**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents were free from abuse for 2 of 6 residents (Resident #6 and Resident #8) reviewed for abuse. 1. The facility failed to ensure Resident #8 had the right to be free from abuse on 03/01/25 when Resident #9 hit him with a ruler 2-3 times, as the argument escalated further, Resident #9 then stabbed Resident #8 with a pen which resulted in scratches on his abdomen and the back of his neck. Resident #8 was sent to the hospital for further evaluation. 2. The facility failed to ensure Resident #6 had the right to be free from abuse when Resident #7 pushed her on 03/09/25 while on the secure unit, causing Resident #6 to fall which resulted in a right hip fracture that required a hospital stay and surgery to repair the injury. The noncompliance was identified as PNC. The IJ began on 03/01/25 and ended on 03/09/25. The facility had corrected the noncompliance before the investigation visit began. This failure placed residents at risk for injury, hospitalization, and emotional distress. Findings included: 1. Record review of Resident #8's face sheet, dated 06/19/25, reflected the resident was a [AGE] year-old male who admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #8's Quarterly MDS Assessment, dated 05/15/25, reflected his BIMS score was blank, indicating severe cognitive impairment. Her diagnoses included Seizure Disorder or Epilepsy, Bipolar Disorder and Schizophrenia. Record review of Resident #'8s care plan, updated 02/20/25, reflected Resident #8 was a fall risk related to fall [03/01/25]. Goals: Resident will be free from complications related to falling. Resident at risk for falls, resident safety will be maintained. Interventions included to Administer first aid as needed. Assess contributing factors related to fall history. Assess for potential fall-related injury prevention, looking at circumstances, location, new or worsening medical problems. Keep call light and most frequently used personal items withing reach. Record review of Resident #8's Nurses Notes dated 03/01/25 written by LVN AA reflected the following: Upon arrival to resident room, Resident witnessed to be positioned on the floor of his room perpendicular to the foot of his bed. Resident noted to have [varies] wounds on his body starting at the base of his neck an approximate 1.5-2 cm laceration, on his right proximate of spine there are 2 bright red scratched on his back. There were two superficial lacerations observed on upper abdomen. On the left shoulder the resident appears to possess a contusion. The neighboring end table appeared to have been flipped over laying on top of a broken bedside table. Various contents of food were on the floor of the room. The resident's G-tube was still connected at the item of the incident. When arriving to the room the G-tube was paused and disconnected. When assessing the resident, breathing was even but labored related to an emotional state of distress. Resident was redirected verbally to a state of ease. Resident was alert and oriented to person and place. Resident stated, I'm ok, but my neck hurts a little, resident was referred to hospital for further evaluation due to unwitnessed patent altercation. Family and Administrative staff has been notified of incident. Record review of Resident #8's Nurses Notes dated 03/01/25 written by LVN OO reflected the following: Resident was evaluated after altercation between roommate and self. Due to present injuries on body, Resident will be sent emergency room by Emergency Service to hospital. Resident is alert and orientated to person, place, and time. Resident sated to possess pain localized at the back of his head. Record review of Resident #8's Nurses Notes dated 03/01/25 written by LVN AA reflected the following: Resident returned from hospital with no change in condition. Resident was transferred to room [ROOM NUMBER]a. Vistal signs 119/96-83-17-98.5 New order for Bacitracin 500gm apply topically twice a day for 7 days. Nurse Practitioner made aware of new order. Skin assessment completed left voice message with his mother to contact the facility regarding update. Call light in reach. Plan of care ongoing. Record review of LVN OO's interview statement dated 03/01/25 at 12:30 PM reflected Did not hear commotion, was alerted resident was on the floor. When I arrived to the room, I witnessed [Resident #9] ]sitting at the end of hall and [Resident #8] was on the floor. I asked [Resident #8] how he got on the floor he stated, he did it. First aide was provided for superficial scratches, transported to the emergency room for evaluation and treatment. Record review of Resident #8's Psychiatric Periodic Evaluation, dated 03/03/25, reflected the following: Patient lying in bed with multiple scratches/abrasions over body. Tube feeds infusing. Patient was involved in altercation with his roommate 2 days ago. Per nursing report roommate attacked the patient. Patient was sent out to the ER for evaluations of wounds and PEG tube positioning. Patient was sent back to facility with bacitracin ordered twice daily to wounds. Patient denies any complaints at this time. Observation and interview on 06/18/25 at 10:35 AM with Resident #8 revealed him stating he stabbed me, and I had to go to the hospital, he wanted to get his anger out on me. He had a weapon, stabbing me in the stomach and the neck area. (Surveyor observations did not reveal any skin tears or scratches) To be that angry and take it out on someone, it was methodically planned out. Resident #8 stated he stayed at the hospital for a day and returned to the facility to a new room. Resident #8 stated he felt nervous and upset about the incident at the time, however now felt safe to remain in the facility, that he did not see Resident #9, but if he did, he would avoid him. Resident #8 expressed he never got his map pencils and activity books back, he believed that Resident #9 stole them, he did not want to bring that up to staff, he would let it go. Interview on 06/18/25 at 11:34 AM with Resident #9 revealed he was in his room, sitting in wheelchair soaking his feet looking at activity books. According to Resident #9, there was a lot going on between he and Resident #8, Resident #9 stated it escalated so fast that it got out of hand. We both said some racial things to each other, then it got physical between us. I was trying to defend myself, I hit him on the right shoulder with a wood staff, like a ruler 2-3 times. [Resident #8] kept talking and agitating me, so I picked up a pen and stabbed him in the left collar bone. One of the nurses came by and stopped the incident. When she asked what happened I told her that I was in the restroom and when I came out, I saw him on my side of the room trying to get something. [Resident #9] stated that he knew [Resident #8] was weak on one side of his body therefore he could have very well just fell out of the bed and landed on his side of the room, but it all escalated very fast. Interview on 06/18/25 at 1:32 PM with CNA I revealed Resident #8 was seen on the floor when she entered the room to pick up food trays. CNA I stated Resident #8 was laying flat on his back, Resident #9 was sitting on the side of his bed. CNA I stated Resident #8 was saying something like he did it, my roommate did this to me. CNA I stated Resident #8 was yelling and upset, when she entered the room she noticed Resident #8 with scratches with some bleeding, at this point she alerted the nurse. According to CNA I, Resident #9 was usually a loner and keeps to himself. Interview on 06/18/25 at 2:18 PM with LVN AA revealed she was working the opposite side of the hall, but due to the situation she came to help LVN OO. LVN AA stated Resident #9 was removed from the room to keep both residents safe. Resident #9 was sitting down the hall away from the room. LVN AA stated the room presented that violence had occurred, room was in shambles, furniture was flipped over, food was all over the floor, Resident #8 was on the floor. Resident #8 had abrasion to his abdomen and there was a laceration to the back of his neck. LVN AA explained Resident #9 was sitting down the hall, with a blank stare, rocking back and forth. According to LVN AA she did not see a weapon or device in Resident #9's hands, but she did not want to get too close. LVN AA stated she had never observed any aggressive behaviors with Resident #9 prior to this incident. LVN AA stated when speaking with the MDS Coordinator, Resident #9 reported he needed help, mediation was provided to him, and he was sent out to hospital for evaluation. LVN AA stated Resident #8 was transported to the hospital for further evaluation, returned to the facility, and relocated to a different room. LVN AA stated Resident #9 also transferred for medication evaluation. She stated upon his return, he was also relocated to a private room. Interview on 06/18/25 at 3:04 PM with MDS Coordinator PP revealed she was alerted to the altercation between Resident #8 and Resident #9, Resident #9 was on my angel rounds, we had a good rapport, so I went to speak with him. At the time, Resident #8 was sent out to hospital for further evaluation, Resident #9 was sitting on his bed. MDS Coordinator PP stated, the room was disheveled with stuff all over the floor from the altercation., She stated when asked if he was ok, Resident #9 responded he was ok, just injustice going on, I just need my medications. MDS Coordinator PP stated Resident #9 stated he had refused his medication that morning, so she went to consult with staff to his medication administered. MDS Coordinator PP stated, there had not been any concerns or behaviors expressed by Resident #9 prior to this incident, he is usually quiet and to himself. Interview on 06/19/25 at 12:30 PM with the Assistant Administrator revealed she was notified about the altercation between Resident #8 and Resident #9. she was told that Resident #8 was found on the floor by staff, and that he was yelling he did it referring to Resident #9 whom was his roommate at the time. The Assistant Administrator stated Resident #8 was assessed and sent out the hospital for further evaluation, and Resident #9 remained in his room with one-on-one monitoring until he was sent out for psychiatric evaluations that day as well. According to the Assistant Administrator, in-services were completed with all staff on abuse, neglect, and resident to resident altercations; to also notify the Administrator, DON, family, and physician. The Assistant Administrator stated resident to resident altercations placed residents at risk of harm, all staff were responsible for resident safety and to separate immediately when there is a reported resident to resident altercation. 2. Record review of Resident #6's face sheet, dated 06/19/25, reflected the resident was a [AGE] year-old female who admitted to the facility on [DATE]. Record review of Resident #6's Quarterly MDS Assessment, dated 12/15/24, reflected her BIMS score was blank, indicating severe cognitive impairment. Her diagnoses included hip fracture, Non-Alzheimer's Dementia, and anxiety disorder. The MDS indicated she utilized a walker and wheelchair for mobility. Record review of Resident #6's care plan, updated 03/14/25, reflected she was a fall risk evidenced by fall within the last month. Goal: Resident at risk for fall resident safety will be maintained. Interventions included to anticipate resident's needs check frequently. Assess contributing factors related to fall history. Assess medications for contributing factors. Assist resident with toileting as needed. Keep call light and most frequently used personal items within reach. Keep glasses clean and fit with adequate prescription. Remind resident to call when needing assistance. Impaired physical mobility evidenced by left side weakness. Goal: Resident will maintain or improve physical function in Bed Mobility, Transfer, Ambulation, Locomotion, and Range of Motion. Interventions included to provide appropriate level of assistance to promote safety of resident. Record review of Resident #6's Nurses Notes dated 03/09/25 written by LVN QQ reflected the following: 4:21 PM - Resident was standing in common area on the side of another resident's wheelchair, when the resident pushed her down causing her to fall to the floor landing on her back. While attempting to stand Resident up, she began to yell she is also noted to yell when left hand is touched. There is no discoloration noted to hand. Nurse Practitioner notified with new order given for x-rays. Xray notified. Responsible Party and DON notified with message left as there were no answers. 