**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 2 of 5 residents (Resident #8 and Resident #9) reviewed for supervision. The facility failed to ensure adequate supervision was provided to prevent a physical altercation between Residents #8 and #9 on the facility's memory care unit on 06/17/25 and failed to ensure the nurse on the unit, RN K, had visual access to the residents to be able to intervene timely. Resident #9 punched Resident #8 approximately eight times in the face/head resulting in Resident #8 having an abrasion and swelling on the left side of his face. The noncompliance was identified as a past non-compliance. The Immediate Jeopardy (IJ) began on 06/17/25 and ended on 06/19/25. The facility had corrected the noncompliance before the abbreviated survey began. This failure placed residents at risk of harm and/or serious injury. Findings included: Record review of Resident #8's most recent Quarterly MDS Assessment, dated 04/06/25, reflected the resident was a [AGE] year-old male, who admitted to the facility on [DATE]. Resident #8's cognition was moderately impaired with a BIMS score of 6. The resident's diagnoses included: non-Alzheimer's dementia (various types of dementia), unspecified dementia, unspecified severity, with other behavioral disturbances, coronary artery disease (general decline in cognitive abilities that affect a person's ability to perform everyday activities) and high blood pressure. Resident #8's MDS indicated he had shown no signs of behavior or mood swings. Record review of Resident #8's undated care plan reflected the following care plans that had been developed:- Resident #8 had a history of trauma that may have a negative impact related to physical aggression from another resident. The care plan goals included: maintain resident's safety and integrity during post trauma episode, using appropriate interventions. The care plan interventions included consult with family regarding the resident's condition as appropriate. Identify situation/event/images that trigger recollections of the traumatic event and limit the resident's exposure to these as much as possible. These triggers could include physical aggression from others. - Resident #8 had delirium or an acute confusional episode related to change in condition. The care plan goal reflected: Resident will be free of signs and symptoms of delirium (changes in behavior, mood, cognitive function, communication, level of consciousness, restlessness. The care plan interventions included to consult with family and interdisciplinary team, review chart to establish baseline level of functioning. Educate resident/family/caregivers to observe for and report any signs or symptoms of delirium. Ensure fluid intake of at least 1500 cc /24 hours. - Resident #8's had potential to demonstrate physical behaviors Dementia, History of harm to other, poor impulse control. The care plan goals included: The resident will demonstrate effective coping skills. The care plan interventions included: analyze [sic] of key times, places, circumstances, triggers, and what deescalates behaviors and document. Assess and address for contributing sensory deficits. Assess and anticipate resident's needs: food, thirst, toileting needs, comfort level, body positioning, pain. If resident has physical behaviors toward another resident, immediately intervene to protect the residents involved and call for assistance. If intervening would be unsafe, call out for staff assistance immediately. Resident to be 1:1 for 24 hours, every 15minutes for 24 hours, every 30 minutes for 24 hours, every 1 hour for 24 hours, every 8 hours for 24 hours. When resident becomes agitated: intervene before agitation escalates; Guide away from the source of distress; engage calmly in conversation; if response is aggressive, staff to walk calmly away; and approach later. - Resident #8 resided in the Secure Care Unit, related to diagnosis of dementia and risk for elopement. Disease Process, Disoriented to place, Memory loss. Goal: Resident will not have feelings of isolation and will feel safe and secure in the care received while on the Secure Care Unit. Interventions included: Admit to Secure Care unit per physician orders, Engage resident in group activities and provide them with individualized meaningful projects that they will accomplish throughout the day, Involve resident in daily activities designed for Secure Care Unit, Monitor for S/S of depression, withdrawal from usual activities, Notify MD of any changes, Psych services per MD orders.Record review of Resident #8's progress notes written by RN K on 06/17/25 at 12:00 PM revealed Writer heard yelling, saw patients Resident #8 and Resident #9 hitting one another and rolling on the dry floor. RN K went out and grabbed Resident #8's arm to prevent him from hitting and telling him to let go of Resident #9's shirt. After he let go then I pulled him away. Resident #9 then sat on the couch. Resident #8 laid on the floor. Vitals were taken. Neuros taken. All withing normal limits. Resident #8 complaint of face hurting. Resident #9 complaint of right-hand hurting. RN K notified ADON C. RN K placed ice pack on Resident #8's left side of face and assisted him to chair. Record review of Resident #8's progress note Initial Skin Assessment written by ADON C on 06/17/25 at 12:30 PM revealed Skin Color: Normal; Temperature of skin: Warm; Bruise present: Yes. Location, measurements of bruising: left facial abrasion; Skin Tear Present: No; Abrasion present: Yes. Location, measurements of abrasion: left side facial abrasion; Laceration present: No; Surgical incision present: No; Rash present: No; Moisture Associated Skin Damage present: No; Pressure, venous, arterial, or diabetic ulcer present: No; Other skin findings: Left facial abrasion / swollen. Record review of Resident #8 progress note Transfer Notification written by ADON C on 06/17/25 at 1:00 PM revealed Resident #8 was transferred to a hospital on [DATE] 1:00 PM related to Unresponsive. This is intended to serve as notice of an emergency transfer. Record review of Resident #8's progress note Activity Note written by LVN L on 06/17/25 at 8:32 PM revealed resident returned from emergency room with no new orders. Resident remains alert and confused, resident at baseline. resident neuros restarted as per facility protocol. Resident assessed, resident noted with left facial swelling with bruising noted, abrasion to left lower leg. Physician notified of return new order to increase tramadol 50mg one po daily to bid. Resident's Responsible Party made aware of return, made aware of resident overall condition and any new findings and new orders. Responsible Party had no questions or concerns at this time. Record review of Resident #9's most recent Quarterly MDS (Minimum Data Set) Assessment, dated 05/22/25, reflected a [AGE] year-old male admitted to the facility on [DATE]. Resident #6 had BIMS of 06 indicating moderate cognitive impairment. Diagnosis included Unspecified Dementia (various types of dementia), Unspecified severity, without behavioral/psychotic/mood/anxiety disturbances (general decline in cognitive abilities that affect a person's ability to perform everyday activities). Depression (persistent feeling of sadness and loss of interest), and high blood pressure. Resident #'s MDS indicated he had shown mood signs of little interest or pleasure in doing things and feeling down, depressed, or hopeless with no signs of behaviors. Record review of Resident #9's care plan last revised 06/17/25 revealed Resident #9 had been identified as having Resident at risk to exhibit physical aggression. Goal: Resident to not have any episodes of physical aggression. Intervention include resident to remain 1:1 related to physical aggression. Care Plan revealed: Resident #9 has potential to demonstrate physical behaviors Anger, Dementia, Poor impulse control was put on by another resident and responded by pushing leading to altercation. Goal: The resident will demonstrate effective coping skills. Interventions included: 1:1 supervision prn physical aggression or other aggressive behavior. Analyze [sic] of key times, places, circumstances, triggers, and what de-escalates. Assess and address for contributing sensory deficits. Assess and anticipate resident's needs: food, thirst. toileting needs, comfort level, body positioning, pain etc. COMMUNICATION: provide physical and verbal cues to alleviate anxiety; give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff member when agitated. If the resident has physical behaviors toward another resident, immediately intervene to protect the residents involved and call for assistance. If intervening would be unsafe, call out for staff assistance immediately. Secure care consult for behavior management. Send to emergency room for psychiatric evaluation as needed. When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later. Care Plan revealed: Resident #9 resides in the Secure Care Unit, related to diagnosis of dementia (or related diagnosis) and risk for elopement. Goal: Resident will not have feelings of isolation and will feel safe and secure in the care received while on the Secure Care Unit. Interventions include: Admit to Secure Care unit per physician orders. Engage resident in group activities and provide them with individualized meaningful projects that they will accomplish throughout the day. Involve resident in daily activities designed for Secure Care Unit. Monitor for signs and symptoms of depression, withdrawal from usual activities. Notify physician of any changes. Psych services as doctor orders. Record review of Resident #'s progress note Neuro Assessment written by ADON C on 06/17/25 at 12:02 PM revealed the physician was notified of a negative change. Comments and/or new orders: Transfer to the hospital. Record review of Resident #9's progress note written by RN K on 06/17/25 at 12:11 PM revealed Writer heard yelling and saw Resident #8 and Resident #9 on the dry floor rolling and hitting one another. I held Resident #8 arm and told him to let go of Resident #9's shirt. After several minutes he let go and Resident #9 got up and sat on the couch. Resident #9 then went to his room and changed his shirt. Vital signs, neuros, blood sugar done. Resident #9 to be transferred to hospital. Record review of Resident #9's progress note written by Social Services Director on 0617/25 at 3:06 PM reflected: Social Services Director met with the resident to assess any trauma after an incident between he and another resident. Resident denies any trauma. Social Services Director did not observe any trauma symptoms or behaviors. Resident continues to state he feels safe in the facility and not fearful of the other resident. Resident will be transported to the hospital for further assessment. Observation of the facility's surveillance video dated 06/17/25 at 11:42 AM revealed the nurse office door was closed and both Resident #8 and Resident #9 were in the television room within feet of each other, Resident #8 stood between a female resident in her wheelchair sitting next to the exit door and a credenza in front the television wall. As Resident #9 headed towards the exit he passed Resident #8 and pushed him in the back. As Resident #8 stumbled a couple of feet he went after Resident #9 almost tripping over the wheelchair. Both residents stepped out of the camera, within seconds they returned back in the frame tussling at each other. Resident #9 began punching Resident #8 eight times in the face. This continued until they both fell onto the floor holding onto each other's shirts. At 11:43.25 the door opened, however, RN K did not exit the office to assist until 11:43.51, at this time she walked over to Resident #8 and placed her hand on his wrist. The video ended. Record review of the provider investigator report revealed on 06/17/25 at 11:45 AM Residents were in the secure unit living area when they began to have a verbal altercation. Resident #9 pushed Resident #8 in the back and then proceeded to punch Resident #8 in the face several times before both residents went to the ground and continued to hold each other by the clothing before Charge Nurse, RN K, separated residents. Resident #8 was sent to the emergency room for further evaluation due to facial swelling - no further injuries noted. Immediate discharge notice delivered to Resident #9 at hospital due to aggression and unable to be redirected during altercation. Staff interviews completed. In-services regarding abuse/neglect, resident rights, how to deal with residents aggressive behavior, behavior management. Record review of hospital records for Resident #8 reflected on 06/17/25 Resident #8 presented with a fall after an assault at the nursing home. The resident was punched in the face at least 10 times per Emergency Medical Service. It reflected the resident was assaulted at 11:00 AM. The resident then walked to the dining room on his own, had lunch, fell, and was then unresponsive. Emergency Medical Service stated the resident was found down supine, no blood thinners, and the resident's blood sugar was 375. The hospital findings reflected Resident #8 had no fractures, no acute intracranial abnormality (no immediate or urgent issues detected in the brain), no acute osseous cervical spine abnormality (no severe bone issues). Record review of facility log 15 Minute Monitoring revealed Resident #9 was placed on 15-minute monitoring starting at 12:30 PM until he exited the building to hospital for further evaluation at 2:30 PM . Record review of RN K statement dated 06/17/25 I [RN K] was sitting in the office when [Resident #8 and Resident #9] were heard making a lot of commotion. I had the door partially open. As I began to open the door to see what was going on the I noticed the two residents were rolling on the floor. I felt I was in shock at what I was seeing and thinking to myself what was going on and what was I going to do? I then thought of separating the two of them. I tried to separate them, but it was hard. I did not think to yell for help. Record review of Employee Disciplinary Report dated 06/17/25 revealed Investigation Suspension: [RN K] will be placed on an investigatory suspension pending an investigation into allegations of failing to meet their job duty/responsibility expectations. Corrective plan of Action: Due to the allegations, [RN K] will be placed on unpaid investigatory suspension. [RN K] will remain on investigatory suspension until the investigation is completed into the above allegation. [RN K] will be notified when the investigation is completed. [RN K] may provide a written statement. Employee comments: I think I tried to remain calm during the action of the residents. Interview on 09/09/25 on 11:28 AM with CNA I revealed during the time of the incident she was in the shower room with another resident leaving RN on the floor and charting in the nurse office. CNA I stated when she finished in the shower she was informed there had been an altercation between Resident #8 and Resident #9. CNA I stated she saw Resident #8 after the fight and observed swelling on Resident #8's face while in the dining room, he ate well, however soon after lunch he became nonresponsive and was sent out to the hospital. Resident #9 was also sent to the hospital for evaluation and had not returned. According to CNA I, she was inserviced over resident-to-resident altercations, resident confrontations, ensure to separate residents immediately and report. CNA I stated not monitoring residents and separating immediately during an altercation placed residents at risk for injuries or hospitalization. Attempted interview on 09/09/25 at 1:30 PM with RN K was unsuccessful. Attempted interview on 09/09/25 at 1:32 PM with LVN L was unsuccessful. Interview on 09/09/25 at 2:25 PM with ADON C revealed on video, Resident #9 was offering Resident #8 a chair to sit but Resident #8 was spitting on Resident #9, as they passed each other Resident #9 pushed Resident #8. Resident #8 then turned and started hitting Resident #9, both residents ended up on the floor. ADON C stated RN K was in the office when she heard commotion and stepped out. ADON C stated RN K was slow to react to the commotion and in separating the residents. ADON C stated emergency serivces was called, Resident #9 was placed on one-on-one monitoring until he was sent to the hospital for evaluation due to his aggressive behavior, punching Resident #8 causing a scratch and swelling to the left side of Resident #8's face. According to ADON C Resident #8 was also placed on one-to-one monitoring, assessed and injuries cleaned, and started neuro checks. ADON C further stated after the altercation there were no further signs or symptoms of injury, after lunch RN K called her to say Resident #8 was unresponsive, emergency services was called to send him to the hospital. ADON C stated in-service trainings were completed over abuse and neglect and staff surveys to ensure staff were knowledgeable about what to do during resident-to-resident altercations. ADON C stated all staff including CNAs and Nurses were responsible for monitoring and engaging with residents, not reacting quickly to altercations placed residents at risk of harm. Interview on 09/10/25 at 11:32 AM with the DON revealed she was not in the facility during the time of the incident however when she returned she followed up on the incident. The DON stated she reviewed the video revealing both residents ended up on the floor hitting each other. The DON stated the video also revealed RN K in the nurse office with the door closed and her slow to respond to the altercation. The DON stated RN K was suspended immediately and terminated due to the evolvement of the incident. The DON stated she expected staff on the secure unit to be out in the open and engaged with residents, not behind closed doors. The DON stated resident safety is top priority, so getting residents separated during altercations are immediate and to follow up with assessments. The DON stated Resident #8 was placed one on one, and Resident #9 was sent to the hospital with an immediate discharge. The DON stated staff were provided in-service training on abuse, neglect, resident rights, residents with dementia and aggressive behavior, separate during altercations, and one to one and behavior management. The DON stated nurses were responsible for always having eyes on residents especially on the secure unit, along with the one or two aides on duty. The DON further stated not doing so placed residents at risk of their safety, someone could fall and hit their head and possibly die. Interview on 09/10/25 at 11:56 AM with the Administrator revealed she was notified by ADON C of resident-to-resident altercation on the memory care unit, upon return she was able to review the video which showed the altercation between Resident #8 and Resident #9. The Administrator stated Resident #9 was sent to the hospital for further evaluation and immediate discharge. The Administrator stated Resident #8 was placed on one-on-one monitoring and neuro checks, he had lunch with no further signs of injury or distress, until he started showing signs of being non-responsive and altered status. The Administrator stated Resident #8 was sent to the hospital by emergency medical services and returned with no findings or new orders. The Administrator stated upon review of the video it showed RN K was slow to respond to the altercation between the two residents, RN K was in the office behind closed door allowing residents altercation to last close to 2 minutes before she slowly exited the office to separate them. The Administrator stated the nurses should be out of the office as much as possible; both nurses and aides were responsible for always having eyes on residents. The Administrator further stated not having a clear sightline of residents placed them at risk of abuse and harm. The facility took the following actions to correct the non-compliance prior to the investigation: Record review of an in-service, dated 06/17/25, reflected 29 staff including nurses, CNAs, housekeepers, medication aide, Business Office Manager, dietary aides were provided with training on resident-to-resident altercations. The in-service training covered: abuse and neglect; resident rights; how to deal with residents with dementia and aggressive behaviors; immediately separating residents from physical or verbal altercations; placing the aggressor on one-to-one supervision for resident safety; and behavior management Record review of an in-service, dated 06/17/25, reflected 29 staff that included nurses, nurse's aides, housekeeping, medication aide, Business Office Manager, dietary aides were in-serviced regarding: Abuse/Neglect Policy Record review of Resident #8's 15 minute checks dated 06/17/25 revealed monitoring from 12:30 PM until 06/19/25. Record review of Resident #9's 15 minute checks dated 06/17/25 revealed monitoring on 06/17/25 12:30 PM until 06/17/25 12:30 PM. Record review of Resident #9's clinical records revealed Resident #9 was placed one-on-one supervision on 06/17/25 12:30 PM until 06/17/25 2:30 PM until he was sent to the hospital for further evaluation and issued immediate discharge . Record review of Resident #8 and Resident #9's care plans were updated. Record review of Resident #8's clinical records revealed Resident #8 was assessed and transported to the emergency room for further evaluation with no findings or new orders. Record review of Resident #8's clinical records revealed Resident #8 was being monitored for behaviors throughout each shift upon his return from the hospital on [DATE] 8:30 PM until 06/19/25 at 6:00 PM until with no further signs of aggression or agitation. Record review of Staff Surveys were conducted on 06/17/25 - 06/18/25 by 24 staff over what signs and symptoms to look for when resident had a change in condition, how to respond when witnessed a resident-to-resident altercation, who do you report abuse/neglect allegations to? All with the understanding to immediately separate residents during resident-to-resident altercation and report to the nurse and the abuse coordinator which was the Administrator. Observation on 09/09/25 10:00 AM - 09/10/25 4:00 PM throughout investigation revealed the door to the office on the memory care unit has been removed. Both nurse and aide were making constant rounds to visibly check on each resident on the unit. Staff were engaging with residents and not seen in the nurse's office. Interviews on 09/09/25 from 11:22 AM through 09/10/25 3:30 PM with MDS Coordinator, CNA A, LVN B, ADON C, ADON D, LVN E, MA F, LVN G, LVN H, CNA I, CNA J, Social Services Director, Director of Rehabilitation, DON, and the Administrator, Activity Director, Housekeeping Supervisor, 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. Facility staff stated they monitor residents throughout the shifts, if behaviors were identified staff stated they were trained to redirect residents or placed them on 1:1 or q15 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. On 09/10/25 at 3:30 PM, the Administrator and DON stated they were working with corporate to locate a policy on accident and hazards, supervision or quality of care; however, the policies were not provided prior to exit. The noncompliance was identified as PNC. The IJ began on 06/17/25 and ended on 06/19/25. The facility had corrected the noncompliance before the abbreviated survey began.

