**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents had the right to be treated with respect and dignity for 1 of 8 residents reviewed for resident rights. (Resident #1). The facility failed to ensure CNA A respected Resident #1's rights and dignity during her shower on 5/29/24. The noncompliance was identified as PNC. The Immediate Jeopardy began on 5/29/24 and ended on 5/31/24. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of becoming distressed and feeling disrespected. Findings included: Record review of an admission Record dated 6/4/24 indicated Resident #1 was a [AGE] year-old female admitted to the facility on [DATE]. Diagnoses included lymphedema (a condition that results in swelling of the leg or arm. It occurs due to blockage in the lymphatic system which is part of the immune system), hypertension (high blood pressure), diabetes (a disease that occurs when blood glucose, also called blood sugar, is too high), and peripheral vascular disease (a disorder of the blood vessels outside the heart that affects blood flow to the limbs). Record review of the most recent MDS assessment dated [DATE] indicated Resident #1 was able to make herself understood and was able to understand others. She had a BIMS score of 11, which indicated moderately impaired cognition. Resident #1 required partial to moderate assistance with showering (helper doing less than half the effort). Resident #1 had no physical, verbal, or other behavioral symptoms directed towards others Record review of a care plan with a revision date of 4/26/24 indicated Resident #1 had a self-care/mobility focus with a goal to maintain functional abilities. Interventions included, Resident #1 will maintain the ability to bathe self, including washing, rinsing, and drying self. The Resident requires assistance set up supervision with bathing/showering, as necessary. Resident #1 had bladder incontinence, with interventions to ensure Resident #1 had unobstructed pathway to the bathroom, and to monitor/document/report to physician possible medical causes of incontinence. Record Review of Resident #1's Nurses Progress Notes dated 5/29/24 at 11:23 a.m. and signed off by ADON indicated Resident #1 reportedly had an incontinent episode this morning which is unlike the resident. Resident was brought to shower per CNA A and resident was displaying weakness not able to wash self. Resident #1 is yelling/cursing at staff, crying, and not able to be consoled. This is not baseline for resident. Call placed to MD with new order for UA with C &S (urinalysis with culture and sensitivity). Will continue to monitor and assess as allowed. Record review of the facility's provider investigation report dated 6/2/24 indicated the following: date of incident 5/30/24 at 12:14 p.m. Resident #1 was independently ambulatory, interviewable and had the capacity to make informed decisions. Resident #1 had no history of combativeness, similar incidents, wandering, sexual misconduct, verbal aggression, or physical aggression. CNA A was named as the alleged perpetrator and had a history of similar allegations. The agency immediate response, Resident #1 was independent and did not want assistance in showering. Expressed to CNA A she did not want him in the shower room or in her room. Investigation findings were inconclusive. Agency action post investigation, The fact that there were two incidents that were involving CNA A, we determined that in the interest of the residents, it be best if we parted ways with CNA A. Record review of a Grievance/Complaint Report dated 4/7/24 indicated that Resident #2 had reported to a hospital case manager that CNA A was rough in the shower and when transferring her. Document indicated ADON was designated to take action on this concern. Date assigned was 4/8/24. Actions taken included Abuse and neglect in-service, for all staff and in-service CNA A on using a lighter touch when showering. Resolution of grievance/complaint included a written warning was done with CNA A regarding shower techniques, abuse, and neglect. Form signed off by Administrator/grievance officer. Record review of a Verbal Warning Record dated 4/8/24 indicated CNA A indicated ADON educated CNA A on lighter touch while in shower and also proper transfer techniques. Record review of an unnamed document provided by facility dated 4/9/24 indicated CNA A received sensitivity training on abuse and neglect (different forms of abuse), baths, attitude, transfers, and assignments. Document was signed by ADON, and CNA A. Record review of a Grievance/Complaint Report dated 5/30/24 indicated CNA A was neglecting Resident #1's rights to shower. Resident #1 expressed her feeling like her rights had been violated because CNA A would not allow her to independently bathe. Document indicated the ADON and DON were designated to take action on this concern. Date assigned was 5/30/24. Actions taken included in services on abuse and neglect, safe surveys done on residents under the care of CNA A and emotional monitoring done with Residents. Resolution of grievance/complaint included reporting incident to the State, in-services completed, safe surveys completed, emotional monitoring on Resident #1. CNA A was terminated. Document signed by Administrator/Grievance officer and dated 6/4/24. Record review of a witness statement from CNA A dated 5/30/24 