6:26 PM - Xray performed to bilateral hips, bilateral femurs, and left wrist at 5:00 PM. Awaiting results at this time. 8:41 PM - Spoke with DON regarding incident. Xray confirms fracture to left wrist and hip. Nurse Practitioner was called and new order to transport to hospital emergency department was received and processed. Transportation notified with an estimated time of arrival 1 hour and 15 minutes. Resident at this time remains lying in bed on back with eyes closed. Attempts X 3 made to call report to RN at the hospital emergency room, with no answer to call. Resident transferred by stretcher to emergency department accompanied by emergency medical transportation service X2 at 9:30 PM. 03/14/25 8:06 PM - Resident readmitted to facility by stretcher accompanied by emergency medical transportation service X2. Alert to name, orders and advance directive verified by Nurse Practitioner on call for doctor. Resident admitted to hospice. Resident is noted with bruising to back of both hands, there are 24 staples noted to left hip. There is no cast or sling noted to fracture of left wrist. All activities of daily living are provided by 1-2 staff members, resident not able to make needs known due to not making complete sentences, needs are anticipated by staff. Record review of Resident #6's hospital records dated 03/18/25 with discharged date of 03/14/25 reflected the following: Reason for Admission- Chief complaint Patient presents with Fall. Discharge Diagnoses - Principal Problem: Hip Fracture. Active Problem: Wrist fracture. Operative Procedures: Hemi Arthroplasty Hip Anterior Approach Left. Hospital Course: Comminuted and displaced left femoral neck fracture s/p fall . Record review of LVN QQ's interview statement dated 03/09/25 at 7:00 PM reflected [Resident #6] approached Resident #7 while siting the in the wheelchair. Resident #7 began arguing with Resident #6 to move away from her wheelchair and pushed her away from her. Resident #6 fell on her left side and had difficulty bearing weight on her left leg. Physician was contacted and stat x-ray was ordered as a precaution, pain medication given and assisted to bed for comfort. Resident #7 was placed on 15-minute checks as a precaution. Interview on 06/18/25 at 4:07 PM with CNA JJ revealed she worked closely with both Resident #6 and Resident #7. CNA JJ stated Resident #6 used to walk really good around in the television room, had never had behaviors towards staff or other residents, however now upon her return from the hospital she is wheelchair bound. Resident #7 can be aggressive at times and will push others. According to CNA JJ staff often will educate Resident #7 on resident-to-resident altercations, redirect her and complete one on one monitoring when was having behaviors. Interview on 06/18/25 at 3:56 PM with LVN Y revealed during the 2:00 PM-10:00 PM shift, she was sitting at the nursing station when she heard Resident #7 get upset, she was loudly screaming at Resident #6. LVN Y stated by the time she got to both residents to separate them, Resident #7 had pushed Resident #6 down. LVN Y stated she asked what happened however she stated I knew quickly that [Resident #6] was in pain when she grabbed her hip, and I observed her foot was turned in. I called emergency services and she was transferred to the hospital. According to LVN Y the altercation was not provoked, Resident #7 had a temper and did not like to be touched. LVN Y stated, [Resident #7] was educated on sharing space in the television room and on altercations. She was placed on 15-minute checks for behaviors. Attempted interview by phone on 06/18/25 with LVN QQ was unsuccessful. Interview on 06/18/25 at 4:24 PM with the ADON revealed she was not present during the resident-to-resident altercation between Resident #6 and Resident #7. The ADON stated Resident #7 was someone staff had to keep an eye on with constant monitoring because she does not like others in her space. The ADON stated she expected staff to act quickly when there was an altercation between residents. The ADON stated staff were to separate, deescalate the situation, keep residents safe, document the incident and provide 15-minute checks on residents for further behaviors. The ADON stated the CNAs were to notify nursing staff with any allegations of abuse and incidents between residents. The Nurses were to investigate, contact family, physician, and management after assessing to ensure residents were safe. Not doing so placed residents at risk of unknown or delayed injuries. Interview on 06/19/25 at 2:30 PM with the DON revealed Resident #6 had a fall in the memory care unit during an altercation with Resident #7. The DON stated Resident #6 was sent to the hospital in pain. The DON stated, upon findings from the hospital, [Resident #6] had a pathological fracture which led me to believe the fracture could have been there regardless of the fall, The DON stated she did not believe the fracture resulted from Resident #7 pushing Resident #6. The DON further stated upon her investigation with Resident #8, he reported to her that he slid out of his bed, there was not an actual altercation between he and Resident #9. The DON stated in both altercations residents were separated, Resident # 6 was sent to the hospital immediately after the incident due to complaint of pain, Resident #7 was placed on monitoring, Resident #8 was sent to hospital for further evaluation to ensure he was ok, and Resident #9 was sent out for psychiatric evaluation. The DON stated she expected all staff to report any allegations of abuse to the Abuse Coordinator which was the Administrator and herself immediately. The DON stated all staff was to intervene and separate residents to deescalate the situation. The DON stated residents are monitored every 15 minutes for safety for 72 hours, the family and physicians were notified of the incidents. The DON stated the inhouse psychiatrist was also notified to evaluate medications, and if he was not available, residents were sent to a psychiatric facility to be evaluated. The DON stated if these steps were not followed, residents are placed at risk for safety and feeling secure in their environment. The DON stated in-services were completed on both reported incidents to ensure resident safety. Interview on 06/19/25 at 2:59 PM with the Administrator revealed he was the abuse coordinator for the whole campus. The Administrator said all staff were responsible for monitoring residents and their behaviors to ensure they were not getting into an altercation with each other. The Administrator said several things could happen to residents if they were to get into an altercation with each other such as harm or injury. The Administrator said because of the residents' diagnoses, a lot of times they did not remember what they did or who they did something to. The Administrator stated all staff were in-serviced on signs and symptoms of abuse and neglect along with resident-to-resident altercations. Record review of the facility's Abuse, Neglect and Exploitation and Misappropriation of Resident Property policy, dated 02/12/20, reflected: Policy 1. Resident Rights. Each resident has the right to be free from abuse, neglect, exploitation, misappropriation of resident's property, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse, neglect, exploitation, misappropriation of resident's property by anyone, including, but not limited to, facility staff, other residents, consultants, volunteers, staff of other agencies serving the resident, family members, legal guardians, resident representative, friends, or other individuals. 2. Facility Duty to Protect Resident Rights. The facility must prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident's property. This was determined to be a Past Non-Compliance Immediate Jeopardy on 06/18/23 at 4:45 PM. The Administrator and the DON were notified. The Administrator was provided with the IJ template on 06/18/25 at 6:35 PM. The facility took the following actions to correct the non-compliance prior to the abbreviated survey: 1. Record review of an in-service, dated 03/01/25, reflected 34 staff including nurses, nurse aides, housekeeping, medication aide, Business Office Manager, and dietary aides were in-serviced regarding Abuse & Neglect, Abuse Coordinator, Resident Behaviors, Fall Prevention. Record review of Safe surveys were completed on 03/01/25 with five residents with no issues noted. Record review of Resident #8's clinical records reflected Resident # 8was transported to the hospital on [DATE] for further evaluation. Upon return Resident #8 was relocated to another room on 03/01/25. Record review of Resident #8's psych services notes reflected Resident #8 was seen by psych on 03/03/25, and no medication adjustments were made. Record review of Resident #9's clinical records reflected Resident #9 was placed on one-on-one supervision until he was sent to the hospital for further evaluation and medications adjustment. Record review of Resident #9's clinical records reflected Resident #9 was relocated to a private room on 03/01/25. Record review of Resident #9's psych services notes reflected Resident #9 was seen by psych on 03/04/25, medications were adjusted. Resident #9 received an order for Seroquel 150MG, 1.5 TAB PO BID for schizoaffective disorder. Record review of Resident #9's clinical records reflected Resident #9 was being monitored for behaviors throughout each shift. 2. Record review of an in-service, dated 03/09/25, reflected 50 staff including nurses, nurse aides, housekeeping, medication aide, Business Office Manager, dietary aides, and transportation staff were in-serviced regarding Abuse, neglect and exploitation and misappropriation of resident property, Fall Precaution/Fall management, Behaviors (Altercations) of Residents. Record review of safe surveys completed by the facility on 03/10/25 reflected five residents reported no issues. Record review of Resident #6's clinical records reflected Resident #6 was at the hospital from [DATE] and discharged on 03/14/25. Resident #6 had surgery. Resident #6 was provided with pain medication every 4 hours as needed for pain. Record review of Resident #6's clinical records reflected Resident #6 was being monitored for pain. Record review of Resident #7's clinical records reflected she was placed on q15 check for 72 hours. Facility continued to monitor behaviors and document. Record review of Resident #7's progress notes reflected Resident #7's medications were reviewed by Hospice and no new orders were given. Observations completed on 06/18/25 from 11:00 AM through 06/19/25 4:00 PM in the South building and North building memory care unit revealed residents engaged in activities, staff were providing snacks. Observed staff monitoring and redirecting residents from wandering and unwanted behaviors. No observations of aggressive behaviors. Observed staff answering call lights and completing rounds every 2 hours. Interviews on 06/18/25 from 11:22 AM through 06/19/25 3:30 PM with MDS Coordinator PP, LVN OO, LVN LL, CNA JJ, CNA EE, ADON, CNA B, Wound Care Nurse F, CAN I, CNA L, CMA K, RN X, CNA V, LVN Y, LVN AA, CMA RR, CNA SS, CMA TT, LVN UU, Activity Director, [NAME] K, Housekeeping R, Floor Tech Q, CNA J, CNA W. The facility staff were able to verify education was provided to them. Facility staff were able to accurately summarize abuse and neglect, how to work with residents with behaviors, immediately separate residents in altercations and report and fall prevention. Facility staff stated they monitor residents throughout the shifts, if known behaviors they will redirect them, placed them on 1:1 or q15 minute checks depending on the behavior. Staff stated for residents who have had altercations or incidents they monitor closely, keep them separated to prevent any further incidents. Staff stated they provide activities to keep them engaged and provide snacks throughout the day. Staff stated upon shift change they will notify the incoming staff of any incidents or behaviors.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as is possible and each resident received adequate supervision and assistive devices to prevent accidents for 1 of 5 residents (Resident #1) reviewed for supervision. The facility failed to ensure Resident #1 who had a history of wandering and exit-seeking, was provided with adequate supervision to prevent her from eloping on 06/09/25. Resident #1 was found 5 minutes away from the facility by police and was transported to the hospital for evaluation due to the resident experiencing hallucinations and delusions. The noncompliance was identified as a past non-compliance. The Immediate Jeopardy (IJ) began on 06/09/25 and ended on 06/10/25. The facility had corrected the noncompliance before the survey began. This failure placed residents at risk of harm and/or serious injury. Findings included: Record review of Resident #1's face sheet, dated 06/18/25, reflected the resident was a [AGE] year-old female who was admitted to the facility on [DATE]. Record review of Resident #1's quarterly MDS assessment, dated 06/05/25, reflected her diagnoses included unspecified dementia, severe, with other behavioral disturbance, schizophrenia, and delusional disorders. Resident #1's BIMS score was 00 which indicated severe cognitive impairment. The MDS further revealed Section E - Behaviors indicated Resident #1 exhibited wandering behaviors. Record review of Resident #1's care plan, dated 06/04/25, reflected: Care Area/Problem: Attempted to Elopement: Resident is Exit seeking, high elopement risk. Goal: Resident safety will be maintained over the next 90 days. Interventions: Assess for contributing sensory. Check resident location every 15 minutes. Maintain behavior log. Notify physician and family/responsible party. Remove resident from immediate situation to assure safety. Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Record review of Resident #1's Resident Visual Monitoring dated 06/04/25-06/05/25 reflected Resident #1 was on 1:1 supervision. Record review of Resident #1's Nurse Visual Check Individual Resident Monitoring dated 06/06/25 - 06/09/25 reflected Resident #1 was on 15 minutes checks. Record review of Resident #1's progress notes dated 06/09/25 at 6:54 PM by LVN A reflected the following entries: 7:30 AM - in room dressed for the day 7:46 AM - CNA summoned resident to the dining room for breakfast and noted resident not in room and window broken. CNA notified nurse and I contacted DON and Administrator. Staff began searching unit and grounds. All other doors and courtyard exit found to be in locked position. 8:00 AM - unable to find resident in building or on grounds, contacted PD [Police Number] for missing resident. 8:15 AM [Police Department] police contacted nurse, [LVN A], LVN stating they have resident in custody. 8:20 AM - Administrator and nursing staff attempting to calm resident along with PD, but resident remained belligerent and psychotic. Currently, she is delusional and believes buzzards are raping her and nursing staff are putting a curse on her. 8:25 AM - Attempted to transport resident for further evaluation and care via facility van without success. 8:39 AM - [Police Department] PD unable to coax resident in car or ambulance and were forced to restrain resident with handcuffs for everyone's safety and then transported to [Hospital] for further evaluation and treatment. 