**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 5 of 6 residents (Residents #1, #2, #3, #8, and #9) reviewed for abuse. 1. The facility failed to ensure adequate supervision was provided to prevent a physical altercation between Residents #8 and #9 on the facility's memory care unit on 06/17/25 and failed to ensure the nurse on the unit, RN K, had visual access to the residents to be able to intervene timely. Resident #9 punched Resident #8 approximately eight times in the face/head resulting in Resident #8 having an abrasion and swelling on the left side of his face. 2. The facility failed to ensure Resident #1 was free from verbal abuse when he was verbally abused by CNA #1 on 09/04/25. 3. The facility failed to ensure Resident #3 were free from abuse on 05/13/25 when Resident #2 punched him in the face. The noncompliance was identified as a past non-compliance. The Immediate Jeopardy (IJ) began on 05/13/25 and ended on 09/05/25. The facility had corrected the noncompliance before the abbreviated survey began. These failures could place residents at risk of abuse, trauma, and psychological harm. Findings included:1. Record review of Resident #8's most recent Quarterly MDS Assessment, dated 04/06/25, reflected the resident was a [AGE] year-old male, who admitted to the facility on [DATE]. Resident #8's cognition was moderately impaired with a BIMS score of 6. The resident's diagnoses included: non-Alzheimer's dementia (various types of dementia), unspecified dementia, unspecified severity, with other behavioral disturbances, coronary artery disease (general decline in cognitive abilities that affect a person's ability to perform everyday activities) and high blood pressure. Resident #8's MDS indicated he had shown no signs of behavior or mood swings. Record review of Resident #8's undated care plan reflected the following care plans that had been developed:- Resident #8 had a history of trauma that may have a negative impact related to physical aggression from another resident. The care plan goals included: maintain resident's safety and integrity during post trauma episode, using appropriate interventions. The care plan interventions included consult with family regarding the resident's condition as appropriate. Identify situation/event/images that trigger recollections of the traumatic event and limit the resident's exposure to these as much as possible. These triggers could include physical aggression from others. - Resident #8 had delirium or an acute confusional episode related to change in condition. The care plan goal reflected: Resident will be free of signs and symptoms of delirium (changes in behavior, mood, cognitive function, communication, level of consciousness, restlessness. The care plan interventions included to consult with family and interdisciplinary team, review chart to establish baseline level of functioning. Educate resident/family/caregivers to observe for and report any signs or symptoms of delirium. Ensure fluid intake of at least 1500 cc /24 hours. - Resident #8's had potential to demonstrate physical behaviors Dementia, History of harm to other, poor impulse control. The care plan goals included: The resident will demonstrate effective coping skills. The care plan interventions included: analyze [sic] of key times, places, circumstances, triggers, and what deescalates behaviors and document. Assess and address for contributing sensory deficits. Assess and anticipate resident's needs: food, thirst, toileting needs, comfort level, body positioning, pain. If resident has physical behaviors toward another resident, immediately intervene to protect the residents involved and call for assistance. If intervening would be unsafe, call out for staff assistance immediately. Resident to be 1:1 for 24 hours, every 15minutes for 24 hours, every 30 minutes for 24 hours, every 1 hour for 24 hours, every 8 hours for 24 hours. When resident becomes agitated: intervene before agitation escalates; Guide away from the source of distress; engage calmly in conversation; if response is aggressive, staff to walk calmly away; and approach later. - Resident #8 resided in the Secure Care Unit, related to diagnosis of dementia and risk for elopement. Disease Process, Disoriented to place, Memory loss. Goal: Resident will not have feelings of isolation and will feel safe and secure in the care received while on the Secure Care Unit. Interventions included: Admit to Secure Care unit per physician orders, Engage resident in group activities and provide them with individualized meaningful projects that they will accomplish throughout the day, Involve resident in daily activities designed for Secure Care Unit, Monitor for S/S of depression, withdrawal from usual activities, Notify MD of any changes, Psych services per MD orders. Record review of Resident #8's progress notes written by RN K on 06/17/25 at 12:00 PM reflected: Writer heard yelling, saw patients Resident #8 and Resident #9 hitting one another and rolling on the dry floor. RN K went out and grabbed Resident #8's arm to prevent him from hitting and telling him to let go of Resident #9's shirt. After he let go then I pulled him away. Resident #9 then sat on the couch. Resident #8 laid on the floor. Vitals were taken. Neuros taken. All withing normal limits. Resident #8 complaint of face hurting. Resident #9 complaint of right-hand hurting. RN K notified ADON C. RN K placed ice pack on Resident #8's left side of face and assisted him to chair. Record review of Resident #8's progress note Initial Skin Assessment written by ADON C on 06/17/25 at 12:30 PM revealed Skin Color: Normal; Temperature of skin: Warm; Bruise present: Yes. Location, measurements of bruising: left facial abrasion; Skin Tear Present: No; Abrasion present: Yes. Location, measurements of abrasion: left side facial abrasion; Laceration present: No; Surgical incision present: No; Rash present: No; Moisture Associated Skin Damage present: No; Pressure, venous, arterial, or diabetic ulcer present: No; Other skin findings: Left facial abrasion / swollen. Record review of Resident #8 progress note Transfer Notification written by ADON C on 06/17/25 at 1:00 PM revealed Resident #8 was transferred to a hospital on [DATE] 1:00 PM related to Unresponsive. This is intended to serve as notice of an emergency transfer. Record review of Resident #8's progress note Activity Note written by LVN L on 06/17/25 at 8:32 PM revealed resident returned from emergency room with no new orders. Resident remains alert and confused, resident at baseline. resident neuros restarted as per facility protocol. Resident assessed, resident noted with left facial swelling with bruising noted, abrasion to left lower leg. Physician notified of return new order to increase tramadol 50mg one po daily to bid. Resident's Responsible Party made aware of return, made aware of resident overall condition and any new findings and new orders. Responsible Party had no questions or concerns at this time. Record review of Resident #9's most recent Quarterly MDS (Minimum Data Set) Assessment, dated 05/22/25, reflected a [AGE] year-old male admitted to the facility on [DATE]. Resident #6 had BIMS of 06 indicating moderate cognitive impairment. Diagnosis included Unspecified Dementia (various types of dementia), Unspecified severity, without behavioral/psychotic/mood/anxiety disturbances (general decline in cognitive abilities that affect a person's ability to perform everyday activities). Depression (persistent feeling of sadness and loss of interest), and high blood pressure. Resident #'s MDS indicated he had shown mood signs of little interest or pleasure in doing things and feeling down, depressed, or hopeless with no signs of behaviors. Record review of Resident #9's care plan last revised 06/17/25 revealed Resident #9 had been identified as having Resident at risk to exhibit physical aggression. Goal: Resident to not have any episodes of physical aggression. Intervention include resident to remain 1:1 related to physical aggression. Care Plan revealed: Resident #9 has potential to demonstrate physical behaviors Anger, Dementia, Poor impulse control was put on by another resident and responded by pushing leading to altercation. Goal: The resident will demonstrate effective coping skills. Interventions included: 1:1 supervision prn physical aggression or other aggressive behavior. Analyze [sic] of key times, places, circumstances, triggers, and what de-escalates. Assess and address for contributing sensory deficits. Assess and anticipate resident's needs: food, thirst. toileting needs, comfort level, body positioning, pain etc. COMMUNICATION: provide physical and verbal cues to alleviate anxiety; give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff member when agitated. If the resident has physical behaviors toward another resident, immediately intervene to protect the residents involved and call for assistance. If intervening would be unsafe, call out for staff assistance immediately. Secure care consult for behavior management. Send to emergency room for psychiatric evaluation as needed. When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later. Care Plan revealed: Resident #9 resides in the Secure Care Unit, related to diagnosis of dementia (or related diagnosis) and risk for elopement. Goal: Resident will not have feelings of isolation and will feel safe and secure in the care received while on the Secure Care Unit. Interventions include: Admit to Secure Care unit per physician orders. Engage resident in group activities and provide them with individualized meaningful projects that they will accomplish throughout the day. Involve resident in daily activities designed for Secure Care Unit. Monitor for signs and symptoms of depression, withdrawal from usual activities. Notify physician of any changes. Psych services as doctor orders. Record review of Resident #'s progress note Neuro Assessment written by ADON C on 06/17/25 at 12:02 PM revealed the physician was notified of a negative change. Comments and/or new orders: Transfer to the hospital. Record review of Resident #9's progress note written by RN K on 06/17/25 at 12:11 PM revealed Writer heard yelling and saw Resident #8 and Resident #9 on the dry floor rolling and hitting one another. I held Resident #8 arm and told him to let go of Resident #9's shirt. After several minutes he let go and Resident #9 got up and sat on the couch. Resident #9 then went to his room and changed his shirt. Vital signs, neuros, blood sugar done. Resident #9 to be transferred to hospital. Record review of Resident #9's progress note written by Social Services Director on 0617/25 at 3:06 PM reflected: Social Services Director met with the resident to assess any trauma after an incident between he and another resident. Resident denies any trauma. Social Services Director did not observe any trauma symptoms or behaviors. Resident continues to state he feels safe in the facility and not fearful of the other resident. Resident will be transported to the hospital for further assessment. Observation of the facility's surveillance video dated 06/17/25 at 11:42 AM revealed the nurse office door was closed and both Resident #8 and Resident #9 were in the television room within feet of each other, Resident #8 stood between a female resident in her wheelchair sitting next to the exit door and a credenza in front the television wall. As Resident #9 headed towards the exit he passed Resident #8 and pushed him in the back. As Resident #8 stumbled a couple of feet he went after Resident #9 almost tripping over the wheelchair. Both residents stepped out of the camera, within seconds they returned back in the frame tussling at each other. Resident #9 began punching Resident #8 eight times in the face. This continued until they both fell onto the floor holding onto each other's shirts. At 11:43.25 the door opened, however, RN K did not exit the office to assist until 11:43.51, at this time she walked over to Resident #8 and placed her hand on his wrist. The video ended. Record review of the provider investigator report revealed on 06/17/25 at 11:45 AM Residents were in the secure unit living area when they began to have a verbal altercation. Resident #9 pushed Resident #8 in the back and then proceeded to punch Resident #8 in the face several times before both residents went to the ground and continued to hold each other by the clothing before Charge Nurse, RN K, separated residents. Resident #8 was sent to the emergency room for further evaluation due to facial swelling - no further injuries noted. Immediate discharge notice delivered to Resident #9 at hospital due to aggression and unable to be redirected during altercation. Staff interviews completed. In-services regarding abuse/neglect, resident rights, how to deal with residents aggressive behavior, behavior management. Record review of hospital records for Resident #8 reflected on 06/17/25 Resident #8 presented with a fall after an assault at the nursing home. The resident was punched in the face at least 10 times per Emergency Medical Service. It reflected the resident was assaulted at 11:00 AM. The resident then walked to the dining room on his own, had lunch, fell, and was then unresponsive. Emergency Medical Service stated the resident was found down supine, no blood thinners, and the resident's blood sugar was 375. The hospital findings reflected Resident #8 had no fractures, no acute intracranial abnormality (no immediate or urgent issues detected in the brain), no acute osseous cervical spine abnormality (no severe bone issues). Record review of facility log 15 Minute Monitoring revealed Resident #9 was placed on 15-minute monitoring starting at 12:30 PM until he exited the building to hospital for further evaluation at 2:30 PM . Record review of RN K statement dated 06/17/25 I [RN K] was sitting in the office when [Resident #8 and Resident #9] were heard making a lot of commotion. I had the door partially open. As I began to open the door to see what was going on the I noticed the two residents were rolling on the floor. I felt I was in shock at what I was seeing and thinking to myself what was going on and what was I going to do? I then thought of separating the two of them. I tried to separate them, but it was hard. I did not think to yell for help. Record review of Employee Disciplinary Report dated 06/17/25 revealed Investigation Suspension: [RN K] will be placed on an investigatory suspension pending an investigation into allegations of failing to meet their job duty/responsibility expectations. Corrective plan of Action: Due to the allegations, [RN K] will be placed on unpaid investigatory suspension. [RN K] will remain on investigatory suspension until the investigation is completed into the above allegation. [RN K] will be notified when the investigation is completed. [RN K] may provide a written statement. Employee comments: I think I tried to remain calm during the action of the residents. Interview on 09/09/25 on 11:28 AM with CNA I revealed during the time of the incident she was in the shower room with another resident leaving RN on the floor and charting in the nurse office. CNA I stated when she finished in the shower she was informed there had been an altercation between Resident #8 and Resident #9. CNA I stated she saw Resident #8 after the fight and observed swelling on Resident #8's face while in the dining room, he ate well, however soon after lunch he became nonresponsive and was sent out to the hospital. Resident #9 was also sent to the hospital for evaluation and had not returned. According to CNA I, she was inserviced over resident-to-resident altercations, resident confrontations, ensure to separate residents immediately and report. CNA I stated not monitoring residents and separating immediately during an altercation placed residents at risk for injuries or hospitalization. Attempted interview on 09/09/25 at 1:30 PM with RN K was unsuccessful. Attempted interview on 09/09/25 at 1:32 PM with LVN L was unsuccessful. Interview on 09/09/25 at 2:25 PM with ADON C revealed on video, Resident #9 was offering Resident #8 a chair to sit but Resident #8 was spitting on Resident #9, as they passed each other Resident #9 pushed Resident #8. Resident #8 then turned and started hitting Resident #9, both residents ended up on the floor. ADON C stated RN K was in the office when she heard commotion and stepped out. ADON C stated RN K was slow to react to the commotion and in separating the residents. ADON C stated emergency services was called, Resident #9 was placed on one-on-one monitoring until he was sent to the hospital for evaluation due to his aggressive behavior, punching Resident #8 causing a scratch and swelling to the left side of Resident #8's face. According to ADON C Resident #8 was also placed on one-to-one monitoring, assessed and injuries cleaned, and started neuro checks. ADON C further stated after the altercation there were no further signs or symptoms of injury, after lunch RN K called her to say Resident #8 was unresponsive, emergency services was called to send him to the hospital. ADON C stated in-service trainings were completed over abuse and neglect and staff surveys to ensure staff were knowledgeable about what to do during resident-to-resident altercations. ADON C stated all staff including CNAs and Nurses were responsible for monitoring and engaging with residents, not reacting quickly to altercations placed residents at risk of harm. Interview on 09/10/25 at 11:32 AM with the DON revealed she was not in the facility during the time of the incident however when she returned she followed up on the incident. The DON stated she reviewed the video revealing both residents ended up on the floor hitting each other. The DON stated the video also revealed RN K in the nurse office with the door closed and her slow to respond to the altercation. The DON stated RN K was suspended immediately and terminated due to the evolvement of the incident. The DON stated she expected staff on the secure unit to be out in the open and engaged with residents, not behind closed doors. The DON stated resident safety is top priority, so getting residents separated during altercations are immediate and to follow up with assessments. The DON stated Resident #8 was placed one on one, and Resident #9 was sent to the hospital with an immediate discharge. The DON stated staff were provided in-service training on abuse, neglect, resident rights, residents with dementia and aggressive behavior, separate during altercations, and one to one and behavior management. The DON stated nurses were responsible for always having eyes on residents especially on the secure unit, along with the one or two aides on duty. The DON further stated not doing so placed residents at risk of their safety, someone could fall and hit their head and possibly die. Interview on 09/10/25 at 11:56 AM with the Administrator revealed she was notified by ADON C of resident-to-resident altercation on the memory care unit, upon return she was able to review the video which showed the altercation between Resident #8 and Resident #9. The Administrator stated Resident #9 was sent to the hospital for further evaluation and immediate discharge. The Administrator stated Resident #8 was placed on one-on-one monitoring and neuro checks, he had lunch with no further signs of injury or distress, until he started showing signs of being non-responsive and altered status. The Administrator stated Resident #8 was sent to the hospital by emergency medical services and returned with no findings or new orders. The Administrator stated upon review of the video it showed RN K was slow to respond to the altercation between the two residents, RN K was in the office behind closed door allowing residents altercation to last close to 2 minutes before she slowly exited the office to separate them. The Administrator stated the nurses should be out of the office as much as possible; both nurses and aides were responsible for always having eyes on residents. The Administrator further stated not having a clear sightline of residents placed them at risk of abuse and harm. The facility took the following actions to correct the non-compliance prior to the investigation: Record review of an in-service, dated 06/17/25, reflected 29 staff including nurses, CNAs, housekeepers, medication aide, Business Office Manager, dietary aides were provided with training on resident-to-resident altercations. The in-service training covered: abuse and neglect; resident rights; how to deal with residents with dementia and aggressive behaviors; immediately separating residents from physical or verbal altercations; placing the aggressor on one-to-one supervision for resident safety; and behavior management Record review of an in-service, dated 06/17/25, reflected 29 staff that included nurses, nurse's aides, housekeeping, medication aide, Business Office Manager, dietary aides were in-serviced regarding: Abuse/Neglect Policy Record review of Resident #8's 15 minute checks dated 06/17/25 revealed monitoring from 12:30 PM until 06/19/25. Record review of Resident #9's 15 minute checks dated 06/17/25 revealed monitoring on 06/17/25 12:30 PM until 06/17/25 12:30 PM. Record review of Resident #9's clinical records revealed Resident #9 was placed one-on-one supervision on 06/17/25 12:30 PM until 06/17/25 2:30 PM until he was sent to the hospital for further evaluation and issued immediate discharge . Record review of Resident #8 and Resident #9's care plans were updated. Record review of Resident #8's clinical records revealed Resident #8 was assessed and transported to the emergency room for further evaluation with no findings or new orders. Record review of Resident #8's clinical records revealed Resident #8 was being monitored for behaviors throughout each shift upon his return from the hospital on [DATE] 8:30 PM until 06/19/25 at 6:00 PM until with no further signs of aggression or agitation. Record review of Staff Surveys were conducted on 06/17/25 - 06/18/25 by 24 staff over what signs and symptoms to look for when resident had a change in condition, how to respond when witnessed a resident-to-resident altercation, who do you report abuse/neglect allegations to? All with the understanding to immediately separate residents during resident-to-resident altercation and report to the nurse and the abuse coordinator which was the Administrator. Observation on 09/09/25 10:00 AM - 09/10/25 4:00 PM throughout investigation revealed the door to the office on the memory care unit has been removed. Both nurse and aide were making constant rounds to visibly check on each resident on the unit. Staff were engaging with residents and not seen in the nurse's office. Interviews on 09/09/25 from 11:22 AM through 09/10/25 3:30 PM with MDS Coordinator, CNA A, LVN B, ADON C, ADON D, LVN E, MA F, LVN G, LVN H, CNA I, CNA J, Social Services Director, Director of Rehabilitation, DON, and the Administrator, Activity Director, Housekeeping Supervisor, 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. Facility staff stated they monitor residents throughout the shifts, if behaviors were identified staff stated they were trained to redirect residents or placed them on 1:1 or q15 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. 