incident. MAINT B got her to sit down. When asked if there was an incident when she and Resident #1 were back in the building on Thursday at the nurse's station she said Resident #1 screamed at her at the nurse's station, she walked off at the time Record review of the facility work schedule for 04/17/23 revealed MA C was scheduled to work from 7 AM to 7 PM on the 200 and 300 hall and her name was not crossed out for that shift. 2. Record review of Resident #4's, undated, face sheet revealed a [AGE] year-old-female who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included dementia, depression, and anemia (low red blood cell count). Record review of Resident #4's quarterly MDS, dated [DATE], revealed a BIMs score of 4, which indicated the resident had severely impaired cognition. Resident #4 used a walker for mobility and she did not exhibit any behaviors of physical or verbal aggression toward others or self. Record review of Resident #4's care plan, last updated 04/10/23, revealed falls were a problem area, with a start date of 09/28/22, and showed she suffered a fall on 12/20/22 related to confusion and self-transfers. The care plan approach included call bell in reach and explain/encourage use and answer promptly; another approach was don't rush the resident. Record review of Resident #4's medical record, from her visit to the emergency room on [DATE] at 4:12 PM, revealed ambulance medical technicians relayed to the emergency room staff Resident #4 had a witnessed fall at a nursing home and a CNA told the resident to turn around and get her walker and the resident fell in her doorway. Resident #4 told EMS a black girl beat her up and pushed her into the wall, she tore me up. The record further revealed the resident complained of 10 out of 10 pain in her right shoulder; there was a small laceration to the right cheek and lip area. A chest x-ray revealed a right anterior shoulder dislocation which was confirmed by a shoulder x-ray. The facility contacted adult protective services (APS) and provided both versions of the incident. The resident was transferred from the local hospital to another hospital because her dislocated shoulder had attempted reduction (put back in socket), multiple times,. Record review of Resident #4's medical record, from hospital #2, revealed she was admitted on [DATE] and discharged [DATE]. Resident #4 was treated for a right shoulder dislocation, pain management and increased blood pressure. The resident had urinary retention that required placement of a foley catheter while in hospital #2. There were small abrasions and ecchymosis (bruising) to right lower lip and right cheek. Resident #4 told staff at hospital #2 a girl cursed at her, hit her with a heavy object, and pushed her to the ground where she fell on her right shoulder and hip. During an interview and observation on 04/19/23 at 10:20 AM with Resident #4's family member, family member stated that on the day of Resident #4's fall, 04/06/23, Resident #4 stated she was hit and then fell to the floor. Resident #4 suffered a dislocated shoulder, her teeth were chipped and face was bloody. The Family Member said Resident #4 had no history of claiming assault; but she kept saying she hit me in my face several days in a row, and she kept saying she was scared. Family Member subsequently had Resident #4 removed from the secure unit on the 300 hall to the 400 hall because Resident #4 kept expressing fear related to the 300 hall. During an interview on 4/19/23 at 11:57 AM, CNA A, who was at work at the time of this interview, she stated she was the only direct care staff on the secure unit when 2 residents set off the alarm by pushing the door, so she went intervene. CNA A stated Resident #4 was upset that Resident #9 had urinated and defecated in her room, so CNA cleaned it up and then the door alarm went off again. CNA A said Resident #4 was yelling at Resident #9, who was by the door that was alarming. CNA A told Resident #4 to please go get your walker, three times, then turned back to the door alarm and heard Resident #4 hit the ground. She saw Resident #4 with her arm behind her back, face first on floor; arm ended tucked up under her, she doesn't walk off without walker often, she was in room when she fell. During an interview on 04/24/23 at 3:00 PM with HK D, she stated she was on the secure unit at the time when Resident #4 fell. She heard CNA A yelling and cussing at the residents and she pulled out her phone and recorded the audio of what CNA A was saying at the time Resident #4 fell. She provided a copy of the recording to the State Surveyor, which revealed CNA A saying yo mama, yo mama, Senorita then yelling at Resident #4 you go away, and Resident #4 was heard quietly saying shut up, CNA A said you are a mean old lady and I will call the law, Resident #4 could be heard saying I I I will call the nurse, then CNA A said something inaudible and then said not your conversation (twice), go about your work then her voice got louder and she said go away, this is me and him talking not you, go away, then a creaking noise could be heard and 2 squeaks and a scream from Resident #4 as she fell and at least one male voice saying Oh, then staff saying oh shit and then footsteps and