indicated the following, On 5/29 resident was sitting on edge of bed and had an incontinent episode, large amount of urine on the floor. Resident was confused and weak and trembling. The DON notified me of the resident and told me to take resident to the shower. Resident usually bathes self but due to confusion and weakness she could not perform task herself. Resident never stated she felt uncomfortable with me performing shower. Resident kept saying she could do it herself but was falling over in the chair. Resident was upset that she had to have help in the shower and requested this CNA not to go in her room. On 5/30 I left Resident's tray on the cart at breakfast. Resident asked nurse where her tray was. I told nurse the resident requested me not to go in her room, so I left it on the food cart. Resident said she would get it herself. Record review of a witness statement from ADON dated 5/30/24 indicated the following, This nurse heard Resident #1 hollering and cussing in the hallway. Resident #1 was upset that CNA A had to help her in the shower. This nurse tried to talk to Resident #1 and let her know that for her safety in the shower she needed assistance due to new weakness. Resident #1 remains crying and yelling that she was told she could shower alone. This nurse let her know that she always needs to be accompanied by staff in case something happens. Resident becomes more agitated stating she has been lied to that she was told before she came she did not have to be accompanied. Resident exits room to therapy yelling you can all kiss my ass. Record review of an undated form titled Associate Separation Report indicated CNA A's date of hire was 2/23/23 and date of separation was 5/31/24. Reasons for separation included violating federal or state care standards, conduct or neglect of duties determined by management to be detrimental to the welfare of patients, resident, co-workers, the workplace of employer, and must follow all resident care guidelines including but not limited to on-time meals, care and medication and accurate detailed charting. Resident #1 forged a complaint against CNA A regarding her feeling like she was treated with disrespect. CNA A was assisting in resident shower and resident had a history of being independent in showers and she did not feel she needed assistance. The resident was found to have low blood sugar and a UTI, and was not at her baseline, so CNA A expressed that it was his obligation to assist due to her instability. Once the shower was complete, Resident #1 expressed her discontent that she was unable to shower by herself. The next day she lodged a complaint with the Ombudsman regarding CNA A and stated she felt abused. The investigation resulted in showing that abuse was found. Document was signed by Administrator. During an interview with the complainant on 6/3/24 at 4:52 p.m. she stated she had received a call on 5/30/24 sometime between midnight and 3:00 a.m. from LVN L, night shift nurse who told her that Resident #1 was upset over the way she was manhandled by CNA A during her shower on 5/29/24. Complainant stated she could hear Resident #1 in the background crying. Complainant stated she went into the facility on 5/31/24 to talk with Resident #1. Complainant stated Resident #1 told her she thought she had soiled her brief and asked CNA A to help her to the bathroom. CNA A told her get up you're going straight to the shower; I am not going to change you. Resident #1 told him she did not want to be in the shower by herself with a male, and CNA A told her you don't have a choice. Resident #1 stated CNA A kept telling her you're acting crazy, you are not making logical sense. Your blood sugar is low that is why you can't think. Resident #1 then told complainant CNA A forced her into the chair and took her to the shower. Resident #1 stood up and CNA A pushed her up against the shower wall and removed her blouse. Resident #1 told him No, stop, but CNA A continued to remove her blouse. CNA A then shoved Resident #1 down into the shower chair forcefully. Complainant stated Resident #1 told her she felt very afraid and intimidated by CNA A because he was so mean and angry with her. Complainant stated Resident #1 asked for her shampoo and CNA A told her no, you're going to use the shampoo I tell you to use. Resident #1 managed to get her own shampoo and get some in her hair. Complainant stated Resident #1 was very upset, and said she felt embarrassed, and felt that she was assaulted, and did not know what to do about it. Resident #1 told complainant that she refused to go the hospital because she was concerned, they would throw her out of the facility. Resident #1 stated that she liked being there but if they did not do something about that man, she would leave and go to another facility. During an interview on 6/4/24 at 11:50 a.m. Resident #1 stated she had lived in the facility since that last week of April 2024. Resident #1 stated she loved CNA A taking care of her, up until the date of the incident. Resident #1 stated she had been warned by other residents that he was mean and could turn on you real quick. Resident #1 stated that on 5/29/24 CNA A woke her up by slamming her breakfast tray on the table and yelling her name. Resident #1 stated that it startled her and she wet herself. Resident #1 stated she was a bit confused