2. Record review of Resident #1's Annual MDS, dated [DATE], reflected the resident was a [AGE] year-old male, who admitted to the facility on [DATE]. Th resident was cognitively intact with a BIMS (mental status assessment) score of 15. His diagnoses included Type 2 diabetes mellitus (metabolic disorder marked my insulin resistance and impaired insulin secretion); chronic pain syndrome (multifactorial condition characterized by persistent pain lasting longer than 3-6 months, often accompanied by psychological and functional impairment); and cognitive communication deficit (impaired communication due to deficits in attention, memory, or executive function). The MDS reflected Resident #1 did not have any physical or verbal behaviors towards others. The MDS also reflected Resident #1 was dependent upon staff for assistance with ADLs. Record review of Resident #1's Care Plan, initiated on 11/15/24 and revised on 09/05/25, reflected: Focus: Resident has a history of making false accusations, related to but not limited to: the staff, showers, activities of daily living, and preferences. Resident instigates staff by cursing at them and calling them derogatory names. Goal: Reductions or absence or false accusation. Interventions: Anticipate and meet the resident's needs. Assist the resident to develop more appropriate methods of coping and interacting with staff. Encourage the resident to express feelings appropriately. Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. Interview on 09/09/25 at 9:48 AM with Resident #1 revealed on 09/04/25, his roommate called CNA A to his room. Resident #1 said CNA A walked into the room asked who had called her, to which he responded with none ya. Resident #1 said he heard CNA A say fuck you to him, and she immediately walked out of the room. Resident #1 said CNA A saying that made him cry, feel put down, and made him feel uncomfortable. Resident #1 said right after it happened, he told his nurse (LVN B). Resident #1 revealed LVN B switched aides, so CNA A no longer cared for him. Interview on 09/09/25 at 10:17 AM with Resident #4 revealed he was Resident #1's roommate. Resident #4 reported on 09/04/25 CNA A came into the room and was helping Resident #1 get ready for bed. Resident #4 said Resident #1 was cussing and fighting with CNA A when CNA A told Resident #1, Fuck you. Resident #4 stated after it was said, CNA A walked out of the room and another aide came to help Resident #1 finish getting ready. Resident #4 stated CNA A appeared calm when she cussed at Resident #1. Resident #4 revealed he had no issues with CNA A or any other staff members. Interview on 09/09/25 at 2:23 PM with LVN B revealed Resident #1 came to her after the incident with CNA A on 09/04/25. LVN B stated Resident #1 and CNA A used the F word to each other. LVN B said when Resident #1 reported it to her, he appeared visibly upset by it. LVN B said she switched the aides out, so CNA A was no longer caring for Resident #1. LVN B stated she had to calm Resident #1 down, and she went to the Administrator because it was verbal abuse to Resident #1. Interview on 09/09/25 at 2:38 PM with CNA A revealed she was called into Resident#1's room. CNA A asked Resident #1 to turn the call light off twice, and he replied to CNA A by saying, Fuck you. CNA A stated she said Fuck you back to Resident #1. CNA A stated she knew it was not right to say that to any resident, but it slipped out. CNA A confirmed it was verbal abuse. Interview on 09/10/25 at 3:10 PM with the Social Worker revealed on 09/05/25, Resident #1 came and told her that a CNA last night had cussed him out by saying fuck you. The Social Worker reported that Resident #1 was visibly upset when he described what had happened. The Social Worker stated she immediately reported it to the Administrator who was the Abuse Coordinator due to it being verbal abuse. Interview on 09/10/25 at 11:31 AM with the DON revealed she was told about the incident between Resident #1 and CNA A on 09/05/25 by the Social Worker right after he reported it to her. The DON stated it was reported to her that Resident #1 was baiting CNA A by saying, Fuck you first, but then CNA A said it back. The DON stated CNA A admitted it was wrong to say that to a resident. The DON revealed they suspended and then terminated CNA on 09/05/25. The DON stated telling a resident Fuck you was considered verbal abuse which was why CNA A had to be terminated. The DON stated her expectation was for staff to keep all residents safe and free from abuse. Interview on 09/10/25 at 11:56 AM with the Administrator revealed CNA A told Resident #1 Fuck you the previous night (09/04/25) around 6:00 PM. During her interview with Resident #1, he told her that CNA A cursed at him unprovoked. Resident #1's roommate also confirmed that CNA A did say that to Resident #1. The Administrator stated this was considered verbal abuse, and CNA A was terminated after admitting to the allegation. The Administrator reported that verbal abuse could put residents at risk of psychological harm. The Administrator stated she expected her staff to treat residents with respect and to report any abuse immediately. The Administrator stated her number was posted throughout the building, and she wants to be notified at any time if abuse occurs or is suspected. Observation on 09/10/25 at 3:15 PM revealed the Administrator's phone number was posted in multiple locations, including at the nurses' station and in the hallway. Record review of CNA A's personnel file reflected CNA A was suspended and terminated on 09/05/25. Record review of facility's current, undated Abuse/Neglect Policy reflected the following: The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. The facility will provide and ensure the promotion and protection of resident rights. It is each individual's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property abuse and situations that may constitute abuse or neglect to any resident in the facility . Verbal abuse: Any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents, or within their hearing distance, regardless of their age, ability to comprehend or disability . Prior to the HHSC investigation, the facility took the following actions to correct the noncompliance: Record review of Resident #1's Trauma Informed PRN Assessment had been completed on 09/05/25 with no concerns identified. Record review of the facility's Skin Monitoring: Comprehensive CNA Shower Record review had been completed on seven residents on 09/05/25. Record review of safe surveys completed on 09/05/25 showed that nine residents had been interviewed by the facility with no issues noted. Record review of In-Service Training record reflected 41 staff had been provided in-service training on abuse/neglect, resident rights, and behavior management on 09/05/25. Interviews between 09/09/25 from 9:30 AM through 09/10/25 3:15 PM with the Social Worker, LVN B, LVN E, ADON C, ADON D, Housekeeper M, MA F, LVN G, Speech and Language Therapist, LVN H, CNA I, and CNA J revealed the facility staff were able to verify education was provided to them. The staff stated they were educated on different types of abuse and neglect. Staff stated they would intervene if they witnessed any type of abuse and immediately report to the Abuse Coordinator. 3. Record review of Resident #2's Annual MDS, dated [DATE], reflected the resident was a [AGE] year-old male, who admitted to the facility on [DATE]. The resident's diagnoses included hemi[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 1 of 4 residents (Resident #67) reviewed for quality of care. RN C failed to assess Resident #67 for a change in condition in a timely manner when he reported he was not feeling well on 02/09/25 at approximately 7:30 AM, and RN C noticed he did not look well and offered to send the resident to the hospital. An IJ was identified on 02/13/25. The IJ template was provided to the facility on [DATE] at 5:20 PM. While the IJ was removed on 02/14/25, the facility remained out of compliance at a scope of isolated and a severity level potential for more than minimal harm that is not Immediate Jeopardy, due to the facility's need to implement corrective systems. These failures could place residents at risk for a delay in treatment or diagnosis, a decline in the resident's condition and/or the need for hospitalization and prolonged treatment. Findings included: Record review of Resident #67's face sheet reflected the resident was [AGE] year-old male who admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #67's quarterly MDS assessment, dated 11/28/24, reflected a BIMS score of 14, which indicated his cognition was intact. His diagnoses included paraplegia (the inability to voluntarily move the lower parts of the body), neurogenic bladder (the bladder muscles and nerves do not function properly), anxiety disorder, pressure ulcer (damage to an area of the skin caused by constant pressure on the area for a long time) of unspecified buttock, unspecified stage and need for assistance with personal care. The MDS further reflected Section M - Skin Conditions - Skin and Ulcer/Injury Treatment indicated the resident's required pressure ulcer/injury care and surgical wound care. Record review of Resident #67's Care plan, revised date 01/29/25, reflected: Focus: [Resident #67] has a pressure at multiple sites. Please see physician orders and [MAR ] for wound and treatment. Goal: [Resident #67] Pressure ulcer will show signs of healing and remain free form infection by/through review date. Interventions: Administer treatments as ordered and monitor for effectiveness. Replace loose or missing dressing PRN .Wound Vac ordered. Record review of Resident #67's February 2025 MAR physician orders, reflected: Clean the left hip and right ischial ulcer with N/S, Tap Dry, apply granular foam into the ulcer, cover with a drape, connect to Wound VAC with 125 MM mercury pressure, change Q Monday, Wednesday, Friday, and as Needed. In the morning every Mon, Wed, Fri for wound treatment. Record review of Resident #67's February 2025 MAR physician orders, reflected: If Wound VAC is not available, clean bilateral hip ulcer and hip ischial ulcer with normal saline, tap with dry dressing, apply silver alginate rope into all the ulcer, cover with multiple layers of 4 x 4s ABD, secure with [medipore] (cloth) tape , change the dressing every other day and as needed for wound discharge. Every 12 hours as needed for wound treatment related to Pressure Ulcer of Unspecified Buttock, Unspecified state. Record review of Resident #67's physician orders reflected: If wound vac is not available, clean bilateral hip ulcer and hip ischial ulcer with normal saline, tap with dry dressing, apply silver alginate rope into all the ulcer, cover with multiple layers of 4 x 4 s abdominal pads, secure with medipore (cloth) tape, change the dressing every other day and as needed for wound discharge. Every 12 hours as needed for wound treatment related to pressure ulcer of unspecified buttock, unspecified stage 1/9/2025 Clean the left hip and right ischial ulcer with n/s, tap dry, apply granular foam into the ulcer, cover with a drape, connect to wound vac with 125 mm mercury pressure, change every Monday, Wednesday, Friday. and as needed. In the morning every Monday, Wednesday, Friday for wound treatment 01/09/25, Record review of Resident #67's February 2025 MAR reflected Resident #67 was provided care to clean the left hip and right ischial ulcer with normal saline, tap dry, apply granular foam into the ulcer, cover with drape, connect to wound vac with 125 mm mercury pressure, change every Monday, Wednesday, Friday, and as needed. In the morning every Monday, Wednesday, Friday for wound treatment on day 02/03/25, 02/05/25, 02/07/25 and did not indicate care was provided on 02/09/25, and care was not provided on 02/10/25. Record review of Resident #67's progress notes dated 02/09/25 at 1:48 PM written by RN C reflected patient had come to nursing desk and stated he did not feel well, and that wound vac was not working right on left hip. Lips were pale, sclera pale. Went to patient room and discussed going to hospital. Discussed with patient removal of wound vac dressing and placement of wet to dry dressing. Patient refused wet to dry and said he was going to wait until he spoke with his wife and stated that he would let this writer know of his decision. Record review of Resident #67's progress notes dated 02/9/25 at 1:55 PM written by RN C reflected This writer had went to patient room to ask what his decision was. He stated that he wanted left hip wound dressing to be changed. He was informed that dressing would be changed as soon as possible. patient verbalized understanding Record review of Resident #67's progress notes dated 2/9/25 at 7:58 PM written by RN C reflected wound vac dressing change had been done to left hip. patient then informed this writer that his right hip dressing needed to be changed. informed supplies would need to be gathered. Wife present at bedside and offered to change dressing. Wife changed dressing to demonstrate how was taught to change dressing. Pt tolerated well. Record review of Resident #67's progress notes dated 2/10/25 at 12:19 AM written by RN C reflected Patient tolerated MN medications, pt alert, able to answer questions writer asked. Pt held water, accepted snack at this time. Fluids at bedside Gatorade and ice water. Wound vac on, dressing intact upon observation. Pt declined any needs that need to be addressed at this time. Care ongoing. Interview on 02/11/25 11:37 AM with Resident #67 revealed the resident in bed, Resident #67 asked if he could include his Family Member and made a phone call. Resident #67 and Family Member stated there has been a lot of issues in regard to his wound care, stated that the facility staff were not properly trained in providing wound care. Resident #67 stated there had been several times he needed assistance with care with his wound vacuum or needed his dressing changed and he felt staff would ignore him because they did not want to provide wound care. Resident #67 stated he and his Family Member had been speaking with the Administrator and the DON to have consistent and timely wound care. According to the Family Member and Resident #67, nursing staff to include the LVN M were rude and lacked customer service and bedside manner, staff would not want to complete his wound care. Resident #67 stated when the LVN M was not available or had a day off wound care could not be completed because other nurses, they lack the proper training to assist him with administering the wound vacuum. Resident #67 stated he has a wound on each hip and one right below his right butt check. Resident #67 stated upon speaking with the Administrator, wound care and placement of the wound vacuum should be completed early in the mornings at the start of shift. Resident #67 stated on last Sunday (02/09/25) he alerted RN C about 7:30 AM-7:45 AM that he did not feel well, and needed to have his wounds cleaned and vacuum replaced because the wounds were leaking all over his bed and wheelchair. Resident #67 stated RN C did not return to assess, clean, and connect the wound vacuum until 5:30 PM just prior to the end of her shift, at that time it was discovered RN C did not have enough supplies to complete care which resulted in a prolonged wait to get care. According to Resident #67 the vacuum machine was malfunctioning early in the morning hours, it was off and not working, the bandages were coming off allowing the wound to drain and leak all day which was disgusting. Interview on 02/12/25 at 5:38 PM with RN C revealed she worked with Resident #67 on 02/09/25, she stated Resident #67 came to the nursing station around 7:30 - 7:45 AM he stated I'm not feeling good, I had been laying in this, I am leaking all over my bed, myself, and now my wheelchair. RN C stated Resident #67 looked pale, he looked sick (lips were pale, sclera pale). The wound looked like his wound was leaking, and the dressing needed to be changed. RN C stated she then told Resident #67 to contact Family Member and discuss being sent out to the hospital because she did not want to complete the care with a new canister if he was going out. She stated, I needed to know which supplies to use, if he was going to the hospital, I would need to use wet to day supplies. RN C stated she was waiting on Resident #67 to come back to her with a response from Family Member, on what they had decided about him going to the hospital or if he would stay in the facility. RN C stated I should not have waited so long; I should not have allowed him to be last to complete care. RN C stated when she got around to checking on Resident #67 it was after 5:00 PM. RN C stated I completed care on the right hip, and I did not know if you did one side you needed to do the other side as well, there was not enough supplies to complete the left side. I reached out to the DON because I did not have enough supplies to complete wound care for the left side, she then gave me LVN M's number to contact her about obtaining supplies. After contacting LVN M, she came to the facility to provide me with supplies, this was around 6:00 PM. RN C stated, I had other things going on and could not prioritize him above other situations, I did not intently neglect him. RN C stated she never made rounds to check on Resident #67 throughout the shift however she was responsible for ensuring wound care for Resident #67 was completed in a timely manner, not doing so placed him at risk of him being in sepsis and making wounds worst with no suction. RN C stated she did not reach out to anyone during her shift for assistance to provide care for Resident #67, she stated she just thought she would get to him prior to the end of her shift. RN C stated the Family Member entered Resident #67's room upset about him not receiving timely care and completed the wound care with RN C observing. According to RN C she received a video in-service on 02/10/25 and she was also expected to do one on one training with the LVN M on how to use wound vacuum. According to RN C she was trained on wound vacuum in prior positions however, not the way it was requested by Resident #67 and Family Member . RN C stated not providing care to Resident #67 in a timely manner was neglect and she did not intend on neglecting him by not addressing his wounds, not assessing him when he stated he did not feel well and when Resident #67 did not look like he felt well, as well as when she did not follow up on him until the end of her shift which was 10 hours later. RN C stated she had been inserviced several times on neglect, which was what I had done to Resident #67. RN C stated when Resident #67 looked pale, he looked sick (lips were pale, sclera pale). The wound