8:39 AM - Nursing staff at ER bedside to give report on patient. ER nurse stated they would have to continue to restrain her and give her some medication in order to do a proper exam. At bedside, no outward sign of injury or c/o pain noticed. unable to contact family members on file as there is no working number. PCP notified of incident. Record review of the facility's Provider Investigation Report, completed by the Assistant Administrator on 06/16/25, reflected the following: Incident date: 06/09/2025, Time of Incident: 07:45 AM Resident noted by staff to not be in room and window broken. Perimeter search completed and [Police Department] police notified. Assessment Date 06/09/25; Time: 08:15 AM; Resident assessed and no apparent injuries noted. Perimeter search and [Police Department] police notified. Physician [name], notified. Family [name], notified. Safe surveys completed. Staff in-service on Elopement procedures. Entire facility check to ensure all residents accounted for. Investigation Summary: Resident noted by nursing staff to not be in room or on south memory community. Resident room noted with broken window. Perimeter search completed and [Police Department] located resident after resident noted missing and transported resident to [hospital] ER for psychiatric evaluation. Staff interview state resident was currently on every 15 minute checks and when checked resident not in room and window broken. Staff state perimeter check completed and when not able to locate during perimeter check [police department] police were notified. Staff interview stat resident had no attempted to leave memory unit prior to this incident. Resident placed on q 15 minute checks due to pacing and wandering in and out of other resident rooms. Chat review reflects resident referred to psych service for behavioral and medication management. Provider Action Taken Post-Investigation: Resident care plan to be updated upon return from hospital. All staff in-service on Elopement procedures. Window alarms ordered for memory care windows. Resident elopement risk assessments updated. Care plans reviewed and updated for elopement risk residents. QAPI meeting conducted with Medical Director to review elopement protocols and action plan. Record review of CNA C statement, dated 06/09/25 at 9:00 AM, reflected: Summoned resident for breakfast and noticed she was missing from her room and window was broken notified charge nurse immediately and assisted in search for resident. Record review of LVN A statement, dated 06/09/25 at 9:00AM reflected: CNA notified nurse that resident was missing from room and window was broken. We immediately contacted DON/admin and began search on unit and grounds. Admin assisted with search effort and 911 called; last time seen: 7:30, summoned for breakfast 0745, called DON/ED 0746, began search 0746, called 911 0800, police located resident 0815, staff/admin 0820, 0839 [Police} police restrained resident and escorted to [hospital] for further evaluation and treatment. Interview on 06/18/25 at 11:27 AM, CNA B revealed she worked the day Resident #1 eloped from the facility. She stated she was not the CNA assigned to Resident #1. She stated she could not recall the exact time, but she observed Resident #1 standing by her room door and then she closed the door. She stated Resident #1 was on q15 minutes checks and LVN A was completing them. She stated from what she was told Resident #1 was last seen at 7:30 AM in her room, then at 7:45 AM CNA C went to inform Resident #1 it was time for breakfast and that is when they realize she was gone. She stated Resident #1 broke the window and jumped the fence. She stated they called Code Green and initiated a search inside and outside the facility and notified the police department. She stated Resident #1 was found by the police department, unknown where she found. She stated prior to Resident #1's elopement, the resident was placed on 1:1 supervision and then q15 minute checks because Resident #1 was having behaviors and pacing up and down. She stated they were in-serviced on abuse, neglect, and elopement. She stated the facility added alarms to all residents' windows. An attempt was made to contact LVN A on 06/18/25 at 11:55 AM by phone; however, there was no answer. Interview on 06/18/25 at 2:05 PM, the DON revealed Resident #1 eloped from the facility on 06/09/25. She stated she received a call from LVN A at 7:46 AM and informed her Resident #1 had broken the window from her room. She stated they initiated a search inside and outside the facility. She stated the police was notified and they were able to locate Resident #1 about .5 miles from the facility. She stated Resident #1 was a fast walker, when she was found she had no injuries; however, resident was having behaviors and the police decided to take her to the hospital for further evaluation. She stated prior to Resident #1 elopement, resident was not exit-seeking; however, she was pacing the hall and wandering into residents' rooms. She stated Resident #1 had history of eloping at home. She stated since Resident #1 was wandering into residents' room and pacing the hall, as an intervention, they placed Resident #1 on 1:1 supervision and then she was doing better and placed Resident #1 on q15 minute checks. She stated staff were completing q15 minutes checks when Resident #1 eloped, the last time she was observed was at 7:30 AM and then noticed she was gone at 7:45 AM. She stated all staff were in-serviced on abuse and neglect, and elopement. She stated alarms were also added to both North and South memory care unit and they also implemented resident logs which have to be completed before a resident was taken off the unit either for a visit or therapy session. Interview on 06/18/25 at 3:26 PM, the Administrator revealed he had arrived at the facility when he was informed Resident #1 had broken her room window and eloped. He stated the staff had initiated a search inside and outside facility grounds. He stated the police were notified, and the police was able to locate Resident #1 about 5 minutes from the facility. He stated he went to the scene were Resident #1 was located, he stated resident was having behaviors and was transported to the hospital for further evaluation. He stated prior to Resident #1's elopement, they had interventions in place due to Resident #1 having behaviors and refusing medications. He stated Resident #1 was placed on 1:1 and then q15 minute checks due to the resident pacing the halls and wandering into residents' rooms. He stated when Resident #1 eloped, staff were still completing q15 minute checks on Resident #1. He stated they in-serviced all staff on abuse and neglect and elopement. He stated they added alarms to all windows in the memory care unit. The Administrator stated Resident #1 had not returned to the facility since incident. Interview on 06/19/25 at 10:16 AM, CNA C revealed she was the CNA assigned to Resident #1 when she eloped. She stated the last time she observed Resident #1 was around 6:15 AM in her room. She stated Resident #1 was on q15 minutes check and LVN A was completing them while she was assisting other residents with getting them up for the day. She stated when it was time for breakfast, she went to Resident #1's room and that was when she noticed Resident #1 was not in the room and the window was broken. She stated she notified LVN A and they began a search for Resident #1. She stated she was in-serviced on abuse and neglect, and elopement. Record review of facility Elopement Management policy, revised 05/02/25, reflected the following: An immediate investigation and search will be conducted if a resident is considered missing. The resident will be located and returned to a safe environment within standard practice guidelines. This was determined to be a Past Non-Compliance Immediate Jeopardy on 06/18/23 at 4:45 PM. The Administrator and the DON were notified. The Administrator was provided with the IJ template on 06/18/25 at 6:35 PM. The facility took the following actions to correct the non-compliance prior to the abbreviated survey: Record review revealed an elopement assessment were reviewed and completed on residents on 06/09/25. Record review of safe surveys completed by the facility on 06/09/25 with five residents reflected there were no issues noted. Record review of the facility's South Memory Unit Elopement binder located at the nurses' station reflected the binder contained pictures of residents, who were elopement risk, and contained information regarding the residents. Record review of the facility's Resident Log on North and South Memory Unit reflected residents were being signed out when taken off unit for therapy sessions. Observation on 06/18/25 at 11:34 AM revealed all windows in the South Memory Unit had an alarm. Alarms were loud enough to be heard throughout the unit. Record review of the following in-services dated 06/09/2025 reflected all facility staff were in-serviced on abuse, neglect, elopement, missing person, and Code [NAME] for elopements/missing persons. The in-services were conducted and signed by all facility staff. Interviews on 06/18/25 from 11:22 AM through 06/19/25 at 3:30 PM with CNA B, CNA C, LVN D, CNA E, Wound Care Nurse F, MDS Coordinator G, MDS Coordinator H, CNA I, CNA J, CMA K, CNA L, CNA M, [NAME] K. Physical Therapy O, CNA P, Floor Tech Q, Housekeeping R, Housekeeping Supervisor S, LVN/Coordinator T, LVN U, CNA V, CNA W, RN X, LVN Y, LVN Z, LVN AA, LVN BB, LVN CC, CNA EE, CNA FF, CNA GG, CNA HH, Activity Assistant, and the Assistant Administrator revealed the facility staff were able to verify education was provided to them. Facility staff were able to accurately summarize missing person/elopement policy, missing/elopement code, abuse and neglect, completing head counts before and after shift change and alarms added to all windows in the memory care unit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents were free from abuse for one of six residents (Resident #6) reviewed for abuse. The facility failed to ensure Resident #6 had the right to be free from abuse when Resident #7 punched and then pushed her on 02/05/25 located on a secure unit, causing Resident #6 to fall which resulted in a right hip fracture that required a hospital stay and surgery to repair the injury. The noncompliance was identified as PNC. The IJ began on 02/05/25 and ended on 02/05/25. The facility had corrected the noncompliance before the survey began. This failure placed residents at risk for abuse. Findings included: Record review of Resident #6's face sheet, dated 02/26/25, reflected the resident was an [AGE] year-old female who admitted to the facility on [DATE]. Record review of Resident #6's Quarterly MDS Assessment, dated 02/12/25, reflected she had a BIMS score of 01, indicating severe cognitive impairment. Her diagnoses included hip fracture, anxiety disorder, and other orthopedic condition. The MDS indicated she had no behaviors of any kind and that she utilized a wheelchair. Record review of Resident #6's care plan, updated 01/13/25, reflected she was a fall risk. Record review of Resident #6's Nurses Notes reflected the following: - Resident noted standing up off from couch when another resident pushed her, and she went down landing on her sacral area resident removed from area made safe during assessment resident screaming and protecting right leg and hip area prn apap given dr [Physician Z] called 911 called DON preset and aware family called and message left resident transferred to [Hospital Y] for evaluation. Written on 02/05/25 by LVN X. - 1830; Met with [Resident #6's RP] in person to discuss fall and injury. She was made aware, per investigation, fellow resident pushed her as she was standing from sofa, she lost her balance and fell landing on her buttocks. [Resident #6] complained of pain to her right hip and thigh area, could not recall event or how she landed on floor. [Resident #6's RP] informed resident was sent to ER at [Hospital Y] due to c/o pain and inability to bear weight on right leg . written on 02/05/25 by the DON. - Resident returned from [Hospital Y] via stretcher and EMT with oxygen therapy at 2L/min via nasal cannula at 1810. Resident diagnosed with subcapital fracture of the right femoral neck. Resident surgical wound is clean and dry, with no signs of infection . Written by RN W on 02/08/25. Record review of Resident #6's hospital records reflected the following: Hospital Course: patient got into physical altercation with another resident, they pushed to this patient [sic] to the ground when she landed on her bottom, she developed severe pain in the right hip, presented to the ER where she was found to have right neck femur fracture, s/p surgery 02/06 .Active Problems: Closed fracture of neck of right femur . Observation and interview on 02/26/25 at 1:40 PM with Resident #6 revealed she was sitting on the couch in the common area. Resident #6 had her wheelchair next to her and said she was doing okay. Resident #6 said she was not in any pain and felt safe in the facility. Resident #6 said she never had a fall or had anyone push her in the facility before. Attempted phone interview on 02/26/25 at 1:57 PM with Resident #6's RP was unsuccessful as they did not answer or call back. Record review of Resident #7's face sheet, dated 02/26/25, reflected the resident was a [AGE] year-old female who admitted to the facility on [DATE]. Record review of Resident #7's Quarterly MDS Assessment, dated 02/12/25, reflected she had a BIMS score of 07, indicating severe cognitive impairment. Her diagnoses included other neurological conditions, Alzheimer's disease, and anxiety disorder. Her MDS indicated she did not have any behaviors towards anyone. Record review of Resident #7's care plan, updated 04/08/25, did not reflect or include anything about her behaviors. Record review of Resident #7's Nurses Notes reflected the following: - Resident very disruptive and verbally aggressive with other residents, walked over to sofa and pushed another resident unprovoked and then went directly to her room. Dose not recall incident but is paranoid that fellow residents are taking her belongings. DON notified and gave directive to contact PCP for order to send resident to [Hospital S] for eval and treatment, message left with [Resident #7's RP] NO ANSWER WHEN CALLED, [NP N] contacted, order received to send out for eval. Resident placed on 1:1 monitoring until transferred to [Hospital S]. written on 02/05/25 by the DON. - Resident return from [Hospital S] via EMT at 10:19. Resident is alert, appears calm and cooperative at this time. DON and family member notified. Plan of care continues. Written on 02/05/25 by the DON. Record review of Resident #7's Psychiatric Periodic Evaluation, dated 02/07/25, reflected the following: .