at the time because CNA A woke her up out of a dead sleep. Resident #1 stated CNA A asked her did you pee at church?, you're not yourself. Resident #1 stated CNA A kept getting louder and louder saying I wasn't myself over and over. Resident #1 stated she told CNA A to leave her alone. Resident #1 stated that before she moved into the facility it was a top priority for her to be able to shower herself. Resident #1 stated she called the facility prior to moving in and was told she could shower herself, and it was explained to her the shower room was a separate room in the facility. Resident #1 did not remember who she had talked with. Resident #1 stated she was very modest. Resident #1 stated that CNA A said, come on we're going to the shower, and that CNA A kept twisting me to get my clothes off, and I'm trying to stop him. Resident #1 stated CNA A told her, you are not yourself. Resident #1 stated I told him I'm not getting undressed in front of you, and CNA A continued to take her clothes off. Resident #1 stated he kept trying to get her to sit in a shower chair with a hole in the middle and kept pushing her into the chair. Resident #1 stated she asked CNA A to go behind the privacy curtain and CNA stated, No. This is my job, you want to wash your rosebud by yourself? Resident #1 stated that rosebud referred to her vagina. Resident #1 stated that CNA A kept forcing her to sit in the chair. CNA A put shampoo on her head and would not let her use her own shampoo. Resident #1 stated she unwrapped her Unna boots, (compression dressings made by wrapping layers of gauze around the leg and foot. It is often used to protect an ulcer or open wound. The compression of the dressing helps improve blood flow in your lower leg. Compression also helps decrease swelling and pain), and she begged CNA A to go behind the privacy screen again. Resident #1 stated, I felt like dirt. Resident #1 stated she had always showered by herself prior to this incident. Resident #1 stated she told CNA A you are hurting me. I'm humiliated please go behind the privacy screen. Resident #1 stated she kept repeating it and begged him to go behind the privacy screen, and CNA A did not go behind the screen. Resident #1 stated she did not feel comfortable in the shower chair and that it was slippery. Resident #1 stated CNA A stated, sit there, and stop acting like this. Resident #1 stated with all the commotion, no one came in to check on her. Resident #1 stated she had some bruises on her arms, but she got them while in the hospital, and said she had not seen any other bruises. Resident #1 stated that she was a bit disoriented when she woke up, but CNA A had startled her. I was confused when he kept asking if I peed myself at church. I don't know what he was talking about. Resident #1 said when CNA A brought her back to her room, he picked out some clothes for her to wear, and she told him she did not want to wear what he picked out, and he did not listen to her. Resident #1 stated, what really pissed me off was when we got back to my room, he took my wet towel and started mopping up the floor, like I had peed all over the place. It was a small spot. Resident #1 stated after she got dressed, the ADON came in her room, and said she wanted to talk to her while she was upset. Resident #1 stated the ADON was baby talking to her asking why are you mad, and why are your unna boots off? Are you upset because we care? Resident #1 stated the ADON told her we never told you that you could shower alone, and that there was not one resident in the facility that showers by themselves. Resident #1 stated she did not know why the ADON said that because she knew a lot of Residents that showered by themselves, and that she had showered by herself 3 times a week before this incident. Resident #1 stated that she asked the ADON to leave at that time, and the ADON replied, I still want to get to the bottom of why you are mad and why your unna boots are off. Resident #1 stated she told the ADON again she wanted her to leave, and the ADON stated she did not want to leave. Resident #1 stated she got up and went to the therapy department. Resident #1 stated she would take her unna boots off when she showered, a nurse would remove them, or she was capable of removing them herself. Resident #1 stated that one day, (did not know for sure what day it was), the Administrator came in and told her we need to talk. Resident #1 stated they went into her room and the Administrator said, CNA A is over enthusiastic and means well. Resident #1 stated the Administrator promised no one would go in the shower while she was in there. Resident #1 stated the Administrator apologized for the incident, and Resident #1 told her to keep CNA A away from me, I'm humiliated. Resident stated the next day at breakfast time, CNA A was standing by the food cart and said, she (meaning Resident #1) don't want anything to do with me, she can get the damn tray herself. Resident #1 stated she asked the Administrator if she was going to get to eat if no one was going to bring her tray. Resident #1 stated that after CNA A twisted her all around in the shower, she could not stand very well. Resident #1 stated the facility called an ambulance and she was taken to the hospital where she found out she had pneumonia and flu and spent 3 days in the hospital. Resident #1 stated that the left side still hurt after CNA A manhandled her from the front trying to pick her up and put her in the shower chair. Resident #1 stated yes I was fighting him as he was pulling my clothes off. I had a sports bra on which was hard to get off. Everything came off, I had no say in what came off. Resident began to cry stating, I hate a young male kid seeing this fat person, maybe he was used to it, but I wasn't. It was just too much. Resident #1 stated she had heard other residents talk about CNA A in the smoking area calling him an asshole. Resident #1 stated after she heard these comments she did not want to judge CNA A by what other people said, but wanted to make her own decision about him, and they were right. Resident #1 stated she had no issues before this incident and had no issues with him taking care of her. Resident #1 stated CNA A had also gotten into (verbal altercation) with the cook in the dining room in front of other residents. Resident #1 stated CNA A had also made Resident #3 cry twice. Resident#1 stated she loved living in the facility except for this incident. During an interview on 6/4/24 at 12:40 p.m. Resident #2 was lying in her bed. Resident #2 stated she had received care from CNA A. Resident #2 stated CNA A was yelling and was rough when moving me in bed. Resident #2 stated she did not remember when this occurred, and that she did not report it to anyone. During an interview on 6/4/24 at 12:50 p.m. Resident #3 was sitting outside in the smoking area. Resident #3 stated she had lived in the facility since December 2, 2023. Resident #3 stated CNA A was obnoxious and acted like a bully. Resident #3 stated CNA A talked very loud and had hurt her feelings a couple of times and made her cry. Resident #3 stated he mocked her in the hall in front of another employee. Resident #3 stated CNA A was a smart ass and very unprofessional, and it had gotten out of hand. Resident #3 stated CNA A was not very nice and was a smart ass bully. Resident #3 stated it was so bad, she checked herself out of the facility for a week and went to her family member's house just to get away. Resident #3 stated she checked out about 3 weeks after she had come to the facility, and then came back. Resident #3 stated CNA A hurt her feelings by making fun of her needing her medications. Resident #3 stated there was a day CNA A told her never raise your voice like that to me ever again yelling at the top of his lungs in front of all the smokers. Resident #3 did not remember all the details of the event. Resident #1 stated she did not report this to anyone but should have. During an interview on 6/4/24 at 1:24 p.m. MA B sated he had worked in the facility since November 2023. CMA B stated that CNA A was a hard worker, but horse-played (engaging in activities not related to task at hand) a lot. MA B sated CNA A was rude and arrogant to residents as well as other staff. MA B stated on the day of the incident with Resident #1, CNA A had called for help to stand her up. MA B stated Resident #1 had a look of disgust on her face like, I can't believe this is happening. Resident #1 told MA B that she was told by the facility that she could shower by herself. MA B stated Resident #1 had told CNA A to stand behind the privacy curtain, and he did not. Resident #1 was crying when she came out of the shower, and her face was red. Resident #1 stated CNA A had hurt her feelings. CMA B stated what ever happened in that shower room, CNA A never looked the same . CNA A could not make eye contact with Resident #1. MA B stated CNA A had no respect for his peers or for any woman. MA B stated CNA A had said things to other staff such as your mom is a whore, and you are a crack baby. MA B stated he told CNA A that he had victimized Resident #1. MA B stated that looking at Resident #1, he could see so many emotions in the lady's face. MA B stated he knew that CNA A had been banned from a lot of facilities around the area. MA B stated CNA A told him, I don't know if this job is for me. Every facility I go to I get fired. I don't know what I want to do. During an interview on 6/4/24 at 2:30 p.m. CNA E said he had worked with CNA A a few times. CNA E stated he personally had no problems with CNA A, but he had heard from some residents that CNA A was rough with them . CNA E stated the only resident he could remember was Resident #6. During an interview on 6/4/24 at 2:42 p.m. Resident #4 stated she had been in the facility for about a month. Resident #4 stated she had known CNA A for many years when he was working at another facility. Resident #4 stated she felt CNA A had caused a lot of problems in the facility. Resident #4 stated CNA A had inappropriately touched some ladies. Resident #4 stated Resident #1 was one of them. Resident #4 stated she could not remember any other names and that most of the ladies that he had touched had left the facility because of him. Resident #4 stated CNA A grabs the top and in the middle during showers. Resident #4 stated CNA A did not belong giving ladies showers, and Resident #1 was very upset. Resident #4 stated CNA A tried to do it with ladies because he can get away with it. CNA A has cursed at women and was very disrespectful. CNA A had never touched me as he knows better. Some ladies need help with their showers, but not by him. Resident #4 