looked like his wound was leaking, and the dressing needed to be changed, she recognized he had a change in condition and should have reported this change to the DON and the Physician. Interview on 02/13/25 at 12:28 PM with the DON revealed she received a call from RN C around 5:30 PM indicating there were no supplies available to complete wound care for Resident #67, that she thought the wound vacuum was messed up. According to the DON, she instructed RN C to look at the vacuum and contact the LVN M for supplies. The DON stated she called LVN M to bring supplies and was on the phone with the LVN M when she entered the facility to deliver supplies. According to the DON, only a limited number of supplies are put out on the wound cart or in the medication room, when additional supplies are needed, the LVN M was contacted so she can tell us where to get more or she will come to the facility to get them from her office. The DON stated she got confirmation from RN C that the vacuum was changed and working properly. According to the DON, she was in communication with RN C throughout the day and she never reported Resident #67 was not feeling well or did not look well. The DON stated she heard from Family Member that Resident #67 requested earlier in the day to have his wounds changed and machine inspected. The DON stated she would have expected RN C to address Resident #67's concerns with his wounds and wound care in a timely manner, not wait the entire shift to complete care. The DON stated she sent a video to RN C on Monday and had been having all nursing staff to shadow one on one wound care with LVN M, that started weeks ago. The DON stated she started this process, so nurses were comfortable changing the wound vacuum and the supplies, and what to do when wound vacuums were beeping. The DON stated the RN was responsible for addressing Resident #67's needs for his wounds, and reporting when residents have a change in condition to the physician, the DON, and the Administrator. The DON further stated, not completing care in a timely manner placed Resident #67 at risk of sepsis, wound breakdown, hospitalization, and septic shock and because of that we took disciplinary action . According to DON, RN C neglected Resident #67 when she did not provide care in a timely manner when she saw that his wound was leaking and she saw the he did not look as if he was feeling well. DON stated when you are not addressing these concerns you are basically neglect the resident. DON stated when his condition changed, him not looking at his baseline, RN C should have notified myself and the Physician, not providing care or notifying the physician of Resident #67's condition was neglectful and went against facility policy. Interview on 02/13/25 at 4:27 PM with the Administrator revealed he received a call from the Family Member on 02/09/25 that RN C was refusing to replace the wound vacuum for Resident #67 and she was trying to send him out to the hospital instead. According to the Administrator, the Family Member reported she saw supplies in the room. The Administrator stated, I don't know if the nurse knew what she was doing and he expected the nursing staff to address any wound changes or resident needs in a timely manner. The Administrator stated it was reported back to him the dressings and wound care was completed. The Administrator stated he expected nurses to ensure they were following doctor orders, not doing so placed Resident #67 at risk of having to be sent out to the hospital for not addressing his need for wound care. The Administrator stated he did not have the full story of events and he did not investigate the incident; he did not feel he needed to because the wound care was completed . According to the Administrator the DON and ADONs were responsible for ensuring the nurses were trained to complete wound care. The Administrator stated not providing wound care, when the wound is leaking and Resident #67 stated he did not feel well, and not checking on Resident #67 for the entire shift would be a form of neglect, placing Resident #67 at risk of infection or the need to be sent to the hospital. Interview on 02/14/25 at 1:16 PM with the Physician revealed he was not made aware that Resident #67 looked as if he was not feeling well by RN C, that he had a change in condition. The Physician stated he expected to be notified by the facility if there was change in condition with residents. The Physician stated if the wound vacuum machine was beeping that indicated the wound vacuum needed to be checked. The Physician stated at that time the wound should be assessed with the possibility of the dressings to be changed . According the Physician waiting to the end of the shift to address Resident #67's needs, change in condition and assess his wounds was a form of neglect, waiting 10 hours could place the resident at risk of several things and the need to be sent to the hospital. Record review of the facility policy revised 09/09/24 titled Abuse/Neglect Policy reflected The resident has the right to be free from Neglect: is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Record review of the facility's Skin Integrity Management policy, dated 10/05/16 reflected: Wound care should be performed as ordered by the physician. Skin should be cleansed at the time of soiling and the routine intervals. The frequency of skin cleansing should be individualized according to need/and or resident preference. Minimize skin exposure to moisture due to incontinence, perspiration, or wound drainage. Record review of the facility's Physician Orders policy, dated 2015, reflected: to monitor and ensure the accuracy and completeness of the medication orders, treatment orders, and activities of daily living order for each resident. Record review of the facility's Notifying the Physician of Change in Status policy, revised 03/11/23, reflected: The nurse should not hesitate to contact the physician at any time when an assessment and their professional judgement deem it necessary for immediate medical attention. The nurse will notify the physician immediately with significant change in status. The nurse will document signs and symptom of signification change, time/date of call to physician, and interventions that were implemented in the resident's clinical record. This was determined to be an Immediate Jeopardy (IJ) on 02/13/25 at 5:25 PM. The Administrator was notified. The Administrator was provided the IJ template on 02/13/25 at 5:26 PM and a plan of removal was requested. The following plan of removal submitted by the facility was accepted on 02/14/25 at 1:40 PM and included the following: Facility: The {facility} Date: 2/14/25 Plan of Removal Problem: F600 Free from Abuse and Neglect Interventions: As of 2/13/25 [Resident #1] had a complete head to assessment performed by the Treatment Nurse On 2/14/25 [Resident #1] had a head-to-toe assessment completed by the Regional Compliance Nurse, DON, and Tx Nurse. The MD was notified of all wounds by the DON. Orders were received. Wound vac dressing changed on 2.14.25 by the Treatment Nurse. All residents in the facility will receive a head-to-toe skin assessment. Wound treatments including wound vacs will be verified as completed according to MD orders by the Regional Compliance Nurse, DON, ADON. Completion date 2/13/25. Treatment nurse was educated on checking daily, Monday-Friday, to ensure that all wound care supplies is readily available. Completion date 2/14/25. All nurses were educated on the location of wound care supplies. If not available, they need to notify the DON and Administrator immediately. Completion date 2/14/25. The DON and ADON were in-serviced 1:1 on following topics by the Regional Compliance Nurse. Completed 2/13/25. Dressing Change Procedure- procedure to include wound vac dressings . Abuse and Neglect: failure to complete a dressing change according to MD orders including wound vacs could be considered abuse and neglect. Notification of Change in Condition: including notifying a MD for a change in a resident's condition. Resident Rights: to respect a resident's right to request care including dressing changes. The medical director was notified of the immediate jeopardy on 2/13/25. An ADHOC QAPI meeting was completed on 2/13/25 with IDT team including the Medical Director to discuss the immediate jeopardy and plan of removal. In-services: All nursing staff will be in-serviced on 2/13/25 regarding the following topics below by the ADO, the Regional Compliance Nurse, the Administrator, the DON, and the ADON. All staff not present will not be allowed to assume their duties until in-serviced. All PRN staff will be in-serviced prior to their next assignments. All new hires will be in-serviced on their date of hire, during facility orientation. All agency staff will be in-serviced prior to the start of their assignment. Completion date 2/14/25. Dressing Change Procedure- procedure to include wound vac dressings. Dressing Supplies- all supplies needed for treatment services are in the medication room. Notify the DON and Administrator if not available. Abuse and Neglect: failure to complete a dressing change according to MD orders including wound vacs could be considered abuse and neglect. Notification of Change in Condition: including notifying a MD for a change in a resident's condition. Resident Rights: to respect a resident's right to request care including dressing changes. The following Plan of Removal monitoring was conducted: Inservice Training Topic: -Dressing Change Procedure - Procedure to include wound vac dressings. -Abuse and Neglect: Failure to complete a dressing change according to MD order including wound vacs could be considered abuse and neglect. -Notification of Change in Condition: including notifying MD for a change in a resident's condition. -Resident Rights: to respect a resident's right to request care including dressing changes. Date and Time Conducted: 2/13/24. Instructor: Regional DON Attendees: Administrator, ADON A, ADON B, DON Inservice Training Topic: Wound Care Supplies Being Readily Available The wound nurse will ensure that all necessary wound care supplies are readily accessible for nursing staff. If staff encounter any difficulties in finding the supplies, she will guide them on where to locate the required items. From Monday to Friday, the wound nurse will verify that supplies are adequately stocked in the medication room, and on Fridays, she will also confirm that the supplies are prepared for the weekend. Date Conducted: 02/13/25. Instructor: Regional DON Attendees: LVN M Inservice Training Topic: Notification of Changes - see attached policy regarding notification of changes. Date Conducted: 02/13/25. Instructor: Regional DON Attendees to include MA P, MA EE, CNA F, CNA K, CNA N, CNA Q, CNA V, CNA X, CNA BB, RN D, RN GG, LVN H, LVN M, ADON A, CNA HH, CNA II, CNA JJ, CNA KK, CNA LL, CNA DD Inservice Training Topic: Abuse and Neglect Resident Rights Date Conducted: 02/13/25. Instructor: DON Attendees to include: ADON B, LVN H, CNA X, LVN BB, MA CC, MA EE, RN GG, CNA F, CNA JJ, CNA HH, RN D, MA P, CNA K, CNA Q, Med Rec, LVN M, CNA LL Inservice Training Topic: Wound Dressing Care and Changes Date Conducted: 02/13/25. Instructor: Regional DON Attendees to include: ADON B, LVN H, LVN BB, MA CC, CNA LL, MA EE, RN GG, RN D, CNA N, CNA Q, CNA T, LVN M, ADON B, CNA AA, CNA DD Inservice Training Topic: A resident request a change to the wound vac, immediately address the resident, do NOT delay treatment. Call the DON and Wound Care Nurse if there are any issues in applying the wound vac. Monitor the wound vac for changes to suction, taping, leakage, tubing kinked and any other concerns. Operating Manual Revision Date: 2024-08-16 titled extriCARE 3000 Negative Pressure Wound Therapy System Date Conducted: 02/13/25. Instructor: DON Attendees to include: LVN I, LVN BB, ADON B, ADON A, LVN H, MA CC, MA EE, RN D, RN GG, CNA Q, CNA T Interviews conducted with the above staff indicated they had understanding to identify when a resident has a change of condition, signs of abuse/neglect, the need to honor resident rights. Nursing staff was able to reveal where wound care supplies were kept; how and who to notify to restock if items were low, and Nurses stated they understood how to complete wound care on residents with wound vacuums. The Administrator was informed the Immediate Jeopardy was removed on 02/14/2025 at 7:10 PM. The facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to provide the necessary treatment and services, based on the comprehensive assessment and consistent with professional standards of practice, to prevent development of pressure ulcers for 1 (Resident #67) of 2 residents reviewed for pressure ulcers with use of a wound vacuum. RN C failed to provide Resident #67 with wound care when he reported to her on 02/09/25 at approximately 7:30 AM that he was not feeling well and needed his dressing changed because his wound vac was leaking. RN C did not follow-up with Resident #67 for care until 5:30 PM at which time she discovered she did not have enough supplies to complete wound care. The wound care was not provided for approximately 10 hours after the resident had asked to have the dressing changed, which resulted in resident discomfort and wound drainage getting on the resident, his wheelchair, and bed linens. An IJ was identified on 02/13/25. The IJ template was provided to the facility on [DATE] at 5:20 PM. While the IJ was removed on 02/14/25, the facility remained out of compliance at a scope of isolated and a severity level potential for more than minimal harm that is not Immediate Jeopardy, due to the facility's need to implement corrective systems. These failures placed residents with wounds at risk of wound deterioration, wound development, and infection. Findings included: Record review of Resident #67's face sheet reflected the resident was [AGE] years old male who admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #67's quarterly MDS assessment, dated 11/28/24, reflected a BIMS score of 14, which indicated his cognition was intact. His diagnoses included paraplegia (the inability to voluntarily move the lower parts of the body), neurogenic bladder (the bladder muscles and nerves do not function properly), anxiety disorder, pressure ulcer (damage to an area of the skin caused by constant pressure on the area for a long time) of unspecified buttock, unspecified stage and need for assistance with personal care. The MDS further revealed Section M - Skin Conditions - Skin and Ulcer/Injury Treatment indicated the resident's required pressure ulcer/injury care and surgical wound care. Record review of Resident #67's Care plan, revised date 01/29/25, reflected: Focus: [Resident #67] has a pressure at multiple sites. Please see physician orders and [MAR] for wound and treatment. Goal: [Resident #67] Pressure ulcer will show signs of healing and remain free form infection by/through review date. Interventions: Administer treatments as ordered and monitor for effectiveness. Replace loose or missing dressing PRN . Wound Vac ordered. Record review of Resident #67's February 2025 MAR physician orders reflected: Clean the left hip and right ischial ulcer with N/S, Tap Dry, apply granular foam into the ulcer, cover with a drape, connect to Wound VAC with 125 MM mercury pressure, change Q Monday, Wednesday, Friday, and as Needed. In the morning every Mon, Wed, Fri for wound treatment. Record review of Resident #67's February 2025 MAR physician orders reflected: If Wound VAC is not available, clean bilateral hip ulcer and hip ischial ulcer with normal saline, tap with dry dressing, apply silver alginate rope into all the ulcer, cover with multiple layers of 4 x 4s ABD, secure with medipore (cloth) tape, change the dressing every other day and as needed for wound discharge. Every 12 hours as needed for wound treatment related to Pressure Ulcer of Unspecified Buttock, Unspecified state. Record review of Resident #67's physician orders revealed: If wound vac is not available, clean bilateral hip ulcer and hip ischial ulcer with normal saline, tap with dry dressing, apply silver alginate rope into all the ulcer, cover with multiple layers of 4 x 4 s abdominal pads, secure with medipore (cloth) tape, change the dressing every other day and as needed for wound discharge. Every 12 hours as needed for wound treatment related to pressure ulcer of unspecified buttock, unspecified stage 1/9/2025 Clean the left hip and right ischial ulcer with n/s, tap dry, apply granular foam into the ulcer, cover with a drape, connect to wound vac with 125 mm mercury pressure, change every Monday, Wednesday, Friday. and as needed. In the morning every Monday, Wednesday, Friday for wound treatment 1/9/2025 Record review of Resident #67's MAR, for the month of February 2025 (02/01/25 - 02/14/25) revealed Resident #67 was provided care to clean the left hip and right ischial ulcer with normal saline, tap dry, apply granular foam into the ulcer, cover with drape, connect to wound vac with 125MM mercury pressure, change every Monday, Wednesday, Friday, and as needed. In the morning every Monday, Wednesday, Friday for wound treatment on day 02/03/25, 02/05/25, 02/07/25 and did not indicate care was provided on 02/09/25, and care was not provided on 02/10/25. Record review of Resident #67's Wound Evaluation and Management Summary dated 02/12/25 reflected: Chief Complaint - Patient has wounds on his right hip; left hip; left ischium. Focused Wound Exam (Site 1) Stage 4 Pressure Wound of the Left Ischium Full Thickness Etiology (quality) . Pressure MDS 3.0 Stage . 4 Duration . Greater than 395 days Objective . Healing/Maintain Healing Wound Size (LxWxD): . 2 x 1.5 x 1.5 cm Surface Area . 3.00 cm Undermining . 4.2 cm at 3 o'clock Exudate . Moderate Serous Granulation tissue . 100 % Wound progress . Improved evidenced by decrease in depth Focused Wound Exam (Site 2) Stage 4 Pressure Wound of the Left Ischium Full Thickness Etiology (quality) . Pressure MDS 3.0 Stage . 4 Duration . Greater than 345 days Objective . Healing/Maintain Healing Wound Size (LxWxD): . 4.5x 5 x 0.6 cm Surface Area . 22.50 cm Undermining . 3 cm at 9 o'clock Exudate . Moderate Serous Granulation tissue . 100 % Wound progress . Not at Goal Dressing Treatment Plan - Negative pressure wound therapy apply three times per week for 10 days; NPWT , Coarse (green) foam, 120 mmHg suction, continuous mode, change 3 x week and PRN; Irrigate and cleanse wound with ¼ % Dakin's with wound vac dressing changes apply three times per week for 10 days Focused Wound Exam (Site 3) Stage 4 Pressure Wound of the Left Ischium Full Thickness Etiology (quality) . Pressure MDS 3.0 Stage . 4 Duration . Greater than 365 days Objective . Healing/Maintain Healing Wound Size (LxWxD): . 6 x 5 x 1 cm Surface Area . 30.00 cm Undermining . 2 cm at 6 o'clock Exudate . Moderate Serous Granulation tissue . 