[Resident #7] is seen today per staff request due to reports of increased anxiety, compulsivity, restlessness, and for psychotropics management. Resident is sitting up in the common area, she is calm at the moment and denying any pain or discomfort. Aspiration of reports of recent mood swing, agitation, and restlessness reported by nursing staff, patient started crying, and reports that people are 'getting to her face'. She reports mood swing, and spontaneous anxiety and agitation. Chart reviewed, medication profile reviewed, she is on the following psychotropics with no noticeable adverse effects: Aricept 10mg po daily for dementia, Levothyroxine 100 mcg for hypothyroidism, Cymbalta 20 mg p.o. twice daily for depression/anxiety lamotrigine 25 mg p.o. twice for mood regulation, and Atarax 25 mg po daily for anxiety. Due to reports of mood swing, and spontaneous combativeness, will increase lamotrigine and monitor closely. Nursing staff notified. Observation and interview on 02/26/25 at 1:42 PM with Resident #7 revealed she was sitting on a different couch in the common area. Resident #7 said she was doing okay and sometimes argued with others, but she never got into a fight with anyone or pushed anyone down. Resident #7 said she felt safe in the facility. Attempted phone interview on 02/26/25 at 1:55 PM with Resident #7's RP was unsuccessful as they did not answer or call back. Interview on the phone on 02/26/25 at 12:15 PM with CNA V revealed Resident #7 had a tendency to go off and always think someone was in her room. CNA V said she was down the hall making up a resident's bed when Resident #7 was upset at another resident saying things like she's going to jail and I'm going to kill her. CNA V said Resident #7 was not referring to Resident #6 at this time, but she de-escalated the situation and sat Resident #7 down on the couch. CNA V said she turned around and started to walk to the nurse's station when Resident #6 asked to go to the bathroom and stood up to get off the couch. CNA V said Resident #7 went over to Resident #6, punched her, then pushed her to the ground. CNA V said she ran over to the residents and asked Resident #7 why she did that and noticed Resident #7 was still trying to go after Resident #6 who was on the ground. CNA V said everything happened so fast but she was trying to get Resident #7 away from the situation and have her go to her room. CNA V said Resident #6 went to the hospital that night and did not come back for a few days and had a hip fracture. CNA V said Resident #7 was more alert than other residents on the secured unit because one of her triggers was when residents went down the hall who did not have rooms down there. CNA V said she was in-serviced after the incident happened on abuse and resident-to-resident altercations and knew to immediately separate residents and de-escalate any situation between residents. Interview on the phone on 02/26/25 at 12:43 PM with CNA U revealed it was after a meal one day (02/05/25), Resident #7 said that Resident #6 went to her room and stole something and then there was a lot of commotion. CNA U said she went towards Residents #6 and #7 to divide them up because Resident #7 had punched Resident #6 and then pushed her down to the ground. CNA U said she told Resident #7 not to do that and to let staff handle the situation but Resident #6 was already on the ground. CNA U said she was not working on the secured unit at the time but had just stopped by to drop something off. CNA U said she thought Resident #6 was injured when she said her head was hurting and she could not walk. CNA U said she was in-serviced after the incident happened on abuse and resident-to-resident altercations and knew to immediately separate residents and de-escalate any situation between residents. Interview on 02/26/25 at 1:34 PM with LVN X revealed Resident #6 was a sweet lady and Resident #7 was very nasty with her mouth and bossy. LVN X said on 02/05/25, Resident #7 was amped up for whatever reason and staff were not sure why. LVN X said Resident #6 was getting off the couch while talking to Resident #7 when Resident #7 pushed Resident #6. LVN X said she did not witness what happened but heard about it from another aide. LVN X said when Resident #6 was on the ground she called 911 and sent her to the hospital. LVN X said during her assessment while checking Resident #6's range of motion, she yelled when assessing her right side. LVN X said after the incident happened, the NP came to see Resident #7 and adjusted her medications which seems to have worked because she's been extremely pleasant and calm ever since. LVN X said she's never seen Resident #7 be physically aggressive towards others, only verbally aggressive. LVN X said she was in-serviced after the incident happened on abuse and resident-to-resident altercations and knew to immediately separate residents and de-escalate any situation between residents. Interview on 02/26/25 at 1:43 PM with CNA T revealed she was leaving the shower room and heard Resident #7 talking loudly and arguing about something when she hauled off and hit Resident #6 who fell down. CNA T said Resident #7 did not have any injuries from this situation but Resident #6 did because she was grabbing her leg and crying and saying her leg was hurting. CNA T said Resident #6 was sent to the hospital afterwards. CNA T said Resident #7 yells at others when she thought someone was stealing her clothes, but no one was. CNA T said she had never seen Resident #7 be physically aggressive towards anyone before this. CNA T said she was in-serviced after the incident happened on abuse and resident-to-resident altercations and knew to immediately separate residents and de-escalate any situation between residents. Interview on the phone on 02/26/25 at 2:14 PM with NP O revealed Resident #7 she had episodes of psychosis based on her thinking people were taking her things from her room. NP O said Resident #7 was very paranoid and had mood swings with agitation, so she was eventually moved to the all-female secured unit. NP O said he was informed Resident #7 was involved in a resident-to-resident altercation, so he went to assess her and review her medications. NP O said based on the assessment, he thought she needed mood stabilizers, so he added those to her orders. NP O said since then, Resident #7 was more stable and engaged in activities that she's participating more in. NP O said he was not aware of any other physical altercation Resident #7 was involved in. NP O said Resident #7 was now more redirectable. Interview on 02/26/25 at 3:19 PM with the DON revealed the day the incident occurred, LVN X was here and came to get the DON because she was concerned about Resident #6's leg. The DON said she was told that Resident #6 was trying to stand and Resident #7 pushed her, causing Resident #6 to lose her balance and fall in a squatting position since she's so tall. The DON said Resident #6 fell on her bottom and complained of her leg hurting. The DON said she was worried Resident #6 had a fracture from the incident. The DON said Resident #7 had walked away from the situation and went to her room but was clueless about what had just happened. The DON said Resident #7 was put on one-to-one care until she was sent to [Hospital S] where she was evaluated and sent back to the facility the same day. The DON said Resident #7 was also seen by the NP who adjusted her meds and she had been quiet ever since. The DON said Resident #7 had a behavior of thinking someone was stealing her clothes and would get upset but never became violent with anyone. The DON said she was not told that Resident #7 had first punched Resident #6 before pushing her down. The DON said after the situation happened, staff were in-serviced regarding abuse, resident-to-resident altercations, and frequent visual checks of residents. Interview on 02/26/25 at 4:01 PM with the Administrator revealed he was the abuse coordinator for the whole campus, but he had an Administrator's Assistant who was also the abuse coordinator for the South building where Residents #6 and #7 were. The Administrator said he understood that Resident #6 stood up from the sofa and Resident #7 pushed her causing her to fall to the ground when she started to complain of pain. The Administrator said Resident #6 was sent out to have x-rays done which showed she had a fracture. The Administrator said all staff were responsible for monitoring resident's and their behaviors to ensure they were not getting into an altercation with each other. The Administrator said several things could happen to residents if they were to get into an altercation with each other such as harm. The Administrator said because of the resident's diagnoses a lot of times they did not remember what they did or who they did something to. Interview on 02/26/25 at 4:17 PM with the Administrator's Assistant revealed based on what she heard and through her investigation, Resident #7 was the aggressor towards Resident #6. The Administrator's Assistant said Resident #6 was on the couch and as she was getting up, Resident #7 pushed her causing her to fall to the ground. The Administrator's Assistant said the charge nurse did an assessment on Resident #6 and found that she was complaining of pain, so she was sent to the hospital. The Administrator's Assistant said at the hospital, x-rays were done where it was found she had a fracture which required surgery to repair it. The Administrator's Assistant said there had not been any other instances of physical aggression from Resident #7 before this. The Administrator's Assistant said she was also the abuse coordinator for the facility and staff were to report any instance or allegation of abuse to her. The Administrator's Assistant said all residents have the right to be free from abuse in the facility. The Administrator's Assistant said she was not told that Resident #7 punched Resident #6 in the face. The Administrator's Assistant said staff were in-serviced regarding abuse, resident-to-resident altercations, and frequent visual checks of residents. Record review of a provider investigation report reflected the following information: Investigation Summary: On 2/5/25, a resident-to-resident altercation occurred between [Resident #6] and [Resident #7], both residing in the South Memory Community. The incident occurred when [Resident #7], who was loudly fussing, accused [Resident #6] of entering her room. As [Resident #6] attempted to rise from the couch in the dining room, [Resident #7] pushed [Resident #6], causing [Resident #6] to fall to the floor and land on her sacral area. Nursing staff were present and immediately intervened, separating the residents. A head-to-toe assessment was conducted for both residents by the charge nurse, [LVN X]. [Resident #6] complained of right hip pain, held her right leg, and was unable to bear weight on it. Although no visible injuries were noted and vital signs stable. Pain medication was administered and [Resident #6] was sent to the ER for further evaluation and treatment. [Resident #7], [sic] no adverse effect and injuries noted, vital signs stable. Placed on 1:1 supervision pending a transfer to [Hospital S]. Notifications made to Family, [Resident #6's RP and Resident #7's RP] notified. [Physician R and Physician Q] notified. Interview and statements collected from witnesses present attached. Social worker conducted safety survey, noting no concerns. Staff in-service [sic] resident to resident altercation, resident behaviors, resident 1:1, abuse and neglect. [Resident #6] was admitted to the hospital and underwent surgery for a right hip repair. She returned to the facility on 2/8/25 with new order for Tylenol 3 and a follow-up appointment scheduled with [Physician P] on 2/20/25 at 11:30 AM. She is currently alert and resting in bed. [Resident #7] was placed on 1:1 supervision pending a transfer to [Hospital S]. On 2/5/25, [Resident #7] was evaluated by [Hospital S] and cleared to return to the facility the same day. Q15-minute checks were conducted for 72 hours per facility. [Resident #7] is currently cooperative and participating in normal activities without further incidents. Record review of resident safe surveys revealed 5 were completed with residents on 02/05/25 with no additional findings of any other abuse in the facility. Record review of an in-service, dated 02/05/25, reflected staff were in-serviced regarding abuse, falls, resident monitoring, injury of unknown origin, and resident-to-resident altercation. Record review of the facility's Abuse, Neglect and Exploitation and Misappropriation of Resident Property policy, dated 02/12/20, reflected: Policy 1. Resident Rights. Each resident has the right to be free from abuse, neglect, exploitation, misappropriation of resident's property, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse, neglect, exploitation, misappropriation of resident's property by anyone, including, but not limited to, facility staff, other residents, consultants, volunteers, staff of other agencies serving the resident, family members, legal guardians, resident representative, friends, or other individuals. 2. Facility Duty to Protect Resident Rights. The facility must prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident's property. The Administrator was notified on 03/12/25 at 10:00 AM that a past non-compliance IJ situation had been identified due to the above failures. It was determined this failure placed Resident #6 in an IJ situation on 02/05/25.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents had the right to be free from abuse for 1 (Resident #11) of 6 residents reviewed for abuse. The facility failed to supervise and protect Resident #11 from Resident #12, who had a diagnosis of dementia with a behavioral disturbance and was acting out on auditory hallucinations to hit other residents. On 04/02/24, Resident #11 was found on the floor, crying with bloody nostrils, while Resident #12 was standing over her yelling in an aggressive manner. The noncompliance was identified as PNC. The IJ began on 03/27/24 and ended on 04/03/24. The facility had corrected the noncompliance before the investigation began. This failure could place residents at risk of abuse, physical harm, mental anguish, and emotional distress. Finding included: Review of Resident #11's face sheet, dated 04/18/24, reflected the resident was a [AGE] year-old female who admitted to the facility on [DATE]. Her diagnoses included dementia (a condition characterized by the gradual decline of memory, language, and other cognitive abilities). Review of Resident #11's quarterly MDS assessment, dated 03/15/24, reflected she had a BIMS score of 00, indicating sever cognitive impairment. Further review revealed Resident #11 had not had any physical or verbal behaviors directed towards others. Review of Resident #11's undated care plan reflected: Care Area/Problem: *Fall Risk [04/03/24: Updated], Related To: Fall 4/2/24 .[sic]. Review of Resident #11's Psychiatric Periodic Evaluation, dated 03/21/24, reflected under History of Present Illness: Today, resident is seated in the TV room alert and oriented x1 in no distress or discomfort. She is pleasantly confused and collateral information is gathered from Medical records adn staff. Per satf, residenthas been calm with less aggression and is redirectable [sic] Review of Resident #11's hospital records, dated 04/05/24, reflected the following: Chief complaint: Domestic Violence .