the alarm sounded for the door to bring help to the secure unit. HK D stated she felt the way and what CNA A was saying to Resident #4 was verbal abuse and HK D immediately took the recording and played it for DON, but no one else asked to hear it and no follow up was done In an interview on 04/26/23 at 1:27 pm with ADM she stated she was unaware of the audio recording of the verbal abuse of Resident #4 and that the DON did not inform her that HK D played an audio recording of verbal abuse by CNA A to Resident #4. She stated CNA A would be terminated immediately. She also stated she would report the allegation of abuse immediately. Record review of the facility's schedule revealed that CNA A worked on 4/16/23, 4/17/23, 4/18/23, 4/19/23, and 4/20/23. Record review of the facility's, undated, nursing home resident rights policy stated the resident has a right to be free from abuse, neglect, exploitation, and misappropriation of property. Record review of the facility's preventing resident abuse policy, revised in January 2011, revealed the facility will not condone any form of resident abuse or neglect. This was determined to be an Immediate Jeopardy (IJ) on 04/23/23 at 2:35 PM. The Administrator and the Regional Director of Operations were notified. The ADM was provided with the IJ template on 04/23/23 at 2:35 pm. The following Plan of Removal submitted by the facility was accepted on 04/25/23 at 4:40 PM: Impact Statement: F600- Abuse The facility failed to keep residents free from abuse resulting in the abuse of one resident. All residents have the potential to be affected. [Residents #1 and #2] were assessed by RN and support was provided as accepted, physician was notified of the deficiency on 4/23/23. There were no new orders obtained. The affected resident's responsible party was notified by Administrator of alleged deficiencies and a plan of correction. On 4/23/2023 the Administrator, Director of Nursing Assistant Director of Nursing, and Social Worker interviewed all residents in the facility to determine if any other residents were affected by this event or had any physical or psychosocial distress. No residents had any concerns regarding the identified citation of abuse. The interviews were completed on 4/24/23. Ad-Hoc Quality Assurance and Performance Improvement meeting was held on 4/23/2023, with the Medical Director, NHA (Nursing Home Administrator), RDO (Regional Director of Operations), Director of Nursing, and Assistant Director of Nursing to review the deficiencies, Abuse prevention, abuse investigations, unexplained injuries, preventing abuse, protecting residents during abuse, identifying signs of abuse, reporting abuse to facility management, reporting resident to resident abuse, policy and procedure, and the plan for removal of immediacy. On 4/23/2023 the RDO completed 1:1 in-service on Abuse with the Administrator, Director of Nursing, and Assistant Director of Nursing. Starting on 4/23/2023, the facility leadership (Administrator, Director of Nursing, and Regional Director) will complete education with all staff on abuse, to ensure that each resident receives services consistent with the professional standards of practice, comprehensive person-centered care plan, and the resident's goals and preferences. The training was initiated on 4/23/2023 and will be completed on 4/24/2023. Staff will sign in for the in-service. If they are not able to attend in person, then the DON/designee will complete a 1 on 1 in-service due to having to complete the in-service via phone. Staff will be reminded of who the abuse coordinator is in the facility. Staff will not be allowed to work until they receive the training. RDO will verify the completion of the training and in servicing. The policy pertaining to Abuse was reviewed on 4/23/2023 by the NHA (Nursing Home Administrator), Director of Nursing, RDO (Regional Director of Operations), and Medical Director. No changes made to the abuse policy Starting on 4/23/2023, IDT (Interdisciplinary team), including the Administrator, Director of Nursing, Assistant Director of Nursing, MDS Coordinator, Activity Director, HR, and BOM will meet with all residents daily from Monday to Friday, and Manager on Duty Saturday and Sunday to determine if any allegations of abuse arise for 4 weeks, then PRN. The findings will be brought up to the Administrator for further action within 24 hours if necessary. Grievances will be reviewed during the morning meetings with the Administrator and IDT team members for any follow-up needed. All grievances will be entered into the Grievance log by the Administrator starting 4/23/2023 and the investigation form will be filled out by the Administrator accordingly as an ongoing process. On 4/23/2023 the RDO will start reviewing the Grievance log and investigation forms weekly for four (4) weeks followed by monthly reviews after this will be ongoing. 