30 % Wound progress . Improved evidenced by decrease in depth Dressing Treatment Plan - Negative pressure wound therapy apply three times per week for 10 days; Continuous suction at 120 mmHg. Bridge dressing onto left anterior thigh; irrigate and cleanse wound with ¼ % Dakin's with wound vac dressing changes apply three times per week for 10 days Record review of Resident #67's progress notes dated 2/9/25 at 1:48 PM written by RN C revealed patient had come to nursing desk and stated he did not feel well, and that wound vac was not working right on left hip. Lips were pale, sclera pale. Went to patient room and discussed going to hospital. Discussed with patient removal of wound vac dressing and placement of wet to dry dressing. Patient refused wet to dry and said he was going to wait until he spoke with his wife and stated that he would let this writer know of his decision. Record review of Resident #67's progress notes dated 02/9/25 at 1:55 PM written by RN C revealed This writer had gone to patient room to ask what his decision was. He stated that he wanted left hip wound dressing to be changed. He was informed that dressing would be changed as soon as possible. patient verbalized understanding Record review of Resident #67's progress notes dated 2/9/25 at 7:58 PM written by RN C revealed wound vac dressing change had been done to left hip. patient then informed this writer that his right hip dressing needed to be changed. informed supplies would need to be gathered. Wife present at bedside and offered to change dressing. Wife changed dressing to demonstrate how was taught to change dressing. Pt tolerated well. Record review of Resident #67's progress notes dated 2/10/25 at 12:19 AM written by RN C revealed Patient tolerated MN medications, pt alert, able to answer questions writer asked. Pt held water, accepted snack at this time. Fluids at bedside Gatorade and ice water. Wound vac on, dressing intact upon observation. Pt declined any needs that need to be addressed at this time. Care ongoing. Interview on 02/11/25 11:37 AM with Resident #67 revealed the resident in bed, Resident #67 asked if he could include his Family Member and made a phone call. Resident #67 and Family Member stated there has been a lot of issues in regard to his wound care. Resident #67 stated he and his Family Member had been speaking with the Administrator and the DON to have consistent and timely wound care. According to the Family Member and Resident #67, nursing staff to include the LVN M were rude and lacked customer service and bedside manner, staff would not want to complete his wound care. Resident #67 stated when the LVN M was not available or had a day off wound care could not be completed because other nurses, they lack the proper training to assist him with administering the wound vacuum. Resident #67 stated he has a wound on each hip and one right below his right butt check. Resident #67 stated upon speaking with the Administrator, wound care and placement of the wound vacuum should be completed early in the mornings at the start of shift. Resident #67 stated on last Sunday (02/09/25) he alerted RN C about 7:30 - 7:45 AM that he did not feel well, and needed to have his wounds cleaned and vacuum replaced because the wounds were leaking all over his bed and wheelchair. Resident #67 stated RN C did not return to assess, clean, and connect the wound vacuum until 5:30 PM just prior to the end of her shift, at that time it was discovered RN C did not have enough supplies to complete care which resulted in a prolonged wait to get care. According to Resident #67 the vacuum machine was malfunctioning early in the morning hours, it was off and not working, the bandages were coming off allowing the wound to drain and leak all day which was disgusting. Observation on 02/12/25 at 10:55 AM of Resident #67's wound care for Resident #67 with LVN M she explained the procedure was to wash her hands and put all the supplies together then donn PPE. Resident #67 was positioned, and the wound vacuum was disconnected. She removed the old dressings on the left hip and ischium. The wound looks clean no signs of swelling, redness, or bleeding was observed. She cleansed the area with gauze soaked with solution inside out with each swipe. She patted dry. The wound doctor measured the wound. She cleansed again and patted dry. She sprayed the edges with skin prep and waited to dry. She applied xeroform on an open area on the hip. She then applied the film to cover the hip. She cut the film to the size of the wound and applied the black foam. She doffed and washed hands and repeated the same procedure for the ischium. She doffed gloves and washed her hands. She applied the film to cover both areas and a bridge sponge was applied. She applied the tubing and then covered with film, and she anchored the tubing not to touch the body. She washed hands and donned gloves. She removed the old dressing on the right hip. The wound was observed, no swelling, no odor, and no bleeding was observed or redness. The same procedure was applied to the right hip. LVN M then connected both tubes from both hips and connected to a new canister and put it on. The pressure was at 125 mm mercury pressure. The wound vac was left working properly. Observation and interview on 02/12/25 at 11:39 AM with the Wound Care Doctor revealed him stating both wounds are measuring about the same maybe a bit smaller in diameter (left ischium 2x1.5x1.5 cm, left hip 4.5x5x.06 cm, and right hip 6x5x1 cm). According to the Wound Care Doctor, he was not notified about the wound vacuum malfunctioning on 02/09/25. He further stated, Resident #67 left the facility a lot and that may have to do with the reason for the vacuum disconnecting, and I don't think they have staff over the weekend that is able to address that issue. The Wound Care Doctor stated therefore it has to be addressed on the following business day and Resident #67 would usually inform me when I come on Wednesday. The Wound Care Doctor stated he would like the wound to be cared for in a timely manner, and there should be staff trained to address the issue. The Wound Care Doctor stated not caring for the wound or replacing the dressing could place Resident #67 at risk of infection and needing to be sent to the hospital for sepsis. He further stated, I have no concerns with his care and the wound treatments . Interview on 02/12/25 at 1:15 PM with the LVN M revealed she had been working with Resident #67 on wound care. She stated she was notified on 02/09/25 by RN C there were no supplies to complete wound care for Resident #67. LVN M stated she came to the facility to replenish supplies and left some in Resident #67's room. LVN M stated supplies were normally kept on the wound cart and the medication room located behind the nursing station. She stated that she could be contacted, if needed, to gather supplies out of her office if needed. LVN M stated when she arrived at the facility RN C asked her to provide care to Resident #67's wound, she said she responded No, today is my off day and she left the facility. According to the LVN M, Central Supply was responsible to keep supplies stocked, not doing so could place the residents at risk of not receiving timely care as needed. Interview on 02/12/25 at 5:38 PM with RN C revealed she worked with Resident #67 on 02/09/25. She stated Resident #67 came to the nursing station around 7:30 - 7:45 AM. He stated, I'm not feeling good, I had been laying in this, I am leaking all over my bed, myself, and now my wheelchair. RN C stated Resident #67 looked pale, he looked sick (lips were pale, sclera pale). The wound looked like it was leaking, and it needed to be changed. RN C stated she then told Resident #67 to contact Family Member and discuss being sent out to the hospital because she did not want to complete the care with the new canister if he was going out. She stated, I needed to know which supplies to use, if he was going to the hospital, I would need to use wet to day supplies. RN C stated she was waiting on Resident #67 to come back to her with a response from Family Member, on what they had decided about going to the hospital. RN C stated when she got around to checking on Resident #67 it was after 5:00 PM, she stated I completed care on the right hip, and I did not know if you did one side you needed to do the other side as well, there was not enough supplies to complete the left side. I reached out to the DON, and she gave me the LVN M's number to contact her, she then came to the facility to bring me supplies, this was around 6:00 PM. RN C stated, I had other things going on and could not prioritize him, I did not intently neglect him. RN C stated she was responsible for ensuring wound care for Resident #67 was completed in a timely manner, not doing so placed him at risk of him being in sepsis and making wounds worst with no suction. RN C stated the Family Member entered Resident #67's room upset about him not receiving timely care and completed the wound care with RN C observing. According to RN C she received a video in-service on 02/10/25 and she was also expected to do one on one training with the LVN M on how to use wound vacuum. According to RN C she was trained on wound vacuum in prior positions however, not the way it was requested by Resident #67 and Family Member. Interview on 02/13/25 at 12:28 PM with the DON revealed she received a call from RN C around 5:30 PM indicating there was no supplies available to complete wound care for Resident #67, that she thought the wound vacuum was messed up, According to the DON she instructed RN C to look at the vacuum and contact the LVN M for supplies. The DON stated she also called the LVN M to bring supplies and was on the phone with the LVN M when she entered the facility to deliver supplies. According to the DON only a limited number of supplies are put out on the wound cart or in the medication room, when additional supplies are needed, the LVN M was contacted so she can tell us where to get more or she will come to the facility to get them from her office. The DON stated she got confirmation from RN C that the vacuum was changed and working properly. According to the DON she was in communication with RN C throughout the day and she never reported Resident #67 was not feeling or did not look well. The DON stated she heard from Family Member that Resident #67 requested earlier in the day to have his wounds changed and machine inspected. The DON stated she would have expected RN C to address Resident #67's concerns with his wounds and wound care in a timely manner, not wait the entire shift to complete care. The DON stated she sent a you tube video to RN C on Monday and had been having all nursing staff to shadow one on one wound care with the LVN M that started weeks ago. The DON stated she started this process, so nurses were comfortable changing the wound vacuum and the supplies, and what to do when wound vacuums are beeping. The DON stated RN was responsible for addressing Resident #67's needs for his wounds, and reporting when residents have a change in condition to the physician, DON, and the Administrator. The DON further stated, not completing care in a timely manner placed Resident #67 at risk of sepsis, wound breakdown, hospitalization, and septic shock and because of that we took disciplinary action. Interview on 02/13/25 at 4:27 PM with the Administrator revealed he received a call from the Family Member on 02/09/25 that RN C was refusing to replace the wound vacuum for Resident #67, that she was trying to send him out to the hospital instead. According to the Administrator the Family Member reported she saw supplies in the room. The Administrator stated, I don't know if the nurse knew what she was doing and that he expected the nursing staff to address any wound changes or resident needs in a timely manner. According to the Administrator the DON and ADONs were responsible for ensuring the nurses were trained to complete wound care. The Administrator stated it was reported back to him the dressings and wound care was completed that day. The Administrator stated he expected nurses to ensure they are following doctor orders, not doing so placed Resident #67 at risk of infections and having to be sent out to the hospital for not addressing his need for wound care. The Administrator stated he did not have the full story of events and he did not investigate the incident; he did not feel he needed to because the wound care was completed . The Administrator stated that he expected Resident #67's wound care to have been completed in the mornings at the beginning of the 6:00 AM shift. The Administrator stated not providing wound care, when the wound is leaking and Resident #67 stated he did not feel well, and not checking on Resident #67 for the entire shift would be a form of neglect. Interview on 02/14/25 at 1:16 PM with the Physician revealed he was not made aware that Resident #67 had a change in condition, the Physician stated he expected to be notified by the facility if there was change in condition with residents. The Physician stated if the wound vacuum machine was beeping that indicated the wound vacuum needed to be checked. The Physician stated at that time the wound should be assessed with the possibility of the dressings to be changed . According the Physician waiting 10 hours could place the resident at risk of several things and the need to be sent to the hospital Record review of facility policy revised 10/05/16 titled Skin Integrity Management reflected: Wound care should be performed as ordered by the physician. Skin should be cleansed at the time of soiling and the routine intervals. The frequency of skin cleansing should be individualized according to need/and or resident preference. Minimize skin exposure to moisture due to incontinence, perspiration, or wound drainage. Record review of facility policy dated 2015 titled Physician Orders reflected to monitor and ensure the accuracy and completeness of the medication orders, treatment orders, and activities of daily living order for each resident. Record review of facility policy revised 03/11/23 titled Notifying the Physician of Change in Status reflected The nurse should not hesitate to contact the physician at any time when an assessment and their professional judgement deem it necessary for immediate medical attention. The nurse will notify the physician immediately with significant change in status. The nurse will document signs and symptom of signification change, time/date of call to physician, and intervention s that were implemented in the resident's clinical record. This was determined to be an Immediate Jeopardy (IJ) on 02/13/25 at 5:25 PM. The Administration was notified. The Administrator was provided the IJ template on 02/13/25 at 5:26 PM and a plan of removal was requested. The following plan of removal submitted by the facility was accepted on 02/14/25 at 1:40 PM and included the following: Plan of Removal Problem: F686 Failure to Prevent Pressure Ulcers Interventions: As of 2/13/25 resident #1 had a complete head to assessment performed by the Treatment Nurse As of 2/13/25 the wound MD was notified. The wound MD assessed and measured all of resident #1 wounds. No additional orders were received. All residents in the facility will receive a head-to-toe skin assessment. Wound treatments including wound vacs will be verified as completed according to MD orders by the Regional Compliance Nurse, DON, ADON. Completion date 2/13/25. Treatment nurse was educated on checking daily, Monday-Friday, to ensure that all wound care supplies is readily available. Completion date 2/14/25. All nurses were educated on the location of wound care supplies. If not available, they need to notify the DON and Administrator immediately. Completion date 2/14/25. The DON and ADON were in-serviced 1:1 on following topics by the Regional Compliance Nurse. Completed 2/13/25. Dressing Change Procedure- procedure to include wound vac dressings. Abuse and Neglect: failure to complete a dressing change according to MD orders including wound vacs could be considered abuse and neglect. Notification of Change in Condition: including notifying a MD for a change in a resident's condition. Resident Rights: to respect a resident's right to request care including dressing changes. The medical director was notified of the immediate jeopardy on 2/13/25. An ADHOC QAPI meeting was completed on 2/13/25 with IDT team including the Medical Director to discuss the immediate jeopardy and plan of removal. In-services: All nursing staff will be in-serviced on 2/13/25 regarding the following topics below by the and ADO, Regional Compliance Nurse, Administrator, DON, and ADON. All staff not present will not be allowed to assume their duties until in-serviced. All PRN staff will be in-serviced prior to their next assignments. All new hires will be in-service on their date of hire, during facility orientation. All agency staff will be in-serviced prior to the start of their assignment. Completion date 2/14/25. Dressing Change Procedure- procedure to include wound vac dressings. Dressing Supplies- all supplies needed for treatment services are in the medication room. Notify the DON and Administrator if not available. Abuse and Neglect: failure to complete a dressing change according to MD orders including wound vacs could be considered abuse and neglect. Notification of Change in Condition: including notifying a MD for a change in a resident's condition. Resident Rights: to respect a resident's right to request care including dressing changes. Monitoring of POR: Inservice Training Topic: Dressing Change Procedure - Procedure to include wound vac dressings. Abuse and Neglect: Failure to complete a dressing change according to MD order including wound vacs could be considered abuse and neglect. Notification of Change in Condition: including notifying MD for a change in a resident's condition. Resident Rights: to respect a resident's right to request care including dressing changes. Date and Time Conducted: 2/13/24. Instructor: Regional DON Attendees: Administrator, ADON A, ADON B, DON Inservice Training Topic: Wound Care Supplies Being Readily Available The wound nurse will ensure that all necessary wound care supplies are readily accessible for nursing staff. If staff encounter any difficulties in finding the supplies, she will guide them on where to locate the required items. From Monday to Friday, the wound nurse will verify that supplies are adequately stocked in the medication room, and on Fridays, she will also confirm that the supplies are prepared for the weekend. Date Conducted: 02/13/25. Instructor: Regional DON Attendees: LVN M Inservice Training Topic: Notification of Changes - see attached policy regarding notification of changes. Date Conducted: 02/13/25. Instructor: Regional DON Attendees to include MA P, MA EE, CNA F, CNA K, CNA N, CNA Q, CNA V, CNA X, CNA BB, RN D, RN GG, LVN H, LVN M, ADON A, CNA HH, CNA II, CNA JJ, CNA KK, CNA LL, CNA DD Inservice Training Topic: Abuse and Neglect Resident Rights Date Conducted: 02/13/25. Instructor: DON Attendees to include: ADON B, LVN H, CNA X, LVN BB, MA CC, MA EE, RN GG, CNA F, CNA JJ, CNA HH, RN D, MA P, CNA K, CNA Q, Med Rec, LVN M, CNA LL Inservice Training Topic: Wound Dressing Care and Changes Date Conducted: 02/13/25. Instructor: Regional DON Attendees to include: ADON B, LVN H, LVN BB, MA CC, CNA LL, MA EE, RN GG, RN D, CNA N, CNA Q, CNA T, LVN M, ADON B, CNA AA, CNA DD Inservice Training Topic: A resident request a change to the wound vac, immediately address the resident, do NOT delay treatment. Call the DON and Wound Care Nurse if there are any issues in applying the wound vac. Monitor the wound vac for changes to suction, taping, leakage, tubing kinked and any other concerns. Operating Manual Revision Date: 2024-08-16 titled extriCARE 3000 Negative Pressure Wound Therapy System Date Conducted: 02/13/25. Instructor: DON Attendees to include: LVN I, LVN BB, ADON B, ADON A, LVN H, MA CC, MA EE, RN D, RN GG, CNA Q, CNA T Interviews conducted with the above staff indicated they had understanding to identify when a resident has a change of condition, signs of abuse/neglect, the need to honor resident rights. Nursing staff was able to reveal where wound care supplies were kept; how and who to notify to restock if items were low, and Nurses stated they understood how to complete wound care on residents with wound vacuums. The Administrator was informed the Immediate Jeopardy was removed on 02/14/2025 at 7:10 PM. The facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for two of six residents (Resident #67 and Resident #99) reviewed for accidents. 1. The facility failed to provide adequate supervision to prevent Resident #99, who had cognitive impairment and resided on the secure unit, from eloping from the facility on 02/03/25 when the resident pried open the window in his room and made it 0.9 miles away from the facility. An Immediate Jeopardy was identified on 02/12/25 at 3:50 PM. While the Immediate Jeopardy was removed on 02/14/25, the facility remained out of compliance at the severity level of Potential for more than minimal harm that was not immediate jeopardy and a scope of Isolated due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. 2. The facility failed to provide adequate supervision and assistive devices to Resident #67 on 02/06/25 when he was not properly secured on the facility's van, which resulted in the resident falling backwards in his wheelchair and hitting his head on the floor of the van during takeoff in the facility's parking lot. Resident #67 was sent to hospital resulting where he was evaluated and treated for head injury and a contusion of the right hand . An IJ was identified on 02/13/25. The IJ template was provided to the facility on [DATE] at 5:20 PM. While the IJ was removed on 02/14/25, the facility remained out of compliance at a scope of Isolated and a severity level potential for more than minimal harm that was not Immediate Jeopardy, due to the facility's need to implement corrective systems. This failure could place residents at risk for severe injury or harm, decline in health, and decreased quality of life and death. Findings included: 1. Record review of Resident #99's admission Record dated, 02/12/25, reflected the resident was a [AGE] year old male with an initial admit date of 01/14/25 and readmission date of 01/21/25. Resident #99's diagnoses included: unspecified dementia, muscle wasting and atrophy, depression, and chronic kidney disease. Record review of Resident #99's Optional State Assessment MDS dated , 01/18/25, reflected the resident's original admission date of 01/14/25 and readmission date of 01/21/25. Resident #99's MDS also reflected the resident was mildly impaired with a BIMS of 8. The MDS also reflected in Section E900 Wandering Frequency occurred 1 to 3 days per week. Record review of Resident #99's undated Care Plan reflected the resident was at risk for wandering and elopement as evidenced by dementia and previous elopement when the resident convinced the hospital to discharge him to home rather than the facility. The goal was for the resident to not leave the facility unattended using interventions such as distract resident from wandering by offering pleasant diversions, structed activities, food conversation, television, and book. The Care Plan also revealed if the resident was exit seeking, the staff were to stay with the resident and notify the charge nurse by calling out, sending another staff member, call system, etc . Also, the care plan reflected that the staff were to use interventions such as supervise closely and make regular compliance rounds whenever Resident #99 was in his room. The Care Plan also reflected if the resident was using statements such as I'm leaving and I'm going home or attempted to elope from the facility or hospital, it was to be reported to the MD. Record review of Resident #99's progress notes dated 02/03/25 at 5:47 AM by the DON reflected Resident #99 left the facility through his room window and jumped the fence. Per the progress note, the resident was noted to not be in his room or in the secure unit at about 5:30 AM. Nurse was made the staff aware and they began looking for the resident. The resident was noted to have an open window, staff began looking outside. Resident #99 was discovered at the gas station down the road per the progress note. The progress notes also reflected the resident was missing 15 minutes. DON documented that Resident #99 gave no statement when he returned. Progress note reflected the RP was notified and the intervention would be one on one supervision. At 6:28 AM Progress Notes reflected LVN E attempted to redirect the resident, resident