[Resident #11] .presents to the ED with epistaxis [Bleeding from the nostril, nasal cavity or nasopharynx] secondary to an assault which occurred prior to arrival by another fellow nursing home resident. EMS brought patient from facility and reports that they found patient on the ground bleeding from bilateral nares [ the external openings in human nose that leads to the nasal cavity] .Patient endorses facial pain and neck pain . and Discussed case with [hospital doctor]. Reviewed CT and states that current fracture is benign and non displaced (meaning the bone cracked in only one place and remained aligned without shifting). And Final diagnoses: epistaxis due to trauma, facial pain, assault, maxillary fracture (a break in the upper jaw bone) , left side, initial encounter for closed fracture. Review of Resident #12's face sheet, dated 04/18/24, reflected she was a [AGE] year-old female who admitted to the facility on [DATE] and discharged on 04/03/24. Her diagnoses included depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety disorder (a group of mental illnesses that cause constant fear and worry), senile degeneration of the brain (the mental deterioration (loss of intellectual ability) that is associated with or the characteristics of old age), and dementia with behavioral disturbance (a condition characterized by the gradual decline of memory, language, and other cognitive abilities). Review of Resident #12's quarterly MDS assessment, dated 03/08/24, reflected she had a BIMS score of 00, indicating severe cognitive impairment. Further review revealed Resident #12 had not had any physical or verbal behaviors directed towards others. Review of Resident #12's physician's orders, printed 04/18/24 , reflected the following: Transfer to hospital for increased aggression and psych evaluation with a start date of 04/03/24. Review of Resident #12's undated care plan reflected: Care Area/Problem: *Behavioral Changes, Evidence By: Behavioral Aggression, angry/aggressive behavior .Interventions: Frequent visual checks, Maintain behavior log .[sic]. And Physically Aggressive, Related To: Altercation 3/27/24, Altercation 3/28/24 x2, Altercation 3/29/24, Altercation 03/30/24 .Interventions: 15min monitoring . Review of Resident #12's Psychiatric Periodic Evaluation, dated 03/26/24, reflected under History of Present Illness: .[Resident #12] is being seen for follow up, medication check and to monitor for staff c/o of increased anxiety, aggression and irritability .Per staff, resident has been walking up and down the hallway hitting other residents with her doll and getting aggressive and unredirectable. resident is posing a risk to self and others and staff is having to monitor her 1:1. I have instructed staff to continuously monitor and redirect resident. [sic] Review of Resident #12's progress notes reflected the following entries: - On 03/13/24 written by ADON Y, Resident noted with increased agitation, routine buspar administered per orders , redirected to activities, psych NP notified. - On 03/21/24 written by LVN X, Resident is exhibiting aggressive behaviors, constant redirecting by staff noted. - On 03/27/24 written by ADON W, 0930- Resident walking past nurse's station and physically hit another resident on the side of the head with her hand unprovoked. Resident continued walking down hallway and threw garment down while yelling out. - On 03/27/24 written by ADON W, 0939- contacted [Psych NP]. Received new telephone orders .for aggression and agitation .Initiated increased monitoring. - On 03/27/24 written by ADON W, 0955- Contacted patient's [family member], [Resident #12's RP] for update and consent for new medication orders. [Resident #12's RP] refused medications at this time. States, Because [Resident #12] hit someone today yall want to drug her up with medications? No. Don't give her anything. I'm coming up there. Attempted to educate on medications and increased aggression. [Resident #12's RP] continued to refuse treatment. Notified DON. [sic] - On 03/27/24 written by ADON W, 1600 [4:00 PM]- New order per [NP V]: Collect UA .for increased agitation . - On 03/27/24 written by LVN U, 7:30pm- Resident was involved in altercation with another resident. She was swinging her baby doll at the other resident hitting her in the face. Residents were separated. Resident was assessed and no injuries were observed. - On 03/28/24 written by LVN T, Pt is continuing to have random outburst where she is aggressive and agitated for no apparent reason. Pt outburst are not directed towards any individual but general to whomever .Later that day around 10:30 Pt hit a random resident for no reason and walk off afterwards. will continue to monitor. [sic] - On 03/29/24 written by NP Z, .Patient with dementia with agitation and behaviors. Patient resides on memory care unit. She is uncooperative with care .Had an incident where she was aggressive towards another resident for no reason . - On 03/29/24 written by LVN S, 0900:) Resident observed standing in the hallway near her room yelling and making threats at other resident walking in the hallway. Staff re-directed resident and escorted the other residents to their destination. 0930:) Resident observed hitting a male resident with a closed fist in his chest while walking past him in the hallway. Staff re-directed patient and escorted the male resident to his destination. No injuries noted. Management contacted resident's [family member] to notify of behaviors and also requested the [family member] to come into facility to discuss a treatment plan to reduce/prevent these episodes. - On 03/30/24 written by LVN T, Pt was walking down the hallway to hit another resident with her baby doll. Family and MD was noticed will continue to monitor. [sic] - On 04/02/24 written by LVN U, Resident is having auditory hallucinations, she stated her [family member] is telling her to hit other residents. - On 04/02/24 written by LVN R, resident noted with aggression towards other residents, RP contacted and made aware of situation stated [NAME] wanted to speak with social worker at this time. - On 04/02/24 written by ADON Y, Spoke to NP regarding family refusal to allow psych treatment, per NP attempted to call family on multiple attempts with no return call or answer. Resident observed with no behaviors at this time per NP if aggressive behaviors send to ER for further psych evaluation. - On 04/02/24 written by LVN U, Resident was involved in an altercation with another resident. Resident was found standing over another resident while they were on the floor and yelling at them. - On 04/03/24 written by ADON W, 0140- New order to send to [hospital] for increased and psych evaluation. Review of Resident #12's social services notes reflected the following: - On 04/01/24 written by the SW, Call placed to the [family member] and RP for the resident in order to discuss the increased aggression by the resident toward the other residents on the unit. The residents current medical status was discussed and the resident currently has a UTI that is on the second day of treatment . - On 04/02/24 written by the SW, Report received from the Unit staff that the resident continues to be a danger to the other residents on the Memory Unit due to increasing aggression toward residents on the unit. This resident has initiated two physical altercations towards other residents and is stating her [family member] is telling her to 'get them'. The resident has verbalized Auditory Hallucinations and admits to acting out as a result of the voices and commands she believes she is hearing. Medication management has been attempted but the residents' [family member] continues to refuse any attempts at medical intervention. The resident will be referred again for Inpatient psychiatric evaluation for stabilization due to increasing physical aggression and Auditory Hallucinations. [sic]. Review of Resident #12's Individual Resident Monitoring Nurse Visual Checks revealed they were started on 03/27/24 and ended on 03/29/24. Staff were documenting where the resident was seen every 15 minutes . Interview via phone on 04/18/24 at 12:37 PM with RN P revealed the incident between Residents #12 and #11 occurred during her shift. RN P said she turned the corner and Resident #11 was on the floor and Resident #12 was standing over her. RN P said she found the residents like this outside of Resident #12's room. RN P said as she got closer to the two residents, she noticed that Resident #11 was bleeding from her nostrils, and she kept putting her head down as if she was traumatized from what happened. RN P said Resident #11 could not and did not vocalize anything due to her cognitive condition. RN P said she rendered first aid to Resident #11 but when the bleeding did not stop the doctor was notified and she was sent to the hospital. RN P said Resident #12 just kept saying she was tired of this but was unharmed. RN P said she worked PRN, and this was her first time working on the unit in a while, but she was told that Resident #12 had become aggressive in the last week or so towards other residents. RN P said she was not told what to do during her shift to care for Resident #12 and her increased behaviors. RN P said neither Residents #11 or #12 were her residents at the time, but she heard Resident #11 whining and moaning which was what made her go around the corner to see what was happening. RN P said she was not sure how Resident #11 ended up on the floor. Interview on 04/18/24 at 1:17 PM with LVN R revealed she had only recently started working with Resident #12. LVN R said Resident #12 was showing physical aggression towards other residents by randomly hitting other residents. LVN R said she was not told to do anything specifically regarding Resident #12's increased behaviors. LVN R was able to explain what to do when there was a resident-to-resident altercation. LVN R was able to explain the facility's abuse and neglect policies and how to handle a resident with behaviors. Interview on 04/18/24 at 2:44 PM with LVN U revealed she cared for Resident #12 who normally had moods but recently had a UTI that caused her to go on a rampage and wanted to hit and fight everyone. LVN U said she heard yelling in the direction of Resident #12's room where both Residents #11 and #12 were. LVN U said she went to see what happened and saw Resident #11 on the floor and Resident #12 yelling and standing over her. LVN U said she assessed Resident #11 who had a nosebleed which kept bleeding, so she was sent to the hospital for further treatment. LVN U said she was able to look through the window of the closed double doors where the residents were on the other side of the door, and it looked like Resident #12 was fighting with Resident #11 and that it appeared Resident #12 hit Resident #11. LVN U said Resident #11 was crying and was unable to say what happened due to her cognitive condition. LVN U said Resident #12 was yelling but did not sustain any injuries. LVN U said Resident #12 was on observations before this incident which meant staff were documenting where she was every 15 minutes. LVN U said Resident #12 was not currently on every 15-minute checks at the time of this incident though. LVN U said she knew that other staff had contacted the psych doctor who ordered medications, but the family refused them. LVN U said she tried making sure to keep a close eye on Resident #12 because of the increase in behaviors because she had heard Resident #12 had been hitting people lately. LVN U was able to explain the facility's abuse and neglect policies, how to handle a resident with behaviors, and what to do when there was a resident-to-resident altercation. Interview on 04/18/24 at 3:37 PM with ADON W revealed she cared for Resident #12 as her nurse before becoming the unit manager. ADON W said Resident #12 started having outbursts where she was assaulting other residents on the unit. ADON W said Resident #12's attacks were random and unprovoked. ADON W said Resident #12 told her that [Resident #12's family member] was telling her to do these things. ADON W said Resident #12 was being frequently monitored and at one point was on every 15-minute checks by staf f. ADON W said staff communicated with the psych doctor to make medication adjustments for Resident #12, but her family refused it. ADON W said she was not here for the incident between Resident #11 and #12 but heard that Resident #12 hit Resident #11 who fell to the floor. ADON W said Resident #11 was sent to the hospital and returned with a facial fracture. ADON W was able to explain the facility's abuse and neglect policies, how to handle a resident with behaviors, and what to do when there was a resident-to-resident altercation. Interview on 04/18/24 at 4:09 PM with the Administrator revealed Resident #12 was a challenge who started having an increase in behaviors and outbursts. The Administrator said he tried to get psych involved in Resident #12's care, but the family was adamant that they would not allow for any medication adjustments. The Administrator said he told Resident #12's family if her behaviors continued, they would have to consider an inpatient psych facility next. The Administrator said after the first incident Resident #12 was placed on frequent checks and staff were monitoring her consistently. The Administrator said regarding Resident #11 and #12's incident, he was told that they had an altercation and had to send Resident #11 to the hospital because she had a maxillary fracture. The Administrator said Resident #12 was also taken to the hospital for a psychological evaluation, The Administrator said staff could not see what happened between the two residents to determine if Resident #12 pushed or hit Resident #11. The Administrator said Resident #12 had six incidents with other residents in a short period of time from 03/27/24 to 04/02/24. The Administrator said he had tried to send Resident #12 out multiple times related to the behaviors, requested a care conference with her family, had her on every 15-minute checks, and asked staff to redirect her. The Administrator said Resident #12 was not on every 15-minute checks the entire time she was having behaviors, including when she had the incident with Resident #11 on 04/02/24. The Administrator said he thought the behaviors were due to Resident #12 having a UTI at the time of the incidents and she was being treated for that. The Administrator said he continued notifying the psych doctor of Resident #12's behaviors but since the family refused any additional medication adjustments there was nothing to be done. The Administrator said all staff assigned to the unit were responsible for making sure all residents were safe. The Administrator said the purpose of making sure residents were safe was the facility's due diligence to monitor them and try to prevent any accidents/incidents. The Administrator said the risk of not keeping residents safe was that they can have injuries from resident-to-resident altercations. The Administrator was able to explain the facility's abuse and neglect policies, how to handle a resident with behaviors, and what to do when there was a resident-to-resident altercation. Interview on 04/18/24 at 4:26 PM with the SW revealed Resident #12 all of a sudden had a violent streak with multiple physical altercations with other residents. The SW said Resident #12 was actually hitting and fighting people. The SW said he was in the process of getting Resident #12 set up to go to a psych hospital when she was sent to the hospital