4/23/2023 RDO will provide physical oversight at the facility weekly x4 weeks and then monthly x 2 months. The Administrator/designee will monitor compliance that the IDT team is meeting with the residents regarding their grievances or any alleged abuse by completing an audit of ten (10) residents per week for four (4) weeks. This was initiated on 4/24/2023. Any identified concern will be addressed within 24 hours and if trends and patterns are identified, the facility will conduct an Ad-Hoc QAPI via phone meeting to discuss if additional interventions are needed to ensure compliance for the next 2 months. The Administrator will be responsible for ensuring this plan is completed on 4/24/2023. The RDO will provide oversight of the Administrator to ensure that the items on the plan of removal are reviewed and completed for 2 months or until cleared of cited deficiencies. POR monitoring included the following: In an observation on 04/24/23 at 3:30 PM in the 200 hall walk through revealed no concerns. In an observation on 04/24/23 at 3:52 PM in the 300 hall secure unit revealed Staff interacting with residents appropriately. In an interview on 04/24/23 at 4:40 PM the COO stated MA C, the staff from the altercation incident, was terminated yesterday (04/23/23), once they completed their interviews with witnesses. There was additional information that had come to light so they made the decision to terminate her. Record review of in-service sheets, dated 04/23/23 and 04/24/23, revealed facility training of recognition of abuse, neglect and exploitation and reporting of events for all staff and administration. Record review on 05/19/23 of the sign-in sheets revealed 91 staff members had been in-serviced on abuse and 8 staff were trained via telephone. Record review of the sign-in sheet dated 04/23/23 for the Quality Assurance and Performance Improvement committee revealed that the RDO, ADM, DON, Medical Director, and ADON attended the meeting. Record review of in-service sheet dated 04/23/23 from 3:00 pm - 3:15 pm revealed one-on-one instruction related to abuse, neglect, and reporting provided by the RDO and signed by the DON and ADM; no mention of the ADON was documented on this form. In an interview on 05/19/23 at 4:45 pm ADM stated the one-on-one training with the RDO discussed the following topics: Abuse, types of abuse, when to report, abuse investigations, injuries of unknown, abuse prevention, protecting resident during abuse investigations, recognizing signs and symptoms of abuse/neglect, and reporting abuse to facility management. She confirmed the DON resigned 05/16/23. In an interview on 05/19/23 at 5:00 pm ADON stated the one-on-one training with the RDO discussed the follow topics: Abuse, types of abuse, when to report, abuse investigations, injuries of unknown origin, abuse prevention, protection of the resident during abuse investigations, recognizing signs and symptoms of abuse/neglect, and reporting abuse to facility management. Record review of the Termination Record dated 04/23/23 for MA C confirmed she was terminated on 04/23/23 and her last day worked was 04/17/23. Record review of the Employee Status List for the facility revealed MA C's name with a line drawn through it and term under Employee Status. Record review revealed safe survey for all resident at the facility has been completed. Further POR monitoring revealed: In an observation on 05/19/23 at 1:25 PM signage was posted on the facility entrance and hand sanitizer was available. The halls appeared neat, clean, and free of odor. All residents appeared neat and well groomed. In an interview on 05/19/23 at 1:55 with CNA L, she stated she has been working at the facility for 5 years and worked the 6am - 6pm shift and her job duties were grooming, shaving, showering and toileting residents. She stated she had not witnessed any abuse or neglect but stated she would stop it, then make sure the resident was safe then report to the abuse coordinator (ADM) or ADON. CNA L stated she had been in-serviced on abuse and neglect and gave the example of physical (hitting a resident) and verbal abuse (talk to resident in a mean tone or cursing a resident). In an interview on 05/19/23 at 2:00 pm with CNA M, she stated she had worked at the facility for 1 year and worked the 6am-6pm shift. CNA M stated that her job duties were to feed residents, showering residents, and keeping residents safe. She had not witnessed any abuse or neglect but stated she would stop the incident, make sure the resident was safe, and notify the abuse coordinator (ADM). CNA M stated she had been in-serviced on abuse and neglect and gave an example for physical abuse (hitting or pushing a resident) and verbal abuse (yelling at a resident or cursing at a resident). In an interview on 05/19/23 at 2:20 pm with CNA N, she stated she had worked at the facility for 5 years and worked the 6pm-6am shift. CNA N's job duties were to help residents with daily routines, and check and change residents. She had not witnessed any abuse or neglect but stated she would ensure the resident was safe then report the incident to the abuse coordinator (ADM), ADON or charge nurse. CNA N had been in-serviced on abuse and neglect, and she gave the example of physical (hitting a resident) and verbal abuse (yelling or screaming at a resident). In an interview on 05/19/23 at 2:30 pm with CNA O, she stated she had worked here for 2 years and worked the 6pm-6am shift. She stated her job duties were to change residents, assist with toileting, assisting residents in getting ready for bed and making sure [TRUNCATED]