became aggressive and he stated he ready to leave. MD notified new order received, send to [hospital] ER emergency room for further evaluation. Resident put on one on one until EMS arrive. At 6:45 AM progress notes reflected that Resident #99 was transferred to a hospital initiated by an emergency transfer order per physician order documented by LVN E. Record review of progress notes 01/30/25 by PA reflected Dementia with elopement risk .requiring placement in a secure unit due to risk of elopement. Excessive seeking behavior noted. Continue placement in secure unit. Monitor behavior. Review of Resident #99's Elopement Evaluation dated 01/14/25 reflected Resident #99 was at risk for elopement. Interview on 02/11/25 at 10:04 AM with the Administrator revealed that immediately after the resident eloped, he in-serviced on elopement prevention, elopement, abuse/neglect, and resident rights with all staff. The Administrator stated that the CNA and nurse on the secured unit were responsible for making rounds on the residents every two hours. He stated that if a resident eloped from the facility, the resident had a risk of being hurt. The Administrator stated that since Resident #99's elopement, he daily made rounds in the secured unit and checked all the residents' windows to ensure they were properly secured. Administrator also stated that he checked the unit doors and ensured that they were alarmed and secured. The Administrator also stated that he checked the exit door's alarm to ensure that it worked correctly daily. The Administrator stated that he changed the door codes to the secured unit monthly also. The Administrator said that he conducted elopement drills on each shift as well. Interviews on 02/11/25 at 6:12 PM and 02/12/25 at 9:12 AM were attempted with Resident #99's RP but were unsuccessful because the RP did not return calls. Interview via phone on 02/11/25 at 6:33 PM with LVN G revealed that she was the nurse on the 200 and 300 halls when LVN E reported to her that Resident #99 was missing from the secured unit. LVN G stated the staff conducted a room-by-room head count, but they could not locate the resident. LVN G stated she then got into her personal car and drove the area and soon located the resident. Resident #99 was approximately .9 miles away crossing the street in front of a local gas station. LVN E got out of her car and attempted to get the resident into her car. However, he became aggressive. LVN G revealed that Resident #99 had a dinner knife, a fork, and a shaving razor. Resident #99 began to swing at LVN G with his weapons and scratched LVN G on her arms and face. LVN G was not sure which item left the scratches on her. LVN G notified LVN E because she could not persuade Resident #99 to get inside her car. LVN E came immediately. Both nurses, LVN G and LVN E, stated that they were able to persuade Resident #99 to get inside LVN E's car, and she returned him to the facility. LVN G said that LVN E notified the Administrator, DON, and 911 that the resident was located. LVN G stated that if a resident eloped, they could fall. LVN G revealed that after this incident she was in-serviced on abuse/neglect, elopement procedures, and elopement response. Interview via phone on 02/11/25 at 6:49 PM with LVN E revealed that when she went in to give Resident #99 his medications at approximately 5:30 AM, he was not in his room. LVN E stated she checked his restroom, but he was not in it. LVN E said that she then asked CNA F where Resident #99 was located. CNA F told LVN E that she saw the resident in his room about 5:00 AM. LVN E said that she went to the room's window and raised the blinds. LVN E stated that she then observed the window screen lying on the ground. LVN E said at that point she came out and told the aide that the resident had jumped out the window. LVN E then alerted the staff and began a facility wide search for Resident #99. LVN E stated that she eventually found the Resident in the street near a local gas station walking. LVN E got Resident #99 into her car and took him back to the building where he remained on one-on-one supervision until transport arrived. LVN E stated that Resident #99's elopement was a surprise to her because she never heard him talk about leaving and had not seen him exit seeking. LVN E also said that Resident #99 was quiet and just enjoyed watching television in his room alone. LVN E stated that it was the nurse's and CNA's responsibility to make rounds in the secured unit. LVN E stated that if a resident eloped, they could be injured in the process of trying to elope, they could fall, or get run over. LVN E revealed that she was in-serviced after the elopement regarding elopement procedure, elopement precautions, and abuse/neglect. She stated that for an elopement, a code was called, and the facility participates in an all-staff search for the missing resident as well as conduct a head count for all residents to ensure safety of the remaining residents. LVN E concluded by stating that administration should be notified throughout the process. Interview via phone on 02/11/25 at 7:23 PM with CNA F revealed that she heard a loud noise at approximately 4:40 AM that came from Resident #99' Room. CNA F stated that she thought it was Resident #99 coming out of his bathroom and the heavy door shutting. CNA F then said that she went into his room while making her rounds in the secured unit about 5:00 AM. Resident #99 was in his room in his bed. CNA F stated that the nurse went into Resident #99's room at about 5:30 AM to give him his medication. Then she was notified by the nurse that Resident #99 was not in his room or bathroom. CNA F stated that she stayed in the secure unit while the nurse left the unit to search for the resident. CNA F stated that she went into his room and observed his window up. CNA F stated she also observed his bedside table across the secured courtyard next to the privacy fence. CNA F revealed that the previous night when she arrived at the building and began her rounds, she spoke with Resident #99. CNA F said that Resident #99 was awake in bed and said that he was doing ok. CNA F said that it was all staff's responsibility to ensure that residents did not elope. CNA F said that she was in-serviced on abuse/neglect, elopement prevention, and elopement response beginning approximately 1 hour after the elopement. Interview via phone on 02/11/25 at 7:40 PM with LVN H revealed that Resident #99 was a quiet resident who isolated in his room. LVN H stated that she worked the night shift. LVN H said that she made rounds on the resident every two hours. LVN H also revealed that she never heard Resident #99 talk about eloping, and it was not passed down through report that he was exit seeking or talking about elopement. LVN H said that it was all the staff on the unit's responsibility to watch the residents to ensure that they do not elope. LVN H said that if residents elope, they could go missing. LVN H did not recall the elopement in-services following the resident's elopement. But she stated that staff was normally in-serviced following an elopement. Interview on 02/12/25 at 9:42 AM with CNA J revealed that Resident #99 was a quiet and pleasant resident who did not exit seek. CNA J also stated that Resident #99 did not discuss leaving the facility and did not pack his belongings. CNA J stated that she checked on Resident #99 every two hours and more often because the residents on the secure unit need more attention. CNA J also stated that the last time she showered the resident that she did not shave the resident. Therefore, she was unsure how he acquired a razor. CNA J said that she was unsure how Resident #99 had dining utensils because the CNAs and nurses check to ensure that utensils are with the trays when they pick them up from the residents. CNA said that Resident #99 did not have a Wonder guard on him that would signal if he eloped. CNA concluded by stating that there were no residents on the unit that were currently exit seeking. Interview on 02/12/25 at 9:43 AM with LVN I, who worked day shift, revealed that Resident #99 did not show signs of elopement. LVN, I stated that Resident #99 shaved himself. And therefore, Resident #99 could have placed the razor in his pocket. LVN I also revealed that because the Resident primarily stayed in his room and took all his meals in his room, he must have kept a dinner knife and fork from one of the trays. LVN, I stated that it was all staff's responsibility to keep staff safe and to ensure that utensils and razor are not kept by the residents. LVN, I said that residents could injure themselves or another resident if they kept utensils and razors. LVN I also stated that if residents eloped, they would risk not receiving their medications timely, being hurt, etc. Interview on 02/12/25 at 11:36 AM with the DON revealed that Resident #99 usually stayed in his bed and watched television in his room in the secured unit. The DON stated the staff in the secured unit increased rounding on Resident #99 since his admission from the hospital to ensure he was comfortable, The DON stated that the windows in the secured unit are screwed in place so that the windows cannot be raised more than four inches. The DON stated that she did not think that Resident #99 would be capable of getting the screws out of the windows. The DON also said that the windows do not have alarms on them. Therefore, staff were not alerted when the window went up. The DON also stated that because the secured unit's door alarm systems was working correctly, there were no other measures in place to monitor the residents for elopements excluding the secured units entrance/exit door. The DON revealed that the risk to Resident #99's elopement was possible injury. The DON also stated that it was the nurse and the aide's responsibility on the unit to ensure that no elopement occurred, and residents were kept safe at all times. Interview on 02/13/25 at 10:17 AM with the Administrator revealed that he began to in-service all staff on 02/12/25 after the notification of the IJ at 4:00 PM on 02/12/25. The Administrator stated that he in-serviced all staff on elopement prevention, elopement response, and abuse/neglect. The Administrator revealed that the in-service was completed via a text service that went to all facility staff and copies were provided evidencing it. The Administrator also said that the DON and her staff spoke with the staff about the in-service topics before they began their shifts in addition to the text that went out to all facility staff. The Administrator said that as part of the elopement prevention, nurses were instructed to complete elopement assessments. The administrator stated that he made daily rounds and checked all the windows on the secured unit to ensure that they were secured and not tampered. The Administrator also stated that he tested the exit door alarm daily and will change the code monthly. The Administrator said that as part of his abuse/neglect in-service, he spoke with residents to ensure their needs were met. The Administrator revealed that as part of the elopement response in-service, the Administrator informed staff to immediately conduct a head count and then notify the staff in the building before beginning the search. The Administrator then said that the authorities were to be notified if the resident was not found in 30 minutes. The Administrator stated that the nurses were in-serviced to notify the family, the DON, Ombudsman, IDT , (Interdisciplinary Team) and the physician. Record review of the facility's revised January 2023 Elopement Response policy reflected: Nursing personnel must report and investigate all reports of missing residents. When an elopement has occurred or is suspected, our elopement response plan will be immediately implemented. 1. It is the responsibility of all personnel to report any resident attempting to leave the premises, or suspected of being missing, to the charge nurse as soon as practical. 2. Determination of missing resident either by routine nursing rounds or door alarms: A. Note: A resident is determined to be missing when he/she leaves the facility without the staff's knowledge. C. A resident must demonstrate a free and willful intent to leave the facility without prior notification of staff or is a wandering, confused resident who leaves the facility unattended. 4. Should an employee discover the resident is missing from the facility (Code Orange), he/she should: Report to the charge Nurse .Make a thorough search of the building and premises. And if not located, contact the DON, RP, physician .Make and extensive search of the surrounding area. 6. If unable to located resident in the building, proceed as follows: B. Affected Area-Charge Nurse assigns staff to specific outside areas to ensure that all surrounding areas are searched. C. After 30 minutes, if the resident has not been found, the following calls must be made: .Report missing resident to the police . Record review of the facility's revised January 2023 Elopement Prevention policy reflected: Every effort will be made to prevent elopement episodes while maintain the lease restrictive environment for resident who are at risk for elopement. 1. The Elopement Risk will be completed upon admission . Physical Plant 1. All facility exits what resident have access to will have a device in place to alert staff of elopement attempts. Examples include- Wanderguard Wander management Ssystem Placement of the residents' device to alarm the system will be verified each shift and documented on a treatment or other flow record Keypad exit magnetic locks. Keyed alarms Secured Unit Or a combination of the above .Staff Training. Staff will receive training during their orientation process and then annually regarding: Elopement prevention. Operation of all exit devices. Actions to take if elopement occurs . Record review of the facility's revised 05/09/17 Abuse/Neglect Policy reflected: The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat resident's medical symptoms. Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultant or volunteers, staff or other agencies serving the resident, family members or legal guardians, friends, or other individuals. The facility will provide and ensure the promotion and protection of resident rights. It is each individual's responsibility to recognize, report and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property abuse and situations that may constitute abuse or neglect to any resident in the facility. Record review of in-services reflected: Elopement Response completed on 02/12/25, Elopement Prevention completed on 02/12/25, and Abuse/Neglect completed on 02/12/25. Record review of in-services completed prior to survey entry reflected: Elopement completed on 02/03/25, Elopement Prevention completed on 02/03/25, Abuse/Neglect completed on 02/03/25, and Resident Rights completed on 02/03/25. This was determined to be an Immediate Jeopardy (IJ) on 02/12/25 at 3:50 PM. The Administrator was notified of the IJ and was provided the IJ template on 02/12/25 at 4:00 PM and a plan of removal was requested. The following plan of removal submitted by the facility was accepted on 02/13/25 at 9:51 AM and included the following: Plan of Removal Problem: F689 Free from Accidents/Hazards/Supervision Interventions: Record review of elopement drills completed 02/03/25, 02/05/25, 02/07/25, and 02/10/25 reviewed on 02/19/25. 1. Administrator, DON, and/or designee will initiate an in-service regarding: a. Elopement Response b. Elopement Prevention c. Abuse/Neglect All staff scheduled to work through 02/12/25 will be in-serviced by end of day and prior to next shift worked. Completed. 2. The Administrator will conduct 3 elopement drills per week. Administrator began. 3. The Administrator, DON, and ADON were in-serviced by the ADO and Regional Compliance Nurse and completed as of 02/12/25 on Elopement Prevention Policy to include implementing interventions for residents at risk for elopement, Elopement Response Policy, and Abuse/Neglect. Completed on 02/10/25 at 0900, 02/03/25 at 0545, 02/05/25 at 1000, and 02/07/25 at 1600. By Administrator 4. Elopement Risks will be completed for all residents on the secured unit. Completed and provided. 5. AD Hoc QAPI Contributors will meet and review the elopement risk for all residents residing on the secured unit. Completed on 02/12/25. 6. All elopement events were reviewed by the facility QAPI committee members and are completed as of 02/12/25. 7. All elopement risk care plan interventions will be reviewed and have been completed/updated as of 02/12/25 by the Regional Compliance Nurse, DON, and ADON. All interventions are in place and care planned. 8. Administrator will monitor the locking mechanism on all the exit doors and windows in the secured unit (This question was confirmed as Question #1 by administrator on the Missing Resident/Elopement Monitoring form Week 2) on 02/13/25. 02/03/25, 02/04/25, 02/05/25, 02/06/25, 02/07/25, 02/10/25, 02/11/25, 02/12/25, 02/13/25, 02/14/25 - By Administrator 9. Administrator will review for 1:1 monitoring in the secured unit. Completed. 02/03/25, 02/04/25, 02/05/25, 02/06/25, 02/07/25, 02/10/25, 02/11/25, 02/12/25, 02/13/25, 02/14/25- By Administrator Only 02/03/25 had1:1 monitoring. 10. Through daily rounds and duties at least five times per week, observe for visitors allowing residents to exit the facility unsupervised. Completed. No issues noted. 02/03/25, 02/04/25, 02/05/25, 02/06/25, 02/07/25, 02/10/25, 02/11/25, 02/12/25, 02/13/25, 02/14/25- By Administrator 11. Change the door code monthly. Completed. Did not provide the date the code was changed. Only that it was changed. - By Administrator 12. The medical directed was notified of the IJ situation. Identified Residents at Risk: Only 1 resident was affected regarding this incident. The resident was not harmed as a result of this elopement. Systemic Changes: 1. The Administrator will monitor the residents' windows in the secured unit for signs of tampering. 2. The Administrator will also monitor the facility entrance and secured unit doors to ensure their locks are functioning properly as well as their alarms. 3. Elopement drills will be continued so that all shifts are prepared for elopements. Responsibility: It is the Administrator, or designee, and the Director of Nursing, or designee's responsibility to follow the actions and the systematic changes listed above. The Administrator, or designee, and the Director of Nursing, or designee, will report their findings of the above actions and systematic changes through their QAPI [Quality Assessment Performance Improvement] Process. Monitoring the Plan of Removal: The Administrator and DON in-serviced all staff on the following: 1. Elopement Response completed on 02/12/25. 2. Elopement Prevention completed on 02/12/25. 3. Abuse/Neglect completed on 02/12/25. Monitoring interviews for the Immediate Jeopardy were started on 02/13/25 at 10:00 AM and continued through 02/14/25 at 12:00 PM with 40 staff across all three shifts, including weekdays and weekends, including all departments. The staff were interviewed about elopement response, elopement prevention, and abuse/neglect. The following staff's in-service logs were reviewed, and they were interviewed during the monitoring time frame. The were able to articulate what they were taught including the correct protocols and procedures related to elopement prevention, elopement response, and abuse/neglect: RN D, LVN E, CNA F, LVN G, LVN H, LVN I, CNA J, CNA K, MA L, LVN M, CNA N, CNA O, MA P, CNA Q, CNA R, CNA S, CNA T, CNA U, CNA V, CNA W, CNA X, CNA Y, CNA Z, CNA AA, LVN BB, MA CC, CNA DD, MA EE, RN FF, Administrator, DON, ADON A, HR, Laundry Aide, Social Services, Housekeeping Aide, Activities Director, COTA, and Medical Records. 