to try and get an evaluation regarding her medications. The SW said Resident #12's family members refused any medication adjustments from the facility's doctors which would have helped to lessen Resident #12's aggressive behaviors. The SW said Resident #12 reported hearing her dead family members voices telling her to hit and beat people up. The SW said Resident #12 could not go to a psych facility originally because she had been diagnosed with a UTI that she was being treated for. Interview on 04/18/24 at 5:15 PM with the DON revealed the situation with Residents #11 and #12 was not witnessed. The DON said staff observed Resident #11 on the floor and she had an injury which was a facial fracture. The DON said Resident #12 was found standing over Resident #11 who did not have any injuries. The DON said the facility had tried to send Resident #12 out for a psych evaluation, but no facility would take her since she was being treated for a UTI. The DON said the psych doctor had also tried to make medication adjustments for Resident #12, but the family refused them all. The DON said staff were monitoring Resident #12 for her increased aggressive behaviors and were monitoring her every 15 minutes while she still had seven incidents with other residents in a short span of time. The DON said the facility also took her dolls away from her so that she could not use them to continue hitting others with them. The DON said the facility only had Resident #12 on every 15-minute checks from 03/27/24 to 03/29/24. The DON said Resident #12 did not have any noted aggressive behaviors past 03/30/24 so there was no need to continue every 15-minute checks. The DON said the entire nursing department made the decision to keep a resident on every 15-minute checks or not. The DON said the facility was not going to keep Resident #12 on every 15-minute checks for too long of a time. The DON said staff were supposed to be monitoring the residents on the unit in general and separating them if there were any altercations that occurred. Follow-up interview on 05/06/24 at 1:52 PM with ADON W revealed Resident #12's situation taught the facility the harm of delay. ADON W said the facility thought they had intervened and tried things before sending Resident #12 out because they knew the family truly did not want that. ADON W said now the facility understands that they have to think of all the other residents in the facility. ADON W said there were not any current residents on the memory care unit who had aggressive tendencies or any behaviors right now. Follow-up interview on 05/06/24 at 2:27 PM with the DON revealed there were not any current residents on the memory care unit who had aggressive tendencies or behaviors right now. The DON said Resident #11 has not had any changes in her behavior after the incident on 04/02/24. Follow-up interview on 05/06/24 at 3:07 PM with the Administrator revealed there were not any current residents on the memory care unit who had aggressive tendencies or behaviors right now. The Administrator said Resident #11 has not had any changes in her behavior after the incident on 04/02/24. Review of a census, dated 05/06/24, revealed Resident #12 was not a resident of the facility. Review of the facility's Incident Report log from 04/06/24 to 05/06/24 revealed there were no altercations with injuries amongst the residents. Review of the facility's training in-service form, dated 04/03/24, revealed all staff were trained regarding abuse, neglect, exploitation, misappropriation of resident property and resident to resident behaviors. Review of the facility's training in-service form, dated 04/20/24, revealed all staff were trained regarding abuse, neglect, exploitation, misappropriation of resident property and fall prevention/fall management. Review of the facility's policy, revised February 2020, and titled Behavior Management reflected: .A. Anticipating Behaviors: 1. Staff is responsible for preempting behavior problems before they occur. 2. At onset of anxiousness, agitation, or any behavior that signifies the resident is having difficulty, staff is responsible for immediately attempting to rule any unmet needs .[sic]. Review of the facility's policy revised 02/12/20, and titled Abuse, Neglect and Exploitation and Misappropriation of Resident Property reflected: .Each resident has the right to be free from abuse, neglect, exploitation, misappropriation of resident's property, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse, neglect, exploitation, misappropriation of resident's property by anyone, including, but not limited to, facility staff, other residents, consultants, volunteers, staff of other agencies serving the resident, family members, legal guardians, resident representative, friends, or other individuals. On 05/06/24 at 5:05 PM the Administrator was informed an Immediate Jeopardy was determined to have existed from 03/27/24 to 04/02/24. The IJ was determined to have been removed on 04/03/24 due to the facility's implemented actions that corrected the non-compliance prior to the beginning of the investigation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices to meet each resident's physical mental and psychosocial needs for one (Resident #6) of seven residents reviewed for quality of care. The facility failed to ensure Resident # 6 received medications according to physician orders for pain management when the resident experienced a fall with injury that resulted in a fracture to the left hip. Resident # 6 was in pain for three days before being sent to the hospital. This failure placed residents at risk of unrelieved pain and discomfort. An Immediate Jeopardy was determined to have existed from 11/04/22 through 11/07/22. The IJ was removed on 11/08/22 because the facility implemented actions that corrected the non-compliance prior to the beginning of the survey. The facility Administrator was provided the IJ Template on 01/12/23 at 9:52 AM. Findings included: Review of Resident # 6's Face Sheet dated 12/23/2022 revealed a 79-yr-old female who admitted to the facility on [DATE] and discharged on 11/07/2022. Resident # 6's diagnoses included cerebral infarction, unspecified injury of head, diabetes mellitus, and central pain syndrome. Review of Resident # 6's Progress Note dated 11/04/22 written by LVN S reflected, Resident was in her room and was pushed down by another resident, resident fell on her left hip and exhibited signs of pain called dr to report change of condition, ordered x- ray to have left hip examined. Review of Resident # 6's NP Note dated 11/4/22 reflected, The patient is seen for a periodic follow-up visit. She is seen sleeping in her bed recently, easily awoke with verbal stimuli. She is very confused secondary to dementia but denies any acute problem at the present time. Later on I was notified over the phone while I am driving that the patient is complaint pain on the left hip area. She was pushed by another confused patient and the patient fell. Ordered left hip x ray and instructed to treat the pain with the pain medication. Nurse will notify provider if symptoms get worst. She is generally agreeable to care routine and easily redirected. Review of the Incident Report dated 11/04/22 reflected Resident # 6 was involved in a witnessed altercation with a fall and had pain upon movement at a level four on a scale of 1-10. Review of Resident #6's Physician's Orders reflected the only pain ordered for Resident # 6 was 500 mg of Naproxen. One tablet was to be given twice per day as needed for Mild pain on a scale of 1-3. This Naproxen medication was to be given with food and the diagnosis for this medication was central pain syndrome. Review of the Medication Administration Record (MAR) in the electronic medical record on 01/12/23 for Resident #6 revealed she had pain at a level six to her left hip on 11/06/22 in the evening. The MAR also revealed Naproxen was not administered to Resident # 6 from 11/4/22 through 11/7/22. The MAR reflected that no pain medication was given to Resident #6 during that time frame. Review of Resident # 6's Progress Note dated 11/06/22 at 2:13 PM written by LVN S reflected, resident having difficultly standing on left hip has mild edema of left leg, notified NP, ordered x ray STAT per NP if not completed in 3-4hr span was advised to send resident out. Review of Resident # 6's Progress Note dated 11/07/22 at 1:55 PM written by LVNS on reflected, resident having difficultly standing on left hip has mild edema of left leg, notified Dr ordered x ray STAT per NP if not completed in 3-4hr span was advised to send resident out , x- ray not done notified [agency name] ambulance to transport resident to hospital for x- ray and further care, notified family/ unit manager of change of condition, ambulance scheduled for 3:30pm to transport. Review of the Witness Statement dated 11/08/22 reflected LVN S was notified on 11/04/22 that Resident # 6 was pushed by another resident and fell. LVN S found resident on her left side and completed an assessment. The written statement indicated, Assessment noted pain to left hip with no visible injuries. New orders received and inputted for x-ray to left hip. On 11/6/22 x-ray had not been performed, I was notified by aide that resident continued with decrease in mobility and signs of pain upon assessment left hip noted with minimal edema, I notified NP and was given orders to reorder Xray as STAT, I inputted the orders. Upon arrival on 11/7/22 X-rays had not been performed I notified the NP and received orders to send to ER for further evaluation, resident was sent via non-emergency transportation. Review of the Witness Statement dated 11/08/22 reflected CNA AF witnessed the incident with Resident # 6 and notified LVN S immediately. CNA AF's written statement indicated, Resident #6, continued to have symptoms of pain to her left hip and decreased mobility on 11/5/22 and 11/6/22, I notified the charge nurse and resident remained in bed on those dates. Interview on 12/22/22 at 10:20 AM with LVN S revealed the general procedure if a resident had a witnessed fall, the nurse was to complete a full assessment to include skin and pain evaluations, vital signs, then inform the unit manager, the Administrator, the family and the doctor. In a later interview on 01/12/23 at 10:09 AM LVN S stated she gave Resident #6 pain medication after she fell on [DATE]. LVN S stated Resident # 6 typically wanted to stay in bed, but once staff got her up, she would get up and walk around. LVN S said she would personally walk the halls with Resident # 6 but would keep a wheelchair close by in case the resident got weak and needed to sit down. A later phone Interview on 01/12/23 at 3:01 PM with LVN S revealed she attributed not documenting the administration of the Naproxen to the adrenaline of the whole issue. Interview on 01/12/23 at 11:27 AM with CNA AF stated Resident # 6 was able to walk to the dining room on 11/4/22 after the fall with no problem after LVN S did all the assessments. CNA AF stated that on 11/5/22 Resident # 6 was no longer getting up, could not walk and was screaming of pain. CNA AF stated that Resident #6 was able to walk before the fall, although if the staff would let her, she would lay in bed all day. In an interview on 01/12/23 at 12:45 PM the ADON stated she checked their system and did not find any documentation of pain medication given to Resident #6, however she spoke with LVN S who stated she gave Resident # 6 Naproxen. Interview on 12/22/22 at 3:38 PM with Resident # 6's Primary Contact listed on Face Sheet stated Resident #6 was diagnosed with left hip fracture and had surgery where her socket was removed. The primary contact stated the resident was still in pain and was at another (different) facility and had to go on hospice after the surgery. The Primary contact stated Resident #6 used to walk and now she stayed in a fetal position in bed because she was in too much pain. Interview on 01/12/23 at 5:30 PM DON stated if a Resident has had a fall, their pain should be treated. DON stated that if pain medication was not adequate, the staff should contact the doctor to get something stronger so that the resident is not in distress. DON stated If the stronger medication does not help, the resident should be sent to the hospital. DON also stated that in the nursing world if it was not documented, it was not done. Review of the facility's Pain Management and Basic Comfort Measures policy, revised 01/12/20, revealed, .Provide pain medication as prescribed by an authorized prescriber . Consult with family members, other health care providers for assistance with pain management techniques . Observe for unresolved pain and address per physician's orders . Record pain management techniques in the record. The Plan of Removal process was not needed at this time because the facility implemented actions that corrected the non-compliance prior to the beginning of the survey on 12/20/2023. The facility implemented the following interventions to address non-compliance: Review of the facility's one on one in-service (training) titled Fall prevention, Xray ordering process, family communication, dated 11/07/22 with LVN included: pain management, Xray process, review of adverse events that occurred as a purpose for the training or identified gaps during facility assessment (these must be part of the in-service and discussed), all steps in the fall management process and the credentials to login to the online portal for the x-ray company. Review of the facility's In-Service for all nursing staff on falls with injury dated 11/8/22, included pain management. Review of additional in-services dated and completed on 11/29/22, 12/19/22, 12/22/22, 12/23/22 and 1/5/23 revealed staff were trained on all aspects of the fall management process especially when the resident was injured. In an interview on 01/12/23 at 10:09 AM LVN S stated she was in-serviced (one on one) by the Unit Manager (LVN U) after the incident where Resident #6 was sent to the hospital. In a later interview on 1/13/23 at 3:01 PM LVN S stated the Unit Manager discussed with her about the fall process and stressed the importance of documenting administration of medication because if it is documented it means it was not done. The Unit Manager pointed out to her that she needed to call the doctor for a stronger medication since the Naproxen was only for pain on a scale of 1-3. LVN S stated she has since had to call the doctor for stronger pain meds for a different patient with a similar issue. Interviews beginning on 12/20/22 at 7:53 AM through 01/12/23 at 4:30 PM with the nursing staff included: LVN E, LVN V, LVN W, LVN AA, LVN AB, LVN AG, LVN AH, LVN AI, RN AJ, and LVN AK. Interviews revealed nurses knew the procedure for pain management, communicated via the 24 hr report and gave a verbal report at shift change to each other, the nursing staff knew the steps to follow if a resident had a fall with suspected injury, and the nursing staff had been in-serviced on these topics. The nurses also were aware that if there was not a medication to cover the pain level indicated, that they should call the doctor to get another order. Observations from 12/20/22 at 7:40 PM to 01/12/23 at 3:30 PM revealed fall protocols were in place for residents who required such protocols (Resident #'s 4, 7, 8, 10, 11 and 13). Interviews with Residents with PRN pain management on 01/12/23 revealed they got medication when requested and they were not in any pain (Resident #'s 11, 12 and 13). Review of the MAR for Residents with PRN pain management revealed pain assessments were completed and pain medications administered as ordered for Resident #'s 11, 12, 13, 15, 16, 17 and 18. Review of a facility Monitoring Tool dated from 11/7/2022 to 01/12/23 titled Incident/Accident Report and Diagnostic Review was used daily from 11/7/22 to 01/12/23 by the ADON. In an interview on 01/12/23 at 5:45 PM DON revealed signing off on the monitoring tool meant the incident reports were reviewed daily by the ADON and the DON. The ADON and DON were following up to check what was done to address the pain scale on the incident reports. The ADON and DON were monitoring pain meds and ensuring they had meds ordered that covered all numbers on the pain scale. The DON stated for example that if a Resident only had pain medication coverage for pain level of 1-3, the facility would call the doctor to get a medication to cover a higher level of pain. DON stated the IDT team met daily to review each fall and to ensure follow up from each department as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to promptly notify the ordering physician of results that fell outside of clinical procedures for notification of the ordering physician for one (Resident #6) of five residents reviewed for diagnostic services. The facility did not ensure diagnostic services were provided for Resident #6 as ordered when the resident experienced a fall with injury that resulted in a fracture to the left hip. Resident # 6 remained at the facility for three days before being sent to the hospital where the x-rays were obtained. These failures could place residents at risk for delayed identification and treatment of undiagnosed illnesses, hospitalization, pain, and suffering. An Immediate Jeopardy was determined to have existed from 11/04/22 through 11/07/22. The IJ was removed on 11/08/22 because the facility implemented actions that corrected the non-compliance prior to the beginning of the survey. The facility Administrator was provided the IJ Template on 01/12/23 at 9:52 AM. Findings included: Review of Resident # 6's Face Sheet dated 12/23/2022 revealed a 79-yr-old female who admitted to the facility on [DATE] and discharged on 11/07/2022. Resident # 6's diagnoses included cerebral infarction, unspecified injury of head, diabetes mellitus, and central pain syndrome. Review of Resident # 6's Care Plan dated 12/23/22 revealed a 'fall care plan was in place with the following intervention added on 11/04/22, Assess for potential fall-related injury prevention, looking at circumstances, location, medication, new or worsening medical problems, etc. Review of 24-hour report dated 11/4/22 reflected a comment written by LVN S, resident was pushed down by another resident, exhibited pain in left hip call Dr and ordered x-ray. Review of Resident # 6's Progress Note dated 11/04/22 written by LVN S reflected, Resident was in her room and was pushed down by another resident, resident fell on her left hip and exhibited signs of pain called dr to report change of condition, ordered x- ray to have left hip examined. Review of Resident # 6's Progress Note dated 11/06/22 at 2:13 PM written by LVN S reflected, resident having difficultly standing on left hip has mild edema of left leg, notified NP, ordered x ray STAT per NP if not completed in 3-4hr span was advised to send resident out. Review of Resident # 6's Progress Note dated 11/07/22 at 1:55 PM written by LVNS on reflected, resident having difficultly standing on left hip has mild edema of left leg, notified Dr ordered x ray STAT per NP if not completed in 3-4hr span was advised to send resident out , x- ray not done notified [agency name] ambulance to transport resident to hospital for x- ray and further care, notified family/ unit manager of change of condition, ambulance scheduled for 3:30pm to transport. Review of Resident # 6's NP Note dated 11/4/22 reflected, The patient is seen for a periodic follow-up visit. She is seen sleeping in her bed recently, easily awoke with verbal stimuli. She is very confused secondary to dementia but denies any acute problem at the present time. Later on I was notified over the phone while I am driving that the patient is complaint pain on the left hip area. She was pushed by another confused patient and the patient fell. Ordered left hip x ray and instructed to treat the pain with the pain medication. Nurse will notify provider if symptoms get worst. She is generally agreeable to care routine and easily redirected. Review of facility's Provider Investigation Report dated 11/15/22 revealed Resident # 6 was pushed by another resident on 11/08/22 which resulted in a witnessed fall. Resident # 6 was assessed and complained of pain to left lower leg. Further review of the report indicated the resident was sent to ER for further evaluation where x-rays revealed a fracture to the left hip. This report reflected the incident occurred on 11/8/22 even though it occurred on 11/4/22. The facility was informed of Resident # 6's x-ray results on 11/8/22 after sending her to the hospital on [DATE]. The facility in-serviced (trained) staff on abuse, neglect, resident to resident behaviors, fall with injury and x-ray ordering on 11/8/22. Review of the Witness Statement dated 11/08/22 reflected LVN S was notified on 11/04/22 that Resident # 6 was pushed by another resident and fell. LVN S found resident on her left side and completed an assessment. The written statement indicated, Assessment noted pain to left hip with no visible injuries. New orders received and inputted for x-ray to left hip. On 11/6/22 x-ray had not been performed, I was notified by aide that resident continued with decrease in mobility and signs of pain upon assessment left hip noted with minimal edema, I notified NP and was given orders to reorder Xray as STAT, I inputted the orders. Upon arrival on 11/7/22 X-rays had not been performed I notified the NP and received orders to send to ER for further evaluation, resident was sent via non-emergency transportation. Interview and record review on 12/20/22 beginning at 7:53 AM with LVN AA revealed a one-time left hip x-ray (2 views) was ordered for Resident # 6 on Friday 11/04/22. A Stat x-ray with the same views was ordered for Resident # 6 on Sunday 11/06/22. LVN AA stated he did not know why the x-rays were not done. LVN AA stated after reviewing the record that it was LVN S that entered the x-ray orders. LVN AA stated that it was the doctor and not the LVN that determined the type of x-ray that was ordered, whether stat or regular. LVN AA stated that normal practice was if someone had a fall and was in pain, to get an order from the doctor, enter the order into the system and then call it into the x-ray company. Interview on 12/22/22 at 10:20 AM with LVN S stated she entered an x-ray order after Resident # 6 fell on [DATE]. LVN S stated she had some time off in between the two x-ray orders on 11/04/22 and 11/06/22. LVN S stated the general procedure if a resident had a witnessed fall, the nurse was to complete a full assessment to include skin and pain evaluations, vital signs, then inform the unit manager, the Administrator, the family and the doctor. Interview on 01/12/23 at 10:09 AM with LVN S revealed at the time of the fall LVN S did not know she had to call the x-ray company after entering the order in the facility's electronic medical record. LVN S stated she did not call the company on 11/4/22, however she stated she called them on 11/06/22. LVN S stated Resident # 6 typically wanted to stay in bed, but once staff got her up, she would get up and walk around. LVN S said she would personally walk the halls with Resident # 6 but would keep a wheelchair close by in case the resident got weak and needed to sit down. Interview via telephone on 12/22/22 at 11:22 AM with NP AD revealed the x-ray company typically obtained the x-ray the same day it was ordered whether he ordered a stat x-ray or not. He stated that when x-ray orders came in, the facility was supposed to informed him right away. NP AD stated if an x-ray revealed a fracture, it would be an immediate transfer to the ER. NP AD stated with a fall on 11/4/22, if the staff called him on 11/6/22 he would have told them if an x-ray was not done within the hour, that the Resident should be sent out to the hospital. When informed Resident # 6 was not sent out until 11/7/22 after falling on 11/4/22, NP AD was surprised at the length of time that had elapsed, NP AD stated he did not know what happened, and stated that he always answered his phone. Interview on 12/22/22 at 3:38 PM with Resident # 6's primary contact listed on Resident # 6's Face Sheet on revealed Resident was diagnosed with left hip fracture and had surgery where her socket was removed. She stated the resident was still in pain and was at another facility and had to go on hospice after the surgery. She stated Resident #6 used to walk and now she stayed in the fetal position in bed because she was in too much pain. Interview on 12/22/22 beginning at 5:02 PM with the Assistant Administrator and DON revealed LVN S should have called the x-ray company to find out the estimated time of arrival of the x-ray company. They stated LVN S thought that when she entered the order in the facility's electronic medical record platform, that it automatically went to the x-ray company, but there was actually an additional step. DON stated The facility needed to fax the company and then the company would call to confirm. The Assistant Administrator stated that after the incident she told LVN U, the Unit Manager to educate LVN S on the process of x-ray ordering. The Assistant Administrator stated x-ray ordering should have been part of LVN S's new hire training process. The DON stated the LVN that worked 2-10 PM shift on 11/06/22 should have sent Resident # 6 out to the hospital when it was realized that the x-ray was not obtained in the time frame (3-4 hr span of time) provided by the nurse practitioner. The DON stated she understood the danger of having a long-time lapse before being sent to the hospital after a fall. She stated if a person was normally ambulatory and then that changes, they should have an x-ray and often those patients need to be sent out to the hospital for further evaluation. In a later interview on 01/12/23 at 12:01 PM with the DON and ADON, it was clarified that staff could either enter the x-ray order in the online portal of the x-ray company or call them on the phone to communicate the x-ray order. The Plan of Removal process was not needed at this time because the facility implemented actions that corrected the non-compliance prior to the beginning of the survey on 12/20/2023. The facility implemented the following interventions to address non-compliance: Review of the facility's In-Service (training) dated 11/07/22 reflected LVN U, the Unit Manager provided one on one training to LVNS S titled Fall prevention, Xray ordering process, family communication, included pain management, Xray process, review of adverse events that occurred as a purpose for the training or identified gaps during facility assessment (these must be part of the in-service and discussed), all steps in the fall management process and the credentials to login to the online portal for the x-ray company. Review of the facility's in-service dated 11/8/22 reflected training for all nursing staff on Falls with Injury, included instructions on ordering x-rays from the x-ray company. Review of additional in-services dated and completed on 11/29/22, 12/19/22, 12/22/22, 12/23/22 and 1/5/23 revealed staff were trained on all aspects of the fall management process especially when the resident was injured. In an interview on 01/12/23 at 10:09 AM LVN S stated she was in-serviced (one on one) by the Unit Manager (LVN U) after the incident where Resident #6 was sent to the hospital. LVN S stated she was given instructions on the entering the x-ray orders on the online portal of the x-ray company and on calling the company on the phone to get confirmation that the order was received. Interviews beginning on 12/20/22 at 7:53 AM through 01/12/23 at 4:30 PM with the nursing staff included: LVN E, LVN V, LVN W, LVN AA, LVN AB, LVN AG, LVN AH, LVN AI, RN AJ, and LVN AK. Interviews revealed nurses knew the procedure for ensuring x-ray orders were carried out, communicated via the 24 hr report and gave a verbal report at shift change to each other, the nursing staff knew the steps to follow if a resident had a fall with suspected injury, and the nursing staff stated they had been in-serviced on these topics. Observations from 12/20/22 at 7:40 AM to 01/12/23 at 3:30 PM revealed fall protocols were in place for residents who required such protocols (Resident #'s 4, 7, 8, 10, 11 and 13). Review of facility Fall Incidents between November 2022 and December 2022, aside from Resident # 6, reflected facility residents with a fall were sent out to the hospital in a timely manner when a change of condition was identified for Resident #'s 4, 8, 9 and 10. Review of a facility Monitoring Tool dated from 11/7/2022 to 01/12/23 titled Incident/Accident Report and Diagnostic Review was used daily from 11/7/22 to 01/12/23 by the ADON. In an interview on 01/12/23 at 5:45 PM DON revealed signing off on the monitoring tool meant the incident reports were reviewed daily by the ADON and the DON. The ADON and the DON were following up to check that x-rays were completed if ordered. DON stated the IDT Team met daily to review each fall and to ensure follow up from each department as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to maintain an infection prevention and control program to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of COVID-19 for 1 of 2 (Resident # 2) residents and 3 of 5 (CNA B, CNA C, and Med Aide D) staff reviewed for infection control. The facility failed to ensure CNA B, CNA C, and Med Aide D were wearing appropriate PPE and following infection control practices during care of residents positive with