2. Record review of Resident #67's face sheet reflected the resident was [AGE] years old male who admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #67's quarterly MDS assessment, dated 11/28/24, reflected a BIMS score of 14, which indicated his cognition was intact. His diagnoses included osteomyelitis (bone infection that causes inflammation and destruction of bone tissue), paraplegia (the inability to voluntarily move the lower parts of the body), neurogenic bladder (the bladder muscles and nerves do not function properly), anxiety disorder, pressure ulcer (damage to an area of the skin caused by constant pressure on the area for a long time) of unspecified buttock, unspecified stage and need for assistance with personal care. The MDS further revealed Section M - Skin Conditions - Skin and Ulcer/Injury Treatment indicated the resident's required pressure ulcer/injury care and surgical wound care. Record review of Resident #67's Care plan, revised date 01/29/25, reflected: Focus: [Resident #67] at risk for falls paraplegia. Goal: The resident will be free of falls through the review date. [Resident#67] will not sustain serious injury through the review date. Interventions: Anticipate and meet the resident's needs. Staff x 1 to assist with transfers. Record review of Resident #67's progress notes written by RN GG dated 02/06/25 at 1:41 PM reflected Resident had a fall. Location: while on leave . Fall information: Hit Head. Cognition/Behavior at Time of Event: Oriented/no problem, Resident assisted to chair from the fall while in transport van, Resident stated hit his head, Resident stated blacked out, Physician Assistant on site, sent to emergency room for further evaluation. Appears and /or states to be in pain. Describes the pain as: continuous, chronic. Location of pain: head, right wrist pain relieving intervention used at this time: sent to emergency room for evaluation. Initial Treatment/New Orders: send to Emergency Room. Resident Statement: I hit my head and I want to go to the hospital. Record review of Resident #67's progress notes written by RN GG dated 02/06/25 at 2:51 PM reflected Resident #67 was transferred to a hospital on [DATE] at 1:55 PM related to transport van patient had fallen backwards in wheelchair, hitting head. Sent to hospital for evaluation. Record review of Resident #67's progress notes written by LVN G, dated 02/06/25 at 10:58 PM reflected At 8:17 PM. Resident #67 come back from hospital on non-emergency transportation on diagnosis of fall encounter Head injury, contusion of right hand. Initial encounter. Blood pressure 121/69, pulse 67, respiratory 18 saturation 98 percent, Alert, and oriented x 4, able to voice needs and concerns, did head to toe skin assessment. Change both hip dressing to Wet to Dry dressing, ongoing care, call light in reach. Record review of Resident #67's after visit summary dated 02/06/25 reflected Reason for visit: Fall, Diagnoses: Fall, initial encounter, Head injury, initial encounter, Contusion of right hand, initial encounter, History of paraplegia. CT head without contrast, chest x ray, hand x ray. Medications given: Oxycodone-acetaminophen, Instructions: Follow up with provider in two weeks around 02/20/25 if symptoms worsen. Record review of Resident #67's incident report dated 02/10/25 reflected Conclusion: resident in 3rd party transport van, his chair has no anti tippers or brakes. Resident fell backward due to inertia upon the driver taking off. Intervention: parts have been ordered for resident chair, and resident to use transport chair vs personal wheelchair. Therapy to screen. Interview on 02/11/25 at 11:37 AM with Resident #67 revealed on 02/06/25 he had a urology appointment and after he was loaded on the van, he fell backwards hitting his head. According to Resident #67 he had a headache and pain in his right hand from the fall. Resident #67 stated it was not the facility van driver, but an outside provider that was taking him to his appointment. Resident #67 stated he took off like a race car driver in the parking lot and I fell backwards, hitting my head on the floor, and blacked out. Resident #67 stated the van driver did not strap me down correctly, so when he took off, I fell backwards and hit my head, and was sent to the hospital. Interview on 02/13/25 at 12:28 PM the DON revealed she knew Resident #67 was scheduled for urology appointment on 02/06/25, she stated the facility van had other appointments, so he was to be transported by an outside transport provider. The Social Worker stated she did not see Resident #67 exit the building for his appointment. The DON stated she was alerted to come outside. When she got outside, she saw Resident #67 still in his wheelchair; straps were still attached. According to the DON she jumped in the van and removed 2 straps, she stated Resident #67 had to be removed from the chair so they could get the wheelchair out the van. Once the wheelchair was removed from the van, Resident #67 was placed back in the wheelchair, assessed and was one on one with nurse until the emergency medical services arrived to take him to the hospital. The DON stated Resident #67 was delirious and was not able to support his body while sitting in the wheelchair, he was not at his baseline , he complained of head pain and stated that he lost consciousness. The DON stated she did not speak to the Van Driver; she did not recall if an incident report was completed. According to the DON drivers were responsible for entering the facility to transport residents out and back inside upon returning to the facility. Interview on 02/13/25 at 2:47 PM with Social Worker revealed when residents require an outside appointment, they will leave notification for the Facility Transportation Driver to schedule the appointment with the provider and arrange transportation. According to the Social Worker, she was alerted by the Van Driver coming to the door saying, your patient has flipped out here in the van, the Social Worker stated at that point she alerted either the Administrator or the DON. The Social Worker stated when she got out[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 3 residents (Resident #1) reviewed for accidents. CNA A failed to get assistance from another staff member when providing Resident #1, who required two staff for assistance with all ADLs, a bed bath on 12/05/24. During the bed bath, CNA A asked Resident #1 to turn to her side. When the resident turned she fell to the floor, which resulted in the resident sustaining a fracture of her right femur (thigh bone). The noncompliance was identified as past noncompliance. The Immediate Jeopardy began on 12/05/24 and ended on 12/05/24. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for serious injury or harm, decline in health, and decreased quality of life. Findings included: Record review of Resident #1's quarterly MDS dated [DATE] reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included hypertension (high blood pressure), seizure disorder, cellulitis of right lower limb (bacterial infection that affects the skin and underlying tissue), fibromyalgia (chronic condition that causes widespread pain and tenderness in the body), and muscle wasting. The resident had a BIMS score of 9 which indicated her cognition was moderately impaired. The MDS further reflected Resident #1 was dependent for shower/bathing which indicated the helper did all the effort or the assistance of two or more helpers was required for the resident to complete the activity. Record review of Resident #1's care plan revised on 12/16/24 reflected the resident had an ADL self-care performance deficit. Interventions included the resident required the assistance of two staff for bathing and bed mobility. Record review of Resident #1's bathing status in the [NAME] system (documentation system used by reference key resident information for their nursing care plan) printed on 01/13/25 reflected the resident required the assistance of two staff members. Record review of the facility's Provider Investigation Report dated 12/05/24 reflected the following: The resident experienced a fall while in bed during care by the CNA [CNA A]. The CNA [CNA A] notified the nurse and had discovered the resident on the floor, resting against the bed. The resident has skin tears on both great toes, the let wrist, and beneath the right breast The resident reports generalized pain, with a particular emphasis on greater discomfort in her legs compared to other areas. When inquired about the incident, the resident explained 'I threw my foot over too far and fell.' The resident was transferred to the hospital due to experiencing pain the X-ray indicated a fracture in the left femur (left femur was facility documentation error; fracture was on the right leg). The resident subsequently underwent surgery to address the fracture Record review of Resident #1's hospital records dated 12/05/24 reflected the resident was diagnosed with a comminuted distal femoral fracture (a broken bone that has been shattered into multiple pieces and are usually caused by severe trauma) of the right leg. Observation and interview on 01/08/25 at 10:26 PM revealed Resident #1 in bed watching television. The resident was alert and oriented and able to recall the incident when she fell during care. The resident said CNA A was giving her a bed bath, and the aide asked her to turn to her side. The resident said she was turning over onto her side as she was holding on the repositioning bar and fell on the floor. She said CNA A was usually able to catch her when she rolled over, but this time she was not able to. Resident #1 said she was sent to the hospital and had surgery on her leg, as she pointed to her right leg. Resident #1 stated CNA A usually bathed her alone and never had a helper. The resident stated she preferred two people because she felt safer. Resident #1 said she was not experiencing much pain from her fracture but had discomfort due to the cellulitis in her legs. Interview on 01/08/25 at 1:05 PM with CNA A revealed she was giving Resident #1 a bed bath and asked the resident to turn to her side. She stated the resident grabbed the repositioning bar on the bed, threw her leg over her left leg and that was when the resident fell over on to the floor. CNA A stated she then called for the nurse to assist, and the resident was assessed. CNA A stated Resident #1 was on an air mattress, and it was inflating at the time the resident was turning to her side. CNA A said she was aware Resident #1 required two staff for care, but she was not able to find someone to help her. CNA A said she asked another CNA, whose name she could recall, for help. She stated she did not get any help, so she bathed the resident alone. She stated she had bathed the resident alone in the past. The CNA said she felt safe bathing the resident alone because the resident was able to help turn in bed. Interview on 01/13/25 at 1:23 PM with LVN B revealed she was called by CNA A to Resident #1's room and noticed the resident was on the floor. CNA A told her the resident was trying to turn in bed during a bed bath, and the resident fell. LVN B said during Resident #1's assessment, the resident was complaining of pain and noticed the resident's toes were bleeding and other areas of her body such as her side, so she was transferred to the hospital via EMS. LVN B stated Resident #1 required two staff member for care because she was a bariatric resident and for safety. The LVN said she did not know CNA A was caring for Resident #1 alone, and she did not recall the aide asking anyone for help during the bed bath. LVN B further stated the aides could look in the [NAME] system to verify if a resident required one or two staff members during care or ask a charge nurse. Interview on 01/08/25 at 1:28 PM with CNA D revealed she had worked at the facility for about a year and cared for Resident #1. CNA D said Resident #1 was bed bound per choice and required two staff members for assistance for all care because the resident was bariatric and could not be care for by one staff member. Interview on 01/08/25 at 2:07 PM with CNA E revealed she worked with Resident #1 and the resident was bed bound. CNA E said the resident required two staff members for all care including bed baths because she was bariatric and needed more support. CNA E further stated Resident #1 had never been a one-person care resident. Interview on 01/08/25 at 2:39 PM with RN F revealed Resident #1 was bed bound and required two staff members for all care including bed baths because the resident was bariatric and one staff member could not adequately care or clean the resident up during ADL care. Interview on 01/08/25 at 2:29 PM the ADON revealed Resident #1 was bed bound and rarely got out of bed. She said the resident was a two-person assist for all care at all times because she was on an air mattress and could easily roll out of bed and for overall safety. The ADON was made aware CNA A had bathed Resident #1 alone, but the aide was not able to explain why she had not requested for help but only stated she had not seen anyone else. The ADON stated it appeared to her that CNA A had not looked for anyone to help her with the resident. The ADON further stated they immediately began to re-in-service (training) for all nursing staff re-educating them on the importance of using two staff member if the resident required it. They also identified all the residents that required two staff members for care they were monitoring and making observations to ensure two staff were assisting when needed. The monitoring began after the incident with Resident #1 and would be on-going for six weeks to ensure safety. Interview on 01/13/25 at 8:36 AM with the DON revealed she was told Resident #1 was getting a bed bath by CNA A and while the resident was turning to her left side with the assistance of the repositioning rail, Resident threw her leg over too far and continued to roll until she fell out of the bed. Resident #1 was assessed, and they noticed she had bruising to the top of her feet and was complaining of pain throughout her body but mostly to her right knee. The resident was transferred to the hospital where she was diagnosed with a right leg fracture. The DON said Resident #1 required two staff members for care due to being a bariatric resident and for safety. The DON stated CNA A admitted knowing Resident #1 required two staff members for care, but the aide told them she had not been able to find assistance but if she would asked her (DON) she would have assisted. The DON also said if aides did not know if a resident was a one or two person for care, they could look in their [NAME] computer system. After the incident, CNA A was suspended pending their investigation and had a 1:1 counseling and re-in-service (training) on resident care and the aide was pulled from working with Resident #1. The other nursing staff were re-educated on using the [NAME] computer system to ensure a resident required a one- or two-person assistance during care. The DON further stated they had identified all the residents that required two people and were going to monitor but watching care for those resident for 6 weeks. Record review of the facility's Safe Patient Handling policy revised December 2005 reflected the following: The facility has a program to promote and assure safe patient handling for both the resident and the employee. The policy includes identification, assessment and interventions to provide a comfortable, safer transfer, repositioning and resident movement. .3. Nurses will be educated in the identification, assessment and control of risks of injury to resident and nurses during patient handling .5. Nurses will be educated regarding correct safe handling procedures, to report concerns or the inability to perform resident handling or movement that the nurse believes in good faith will expose a resident or nurse to an unacceptable risk of injury Record review of 1:1 in-service with CNA A dated 12/05/24 revealed she had been re-educated on using the [NAME] system to communicate the resident's needs and information to all the CNA's to ensure appropriate resident care. CNA was also re-educated on fall prevention strategies and safe patient handling and abuse and neglect policy. Record review of in-services dated 12/05/24 with all direct nursing reflected the staff had been re-educated using the [NAME] system to communicate the resident's needs and information to all the CNAs to ensure appropriate resident care. CNAs were also re-educated on fall prevention strategies and safe patient handling and abuse and neglect policy. Interview on 01/08/25 at 1:05 PM with CNA A revealed she had been re-in-serviced 1:1 on abuse and neglect, ensure to always use two staff members during care for residents that required it and using the [NAME] system to check the care of the residents if they were unsure. Interviews on 01/08/25 from 11:12 AM to 5:14 PM and on 01/13/25 from 10:01 AM to 1:23 PM with nursing staff from various shifts to include LVN B, CNA C, CNA D, CNA E, RN F, LVN G, CNA H, CNA I, CNA J, and CNA K all revealed they have been in-serviced on abuse/neglect, using the [NAME] system to verify if a resident required one or two staff members for care, and fall prevention to avoid accidents. Record review of the direct care monitoring sheets reflected it included to watch at least 10 episodes of incontinent care or assist with bed mobility weekly to ensure staff was performing correctly and the care-planned number of staff were assisting. The monitoring dates reviewed began 12/05/24 and would continue for 6 weeks, and end on 01/15/25. Observation on 01/08/25 at 11:07 AM revealed Resident #2 was transferred from the bed to the chair via mechanical lift by two staff members. Observation on 01/13/25 at 3:32 PM revealed Resident #3 was transferred to bed via mechanical lift by two staff members.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents had the right to be free from abuse and neglect for 2 of 5 residents (Resident #1 and Resident # 2) reviewed for abuse and neglect. The facility failed to prevent Resident #3 from physically abusing Resident #2, when Resident #3 punched Resident #2 in the face on 08/24/23. The facility failed to ensure Resident #1 was free from abuse and neglect by not providing adequate supervision and services, when the facility allowed Resident #3, who had a history of physically assaulting residents and staff, to continue to reside in the facility. Resident #3 assaulted Resident #1 on 12/08/23, which caused her to be hospitalized with a subdural hematoma (is a type of brain bleed that results in a tear in a blood vessel below the dura mater, a membrane layer between the brain and the skull), contusion of face (small blood vessels get torn and leak blood under the skin), neck sprain, and closed fracture of transverse process (broken bone) of lumbar vertebra (located between the rib cage and the pelvis). The noncompliance was identified as PNC. The IJ began on 12/08/23 and ended on 12/08/23. The facility had corrected the noncompliance before the survey began. This failure could place residents who were in the memory care at risk for abuse and neglect. The findings include: Resident #1 Record review of Resident #1's electronic Face Sheet dated 12/12/23 reflected Resident #1 was a [AGE] year-old female, who admitted to the facility on [DATE]. Resident #1 had the following diagnoses: unspecified dementia; muscle wasting and atrophy ; unsteadiness on feet; age-related osteoporosis (causes bones to become weak and brittle) without fracture; and wandering in diseases. Record review of Resident #1's Comprehensive MDS assessment dated [DATE] indicated a BIMS score of 3, which indicated the resident's cognition was severely impaired. The MDS reflected Resident #1 demonstrated wandering behaviors. Record review of Resident #1's Care Plan dated 10/29/23 indicated a focus on area of a history of exit seeking, so she has been placed on the Secured Unit and the intervention included staff will monitor residents location for safety. The Care Plan indicated a focus area of Resident has delirium or an acute [confusional] episode r/t Dementia, but the Care Plan did not include any interventions. Record review of facility's document titled Event Nurse's Note 12hr , dated 12/8/23 at 5:18 AM, by the ADON, reflected Summoned to hallway, CNA voiced that resident was bleeding, this nurse has just administered medication to resident (Resident #1) at 0435 and at 0500 she asked staff for more water and voiced she was thirsty. This nurse gave resident ice water and took her to her room and encouraged her to lay down Resident stated she would and nurse left to go to administer meds to the other residents. When this nurse entered 400 hall resident immediately stated, that man attacked me! . When male resident (Resident #3) was approached noted blood on his right hand and noted blood on his walking cane . Record review of Resident #1's hospital records, dated 12/08/23, reflected Resident #1 entered the ER on [DATE] at 6:42 AM. The ER summary reflected 78 y.o. (year old) female presents to the ED via EMS (ground) coming from a dementia facility for head injury onset this AM after being assaulted by another resident. Sustained facial swelling and pain and L (left) sided body pain. No LOC (level of consciousness), per NH (nursing home) staff. Pt is on Plavix. Per EMS, pt given 2 rounds of 50 mcg of Fentanyl en (in) route. Imaging in ED shows transverse process fx of L3 (fracture of lumber vertebra) and subdural hematoma. Resident #1's physical exam reflected L sided facial swelling. L periorbital ecchymosis (blood tracking along tissue, causing discoloration in the upper and lower eyelids) and edema (swelling caused by too much fluid trapped in the body's tissues). Large contusion (a region of injured tissue or skin in which blood capillaries have been ruptured) to occiput (the back of the head or skull) and Subconjunctival hemorrhage to L (when a blood vessel breaks in the white of the eye). Resident #1 was diagnosed with the following: subdural hematoma; Assault; Contusion of face; Neck sprain; and Closed fracture of transverse process of lumbar vertebra. The hospital records indicated Resident #1 was transferred to a trauma unit because she required a higher level of care. Resident #2 Record review of Resident #2's electronic Face Sheet dated 12/12/23 reflected Resident #2 was a [AGE] year-old male, who admitted to the facility on [DATE]. Resident #2 had the following diagnoses: Alzheimer's disease; dementia; muscle weakness; and repeated falls. Record review of Resident #2's Comprehensive MDS assessment dated [DATE] indicated a BIMS score of 3, which indicated the resident's cognition was severely impaired. The MDS reflected Resident #2 did not have Physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually), Verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others), nor Other behavioral symptoms not directed toward others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds). Record review of Resident #2's electronic record indicated there was not a Care Plan established and Resident #2 was at the facility for 5 days of respite care. Record review of the form titled admission Nurse Note, dated 08/21/23 at 9:00 AM, reflected Resident #2 had memory problem, was organized in daily routine and made safe decisions in familiar situations, but experienced some difficulty in decision making when faced with new tasks or situations, and required one person assistance with ADLs for bed mobility, transferring, toileting, dressing/hygiene, and bathing. The document indicated Resident #2 had no behaviors that required interventions. A record review of Resident #2's Progress Notes, dated 08/24/23 at 4:39 PM, by LVN C, reflected This nurse was called into pt room by aid, I ran down the hall and immediately heard yelling and cursing. Residents' roommate (Resident #3) assaulted resident by punching him in the face per resident. Resident abuse protocol followed. Head to toe completed on resident and negative injuries noted. Informed [family member]. [Family member] informed me she will be in tonight to pick him up. Resident #3 Record review of Resident #3's electronic Face Sheet dated 12/12/23 reflected Resident #3 was a [AGE] year-old male, who admitted to the facility on [DATE]. Resident #3 had the following diagnoses: unspecified dementia with psychotic disturbance and agitation; muscle wasting and atrophy; and other specified depressive episodes. Record review of Resident #3's Quarterly MDS assessment dated [DATE] indicated a BIMS score of 5, which indicated the resident's cognition was severely impaired. The MDS reflected Resident #3 did not have Physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually), Verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others), nor Other behavioral symptoms not directed toward others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds). Record review of Resident #3's Care Plan dated 10/29/23 indicated a focus area that Resident #3 had potential to demonstrate physical behaviors and the goal was he would not harm self or others. The intervention included If the resident has physical behaviors toward another resident, immediately intervene to protect the residents involved and call for assistance. If intervening would be unsafe, call out for staff assistance immediately; Notify the charge nurse of any physically abusive behaviors; Psych (psychiatric) eval due to increased aggression towards staff when refusing care Psych added Seroquel routine; Resident sent to [hospital] Psych for eval and treatment Roommate was moved from the room Resident placed in a room by himself upon return to the facility Medication change made ----> Depakote; and When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later. Record review of Resident #3's Progress Notes, dated 08/23/23 at 9:35 PM, by LVN D, reflected Resident upset because there is a roommate in his room tonight. Spanish speaking. Talking on the phone with [family member] (who was also here this evening) at this time. [Family Member] states that he says he is going to sneak out tonight because he would rather be in jail. Reassured [family member] that I will call her for behaviors tonight. Record review of Resident #3's Progress Notes, dated 08/24/23 at 4:50 PM, by LVN C, reflected Assaulted roommate by punching him in the face. Resident (aggressor) sent to [psychiatric hospital] via EMT . Pt was aggressive with staff, however when EMT arrived he went with them with no problem. Record review of Resident #3's Progress Notes, dated 11/06/23 at 5:59 PM, by the ADON, reflected This nurse was asked by CNA, to please speak with the resident because he refused his shower, when this nurse approached room CNA and nurse went in, resident was informed that CNA has picked out a beautiful pants and shirt for resident and encouraged him to please take his shower, assessed him for pain and he denied pain when this turned around resident violently struck her twice on the left arm with a closed fist and kicked her four times in the abdomen, and kicked the CNA in the face. Resident yelled out, send me back to prison, I want to go to prison, I am going to kill all of you, I am going to go to prison. [Family member] called and informed and stated, I know exactly what you are saying because I experiences the same thing, No one in the area would take him, and that is why he is at your place, because he beat me so many times at my house, [family member]said he could not come back, he is my [family member], but he is a stranger to me, I did not know he was this violent, he was in prison all my childhood and I thought it was a good thing bringing him to live with me but it was not. [MD] called and informed and orders received to send resident to the hospital for Psych to evaluate and treat. Psych, NP, [psych NP] in house and made aware of the resident's behavior and stated since he is on his way to the hospital he will assess him when he returns. [Family member] called and informed of resident's behavior. 911 called and dispatcher states police will escort EMT. Resident transport to [psychiatric hospital] for Psych to evaluate and treat. Record review of Resident #3's Progress Notes, dated 11/06/23 at 10:02 PM, by the NP, reflected Notified the primary nurse and the nursing assistant working with the patient that they were both reportedly assaulted by the patient. The primary nurse reports that she obtained an order to transfer the patient to a more acute care setting. I will reevaluate the patient upon return. Record review of Resident #3's Progress Notes, dated 12/08/23 at 9:23 AM, by the ADON, reflected Female Resident immediately stated, that man attacked me! She was looking down the hallway, when this nurse looked, a male resident, stated I did it, I will fuck you up too if you come near me! This nurse noticed blood on the male resident's right hand. Nurse assessed the female resident, and noted copious (abundant in supply or quantity) amount of fresh red blood from the back of her head and when site assessed noted a hematoma that was 5cm x 3cm, ice applied and noted bleeding stopped. Noted face to be swollen, +3 edematous her whole face was swollen as well as her nose, and noted blood on her nose. Male resident refused for staff to assess him he kept yelling out at staff, I will fuck yall up and he took his walker and rammed it into the legs of staff and attempted to hit staff. [Family member] called and informed of the incident and she stated she was on her way to get resident, informed her that the police will be called, when [family member] arrived she came in with her [family member] as well and [family member], stated he is very violent and he use to beat my [family member] also and he attacked me before. She went onto say she has encourage to leave, but he refused and she asked when will the police be here. Finally, 0649 resident agreed to leave with [family member]. Police arrived shortly after, at 0655 and resident had already left, [police officers] informed of the incident and [police officer], gave administrator the incident number. Record review of Resident #3's Progress Notes, dated 12/08/23 at 10:40 AM, by the ADON, reflected Resident stated that he attacked resident, when she wandered into his room, resident became very aggressive and agitated, he would not allow staff to come into his room and assess him and refused all staff to do one on one care, staff was able to stand outside his door while he was in his room and was able to do one on one while standing out his door . Record review of Resident #3's Progress Notes, dated 12/08/23 at 10:54 AM, by the ADON, reflected Resident's [family member] informed this nurse that she is trying to take resident out of the facility, but resident would not leave, [family member] encouraged this nurse to call the police and resident, voiced call, the police! Resident went back to bed. This nurse informed [family member], that the police has been called and at that point, resident stated he will go with his [family member]. [Family member], stated, I am just going to take him because I now, you have to protect the other residents. Resident went with his [family member], and his [family member] also accompanied them. In an interview on 12/12/23 at 10:07 AM, the ADON stated on 12/8/23 she was filling in as a nurse for 100/400 halls. The ADON stated about 4:35 AM she gave Resident #1 her meds and left to go to the 100 hall to pass meds. She stated CNA A was doing rounds because the shift change was coming up. The ADON stated CNA A notified her that something happened on the 400 hall, while she was in another resident' room changing them. The ADON stated Resident #1 was bleeding from her face and head and kept saying look what he did to me. She stated Resident #3 was standing in front of his door screaming yes I did it. The ADON stated when she approached Resident #3's door he tried to hit her with his walker and slammed his door. She stated Resident #3 was saying he would kill her and Resident #1. The ADON stated she left him in the room and called 911, the MD, both residents' families, and the Administrator. She stated she felt bad because Resident #3 had attacked her before, so she knew how strong he was and felt so bad he had attacked Resident #1 because she was very petite and frail. The ADON stated Resident #1 was not aware of what was really happening due to her dementia. She stated she was being very calm and was not crying or yelling in pain. The ADON stated the EMS arrived and was working on Resident #1. She stated Resident #3 was standing in his door entrance watching everything. The ADON stated she attempted to approach Resident #3 again to assess him and she could see he had blood on his hands and clothes, and she saw his cane in the doorway, which had blood on it too. She stated she believed he attacked her with the cane based on the blood being on his cane and Resident #1's serious injuries. The ADON stated Resident #3 was yelling to get away from my door or I will kill you. She stated Resident #3's family member came right away and picked him up. She stated the family member arrived before the police. The ADON stated Resident #3's family member told her how he had beat her up a few times when trying to help him. The ADON stated Resident #3 had attacked her and CNA B in November. She stated she believed it happened on the 6th. The ADON stated CNA B went into his room to try to give him a bath and he kicked her in the head. She stated she went to Resident #3's room and asked him if he wanted a bath. The ADON stated Resident #3 attacked her and punched her in the stomach about 3-4 times. She stated CNA B had to help get Resident #3 off her. The ADON stated she contacted Resident #3's family, the MD, and the police. She stated the police came and said there was nothing they could do, so she got an order for him to be transported to a psychiatric hospital. She stated Resident #3 was only at the hospital for a few hours and brought him back to the facility. The ADON stated the psychiatric NP had adjusted Resident #3's medication. She stated as far as she knew there were no other incidents with him being physical until 12/08/23. The ADON stated Resident #3 did have a resident-to-resident altercation sometime in September, but she did not witness the incident. In an interview on 12/12/23 at 10:48 AM, CNA B stated Resident #3 yells and curses at residents and staff. CNA B stated there was an incident in November in which she went to give him a shower and he said no. She stated they were supposed to encourage the residents to shower when they refused, so she was trying to encourage him, but he got mad and started punching and kicking at her. She stated she blocked most of it, but she did get kicked in the forehead. CNA B stated she reported the incident to the ADON. CNA B stated the ADON went to Resident #3's room to ask if he wanted a shower, and he attacked her as well. She stated Resident #3 was punching the ADON in the arm and stomach. CNA B stated she intervened and pulled the ADON away. She stated they did contact the police and he was sent out. CNA B stated she was aware of an altercation in which Resident #3 tried to hit Resident #4. She stated Resident #3 did not like people to come into his room, so he would set at the entrance to his room and yell and curse at people to get away if they approached his door. She stated Resident #4 wandered all day and approached Resident #3's doorway. She stated Resident #3 started yelling and cursing at him and then tried to hit him as he approached the doorway. CNA B stated she jumped in front of Resident #4 to block him from hitting Resident #4. She stated he missed hitting her as well. CNA B stated she moved Resident #4 away from Resident #3 and reported it to the nurse. She could not remember, which nurse was working, that she reported it to. CNA B stated she did not believe it was safe for him to be at the facility. In an interview on 12/12/23 at 12:43 PM, CNA A stated on 12/08/23 about 3:30/4:00 AM Resident #1 got up from bed. CNA A stated Resident #1 had habits of going into other's room and saying, get your ass out of my house and would start hitting their beds to get up. She stated they had to always watch Resident #1 because Resident #3 did not like people going into his room. CNA A stated she gave Resident #1 a snack and then moved her into the living room area and turned on the TV. She stated she was content at the time. CNA A stated about 4:00/4:30 AM the nurse had to leave the unit to give meds on another hall and she started doing rounds. CNA A stated she was in another resident's room changing them and when she left the room, Resident #1 was in the hall and looked as if someone had thrown a bucket of blood on her. CNA A stated Resident #1 stated look what that man did to me and was pointing at Resident #4. She stated she knew Resident #4 did not do that to her because he did not have any blood on him and looked normal. She stated Resident #3 was in hall heading back to his room and did not say anything. CNA A stated she went to get the ADON. She stated the ADON immediately started assessing Resident #1. CNA A stated they saw Resident #3 come out of his room and they noticed the blood on his hands and clothes. She stated the ADON asked Resident #3 if he did that to Resident #1 and he said yes and I'll kick your ass too. CNA A stated he was trying to charge at the ADON with his walker and then went into his room and closed the door. CNA A stated she went into his room because he was always calm with her. She stated Resident #3 let her come in and said Resident #1 went into his room and told him to get his ass out of her house and he told her that was his house and to get out. CNA A stated Resident #3 said Resident #1 would not get out so he beat her ass. CNA A stated Resident #3's family member arrived and told Resident #3 he had to leave the facility and he told her no. She stated the family member was speaking in Spanish to Resident #3, so she did not know what they were saying, but suddenly, he assaulted the family member and the ADON had to break it up. CNA A stated Resident #3 then tried to charge at the ADON again. She stated the family member was finally able to get Resident #3 out of the facility. CNA A stated there was normally two people overnight, but the facility was short nurses, so they had the ADON covering two halls. She stated since the incident with Resident #3, they make sure to always have two people in memory care. In an interview on 12/13/23 at 9:08 AM, the Administrator stated on 12/08/23 she was contacted by the ADON early in the morning and stated that Resident #3 had assaulted Resident #1 when she wandered into his room. The Administrator stated Resident #1 received very serious injuries, so she issued Resident #3 an immediate discharge. She stated until Resident #3's family came to pick him up, they had him on 1 to 1 supervision. The Administrator stated their company took over the facility in October and she started on 11/13/23, so she was not at the facility when Resident #3 was involved in the resident-to-resident incident in August or the incident in which he attacked the ADON and CNA B in November. She stated if she was the Administrator during the second incident on 11/06/23, she would have issued a 30-day discharge and helped the family find a more appropriate facility. The Administrator stated following the incident, they immediately in-serviced staff on abuse and neglect including resident-to-resident altercations, resident rights, behavior management, and customer service. She stated on 12/8/23 they had an AD Hoc QAPI meeting with Corporate Compliance Nurse, Divisional [NAME] President of Clinical Service, Divisional [NAME] President of Operations, and the facility's MD. She stated in the meeting they reviewed the residents and any resident with behavioral issues, they ensured there was appropriate interventions in place on their care plans and some of the resident's medications were adjusted. The Administrator since the incident, they have made sure there was always two people in memory care . She stated even when staff takes their breaks, they had been instructed to get coverage from other halls. A record review of the facility's schedule dated 12/09/23, 12/10/23, 12/11/23, 12/12/23, and 12/13/23 reflected there were always two staff members in the memory care unit. In an interview on 12/13/23 at 2:03 PM, LVN C stated she was called to Resident #3's room in August because he punched his roommate. LVN C stated she did not actually witness the incident but Resident #2 stated Resident #3 punched him in the face. She stated the residents were separated. LVN C stated she contacted the MD and received an order to send Resident #3 to the psychiatric hospital. LVN C stated Resident #3 did not like anyone in his room and would often sit in his doorway and yell if anyone came near. She stated they had to often redirect residents who wandered away from his door. LVN C stated due to this behavior she felt it was not safe to have Resident #3 at the facility because wandering was typical behavior in memory care. Record review of the facility's policy titled Abuse and Neglect, dated 03/29/18, reflected The resident has the right to be free from abuse, neglect . Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents . The facility will provide and ensure the promotion and protection of resident rights. It is each individual's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, exploitation . Definitions: 1. Abuse: Abuse is the willful infliction of injury . with resulting physical harm, pain or mental anguish . Procedure: . C. Prevention: The facility will provide the residents, families, and staff an environment free from abuse and neglect . 4. The facility will be responsible to identify, correct, and intervene in situation of possible abuse/neglect. The facility has in place a method to identify events . occurrences, patterns, and trends that may constitute abuse . G. Protection: The facility will take necessary measures to protect residents and employees from harm during and following an abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property investigation . Resident to Resident: The above policy will apply to potential resident-to-resident abuse . An Immediate Jeopardy (IJ) was identified to have existed from 12/08/23 through 12/08/23. On 12/13/23 the IJ was determined to be past noncompliance as the facility had implemented actions that corrected the noncompliance prior to the beginning of the investigation. The facility took the following actions to correct the non-compliance prior to the investigation: An observation on 12/12/23 at 9:10 AM revealed Resident #3 was no longer at the facility. Record review of the facility's census, dated 12/12/23, reflected Resident #3 was no longer at the facility. Record review of Resident #3's Progress Notes, dated 12/08/23 at 10:00 AM, by the Administrator, reflected Administrator called resident's [family member] and explained immediate discharge process. Immediate discharge notice emailed to resident's [family member] and Ombudsman. Resident's [family member] is taking resident to [psychiatric hospital] for further evaluation. Administrator advised [family member] that facility will assist in seeking alternate placement for resident due to resident is a danger to others. [Family member] verbalized understanding. Record review of the facility's in-services, dated 12/08/23, reflected all staff, were educated on abuse and neglect including resident to resident, resident rights, behavioral management, and customer service. Record review of a document titled Resident to Resident Monitoring dated 12/8/23 to 12/11/23 reflected 10 staff members within the week were asked if they noticed any inappropriate behavior among residents, and if so, verify what the staff member did and if it was reported properly. There were no inappropriate behaviors reported on the document. Record review of document AD Hoc QAPI Contributors, dated 12/8/23, reflected the Administrator, DON, Corporate Compliance Nurse, Divisional [NAME] President of Clinical Service, Divisional [NAME] President of Operations, Assistant Director of Operations and the MD attended the meeting regarding Resident to Resident Physical Aggression and completed checklist that included self-report to state within 2 hours, 1 on 1 monitoring for resident who initiated the encounter or was the aggressor until further notice from the IDT, interview residents involved in the encounter, determine new interventions, the aggressor is capable of staying in the facility, interview staff regarding if they have observed any potential physical abuse among residents, after interviews determine if other residents have the potential to be physically aggressive to other resident, if so act accordingly with new interventions for the resident, initiate risk management entry for behavior related incident and complete event note, notify police if applicable and medical director. Interviews were conducted from 12/12/23 to 12/13/23 at various times, with four nurses, seven CNAs, two Med Aides, and ADON, from various shifts. The staff all stated they had been in-serviced on abuse and neglect including resident to resident, resident rights, behavioral management, and customer service. The staff were able to identify and define abuse, were knowledge on procedures for reporting and preventing abuse, and interventions of resident o resident abuse. The staff were knowledgeable of procedures and interventions for resident with behavioral issues.