COVID-19. The staff subsequently entered rooms of residents who were negative for COVID-19 and did not perform hand hygiene during meal service. An Immediate Jeopardy (IJ) was identified on 12/21/22 at 12:03 PM. While the IJ was removed on 12/23/22 at 4:40 PM, the facility remained out of compliance at a level of no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope of pattern as the facility was continuing to monitor the implementation and effectiveness of their corrective systems. The IJ template was provided to the Assistant Administrator on 12/21/22 at 2:43 PM. These failures could place residents at risk of exposure of Covid-19 virus which could result in serious illness, hospitalization, and/or death. Findings included: Record review of Resident # 2's face sheet, dated 12/23/22, revealed an [AGE] year-old female admitted to the facility on [DATE]. Record review Resident # 2's consolidated orders, dated 12/23/22, revealed she had a diagnosis of COVID-19. Review of the Resident Census Roster dated 12/20/22 revealed as of 12/20/22 two residents (including Resident # 2) were positive for COVID-19 and Resident # 2 was assigned to RM [ROOM NUMBER]. Review of Admission/Discharge log revealed Resident # 2 went to the hospital on [DATE] and returned to the facility on [DATE]. Review of Isolation list revealed Resident # 2 was placed on isolation upon return to the facility on [DATE] because she tested positive for COVID-19 while at the hospital. Interview with Resident # 2's family representative on 12/20/22 at 8:54 AM revealed there was a camera in Resident # 2's room. Review of video footage on 12/20/22 at 9:15 AM revealed CNA A and an unknown agency staff were at bedside of Resident # 2 to perform incontinent care at 4:40 AM that morning. Both staff wore a N95 mask and gloves. No eye protection or gowns were noted. CNA A wore two N95 masks with the top strap of both masks behind her head, while the bottom straps of both masks hung underneath her chin. Review of the staff schedule dated 12/19/22 revealed CNA A was assigned to 23 residents on 12/19/22 10PM-6AM shift, including Residents #2 and #3. The schedule also revealed 2 agency aides had worked on that shift as well. Interview via telephone with CNA A on 12/21/22 at 7:07 AM revealed she did not know the name of the aide that helped her change Resident # 2 in the morning on 12/20/22. When asked what the appropriate PPE was for entering a covid-19 positive room, CNA A stated gown, gloves, face shield and mask. Interview with Staffing Coordinator on 12/20/22 at 3:30 PM revealed she did not have access to the phone numbers of the staff sent to her from the agency company with whom the facility had a contract. Observation on 12/20/22 at 5:56 PM revealed CNA B entered Resident # 2's room to answer the call light. CNA B was wearing an N95 and a face shield. He did not wear a gown. Review of video footage of Resident # 2's room from 12/20/22 at 5:56 PM when CNA B answered the call light revealed CNA B reached over without gloves, grabbed the resident with both hands and pulled her over so that she was positioned in the center of the bed. The video footage revealed hand hygiene was not performed while CNA B was in the room. Observation on 12/20/22 at 5:58 PM revealed CNA B exited Resident # 2's room pushed his face shield up to his forehead leaving the face shield at an angle and pulled his N95 down below his chin and turned around to speak with the resident from the doorway. No hand hygiene was performed. Observation on 12/20/22 at 6:02 PM to 6:14 PM revealed CNA B in a COVID-19 negative room delivering dinner meals. CNA B exited the COVID-19 negative room and proceeded to the beverage cart on the hallway. CNA B picked up drinking cups by the rim and lined them up on the cart, grabbed pitchers of water and iced tea and poured drinks into the respective cups. CNA C then grabbed those same beverage pitchers to pour drinks that were delivered to other residents as well. CNA B delivered resident meals and beverages, and helped residents get set up to eat in four covid negative resident rooms. Each room housed two residents each (8 residents total). CNA B used hand sanitizer only once upon exit of one of the four rooms. Observation on 12/20/22 at 6:15 PM revealed CNA C and the kitchen server pushed the beverage and hot food cart down to the other side of the 100 hall to continue serving meals to covid negative residents (the same cart CNA B had touched to deliver food to residents after entering Resident #2's room). Interview via telephone on 12/21/22 at 12:36 PM with CNA B revealed he recalled entering Resident # 2's room without a gown during the evening shift on 12/20/22. CNA B stated there were gowns available in the gray container outside the resident's room and stated he could not explain why he did not wear a gown before entering the room. He stated he had been in-serviced recently on the need to wear N95, face shield and gown to enter a covid positive room. He stated handwashing was covered in the recent in-services. CNA B stated entering a covid positive room without proper PPE and then entering a covid negative room could increase the chances of getting other residents sick or contamination of other things. Review of video footage revealed on 12/20/22 at 7:13 PM Med aide D entered Resident # 2's room with medications and a cup. Med aide D wore gloves, N95 mask and goggles. He was not wearing a gown. Observation on 12/20/22 at 7:30 PM revealed Med aide D entered a covid negative room to administer medications to both residents in that room. In an interview on 12/21/22 at 4:10 PM Med aide D revealed he gave Resident # 2 her medications first for the 7PM medication pass on 12/20/22. Med aide D stated after Resident # 2, he gave meds to two residents on the same side of the hall as Resident # 2, and then gave meds to the residents on the A side of 100 hall as most of the residents on that hall had 7PM meds ordered. Med aide D stated it escaped his mind to use the gown when he administered meds to Resident # 2 on 12/20/22. He stated the risk for entering covid negative rooms after not wearing appropriate PPE in a covid positive room was transmission of covid-19. Record review of the Coronavirus Management Plan Texas Phase 2 & 3, which the facility was using as their policy, dated 11/03/22, revealed COVID Positive Unit .Personnel who enter the room will wear N95 respirators. In addition, staff should wear a gown, gloves, and face shield or goggles. Review of the CDC Guidance titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-10) Pandemic, dated 09/23/22, reflected HCP who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved particulate respirator with N95 filters or higher , gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). On 12/21/22 at 1:11 PM the Assistant Administrator, DON and Regional Director of Operations were notified an Immediate Jeopardy (IJ) situation was identified due to the above failures. The IJ template was provided to the Assistant Administrator on 12/21/22 at 2:43 PM. The facility's Plan of Removal was accepted on 12/22/22 at 12:14 PM and reflected the following: [name of the facility] PLAN OF REMOVAL FOR IMMEDIATE JEOPARDY on 12/21/22 To Whom it May Concern, Infection Control F880- The facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Identify residents who could be affected All residents have the potential to be affected by this alleged proficient practice Problem Staff members were seen providing care for a COVID positive resident without wearing appropriate PPE and/or wearing PPE in an inappropriate manner. Staff members were seen not performing hand hygiene after entering a COVID positive resident's room and when passing meal trays to residents. Action Taken Infection Control ¢ ICP will re-educate Director of Nursing and Assistant Director of Nursing on company's infection control policy related to Covid 19 by end of day on 12/22/2022. ¢ Use of alcohol-based hand sanitizer and hand washing with soap and water with emphasis on when to use soap and water versus alcohol-based hand sanitizer ¢ Donning/Doffing of proper PPE for N95, gowns, gloves, face-shields/goggles before entering and exiting Covid positive rooms ¢ ICP is responsible for monitoring the education of the Director of Nursing and the Assistant Director of Nursing on company's infection control policy related to Covid 19 Hand Hygiene and Competency ¢ Staff in-servicing on alcohol-based hand sanitizer and hand washing with soap and water with emphasis on when to use soap and water versus alcohol-based hand sanitizer with competency conducted by ICP, Director of Nursing, Assistant Director of Nursing, and/or Designee include staff handwashing and when to use hand sanitizer. ¢ Competencies consist of review of necessary steps and 100 % accuracy on return demonstration. ¢ Inservicing was implemented on 12/21/2022. All staff to be included in training. Training to be completed by 12/23/22. Staff not physically in community to receive their education in person prior to their next shift by ICP, Director of Nursing or Assistant Director of Nursing and/or Designee and will be able to perform a return demonstration. ¢ This training will be part of new hire orientation checklist starting 12/22/2022 to include any new agency staff prior to working their next shift. ¢ Monitoring will begin 12/22/2022 and will be conducted by ICP, Director of Nursing, Assistant Director of Nursing, and/or designee to observe and document hand hygiene compliance twice daily throughout the outbreak then three times a week for four weeks, then two times a week for two weeks, then weekly for one month then as needed thereafter to ensure continued compliance. If the Director of Nursing or designee sees that a staff member is not following the company's infection policy, immediate on the spot re-education and redirection will be given. PPE and Competency ¢ ICP, Director of Nursing, Assistant Director of Nursing, and Designee in-serviced all staff on what PPE to wear to include type of mask i.e. N95, gowns, gloves, face-shields/goggles before entering and exiting Covid positive rooms ¢ All staff will be in-serviced in person prior to working their shift. Training to be completed by 12/23/22 Those not physically in community will receive their education in-service in person prior to working their shift by ICP, Director of Nursing or Assistant Director of Nursing and/or Designee and will be able to perform a return demonstration prior to working their next shift. ¢ This training will be part of new hire orientation checklist starting 12/22/2022 to include any new agency staff prior to working their first shift. ¢ Monitoring began 12/22/2022 and will be done by ICP, Director of Nursing, Assistant Director of Nursing, or designee through random questioning on PPE and hand hygiene to ensure knowledge has been retained on various eight hour shifts to begin 12/22/2022. ¢ Director of Nursing or designee is rounding twice daily throughout the outbreak then three times a week for four weeks, then two times a week for two weeks, then weekly for one month then as needed thereafter to ensure continued compliance ensuring proper infection control practices are in place through observation and questioning. If the Director of Nursing or designee sees that a staff member is not following the company's infection policy, immediate on the spot re-education and redirection will be given. On 12/22/22 to 12/23/22 the surveyor confirmed the facility implemented their Plan of Removal sufficiently to remove the IJ by: Review of the facility's in-service and competency testing records revealed: 1.The DON's name was listed as the facilitator of the in-services. The in-service topic was Infection Control, Covid-19 with an emphasis on hand hygiene and donning/doffing PPE. 2.As of 12/23/22 at 4:40 PM a total of 132 staff employed at the facility had been in-serviced and passed the hand hygiene and PPE competency. Observations conducted from 12/22/22 at 10:55 AM to 5:00 PM on 12/23/22 revealed staff were donning and doffing PPE appropriately upon entrance and exit of covid-19 positive rooms. Interviews conducted on 12/23/22 from 9:48 AM to 5:30 PM with staff from all three shifts(LVN E, Med aide F, CNA G, CNA H, CNA I, CNA J, COTA, ST Assistant Director, LVN K, Housekeeper L, Environmental Director, Laundry aide, Dietary cook M, Dietary cook N, PT O, CNA P, RN Q, CNA R, LVN S, CNA T, LVN U, LVN V, Housekeeper Z, LVN W, RN X, CNA Y, and Rehab tech), revealed staff were knowledgeable about what PPE was required to enter a COVID-19 positive room and why hand hygiene was important after doffing to prevent the spread of infection. The staff stated they had to watch videos on hand hygiene and PPE and had to perform a skills test. In an interview with the ADON on 12/23/22 at 4:56 PM it was revealed that utilizing PPE and performing hand hygiene was the way to ensure COVID-19 was not being spread when going from a positive room to a negative room. The ADON stated charge nurses, direct supervisors and everyone was in charge of going behind staff to ensure they followed infection control protocols. They could make rounds and address any issues at that time. The ADON stated an IJ was identified because the staff were not following the proper PPE and hand hygiene protocols, thereby placing residents at risk. The ADON stated the facility was going to implement ongoing monitoring, monitoring tools and schedules to ensure proper infection control measures were followed. In an interview with the DON on 12/22/22 at 8:39 AM she stated an IJ was identified because staff was caring for sick residents and then entered rooms of residents who were not sick without proper PPE or hand hygiene, thereby spreading germs to others. In an interview with the DON on 12/22/22 at 8:39 AM she stated she understood why this was identified as an IJ because staff was caring for sick residents and then entered rooms of residents who were not sick without proper PPE or hand hygiene, thereby spreading germs to others. In an interview on 12/23/22 at 5:48 PM, the Assistant Administrator stated an IJ was identified because of the failure of staff to wear the proper PPE, going in and out of resident rooms that were covid positive and negative in addition to concerns with handwashing and sanitizing. She stated all this could lead to potential harm or spread of infections and diseases. An Immediate Jeopardy (IJ) was identified on 12/21/22 at 12:03 PM. While the IJ was removed on 12/23/22 at 4:40 PM, the facility remained out of compliance at a level of no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope of pattern as the facility was continuing to monitor the implementation and effectiveness of their corrective systems.