stated she showered by herself. During an interview on 6/6/24 at 10:55 a.m. Resident #5 stated that she showered by herself. Resident #5 stated CNA A acted like a child. Resident #5 stated she had never witnessed any abuse with him but wouldn't doubt it. Resident #5 stated CNA A was mean to other staff bullying them, and his mouth was always running and he talked very loud. Resident #5 stated she got mad at CNA A because every time she would be walking around in the facility, CNA A kept saying we're going to find you a boyfriend. He would say how bout that one, or that one, and kept pointing at different men. Resident #5 stated she asked him to please not do that as I was embarrassed. During an interview on 6/6/24 at 10:15 a.m. Rehab employee G stated CNA A did not have a good bedside manner. CNA A would joke a lot and did not realize it could hurt feelings. Rehab employee G stated she felt CNA A meant well and was always in a joking mood. Rehab employee G stated she had become close to Resident #1 and helped her get into the facility. Rehab employee G stated she told Resident #1 that therapy would always be a safe place for her to come to if she needed to. Rehab employee G stated Resident #1 told her CNA A had been rough in the shower, and that she was leaning forward in her chair and CNA A grabbed her around the chest area to sit her up, as he was afraid she was going to fall. Rehab employee G stated Resident #1 told her that CNA A put his arms across her chest to sit her up and hurt her ribs when pulling her back in the chair. Rehab employee G stated Resident #1 talked to her the day of the incident. Rehab employee G stated Resident #1 was hysterical when she came to the department, to the point they closed the door for her privacy. Rehab employee G stated Resident #1 was crying. Rehab employee G stated that Resident #1 stayed in the department for about 2 hours. Rehab employee G stated they let her lay down and gave her a heating pad for her back and applied Bio freeze to her shoulders. Rehab employee G stated the day after the incident Resident #1 had told her that CNA A would not bring her breakfast tray to her, and that she could get her own damn tray. Rehab employee G stated she had heard hearsay that CNA A had touched women prior to coming here, but it was just hearsay and she had never witnessed it. During an interview on 6/6/24 at 10:48 a.m. CNA H stated she had worked in the facility since 2012. CNA H said she would sometimes pick up a shift on CNA A's rotation but did not like to work with him. CNA H stated CNA A was different but could not explain how. CNA H stated she had never witnessed any abuse by CNA A. CNA H stated Resident #1 had always showered by herself. CNA H stated Resident #1 told her CNA A roughed her up and that she did not want him in the shower with her, and that he kept pulling her shirt off and pulled her sports bra down. During an interview on 6/6/24 at 11:24 a.m CNA I stated CNA A was very rude, and played too much to be in the field he is in. CNA I stated she had worked with CNA A in another facility and that he acted the same way. CNA I stated if a resident needed anything CNA A had an attitude and would be mouthy (verbally disrespectful). During an interview on 6/6/24 at 11:50 a.m. CNA K stated she had not worked with CNA A very often but that he was playful, arrogant, rude to coworkers and a smart butt. During an interview on 6/6/24 at 12:20 p.m. the DON stated she had worked in the facility since April 1 of this year. DON stated Resident #1 was under the impression that she could shower alone, and due to Resident #1's state of mind, all showers had to be supervised. DON stated Resident #1 had a fall on 5/31/24 and complained of rib pain the next day and did not want x-rays done. DON stated that when Resident #1 was in the shower with CNA A , when Resident #1 said stop, CNA A should have stopped. DON stated the Ombudsman came to visit that day and was told of the situation. During an interview on 6/6/24 at 1:00 p.m. the Administrator stated that when Resident #1 said stop, CNA A should have stopped. Administrator stated she did grievances and had not received any from any staff member regarding CNA A. Administrator stated she did not have a copy of the provider investigator report that was submitted with all training documentation. During an interview on 6/6/24 at 1:00 p.m. ADON stated she talked with Resident #1 the day of her incident with CNA A. ADON stated Resident #1 was crying and stating, I'm humiliated. ADON told Resident #1 she could not take a shower by herself. ADON stated Resident #1 did not want to speak with her and wanted her out of her room. ADON stated every resident is to have assistance in the shower, and she had instructed the staff about it. ADON said she spoke to CNA A after the incident and wrote up what had happened. DON stated CNA A said Resident #1 felt humiliated that he had to bath her, and CNA A told Resident #1 that for her safety he needed to be there. ADON stated that when Resident #1 said stop, he should have stopped. ADON stated she got a statement from CNA A on 5/30/24 and CNA A was sent home during the investigation and was terminated. ADON said she had not received any grievances from staff regarding CNA A. During an interview on 6/6/24 at 2:11 p.m. Resident #6 stated she had lived in the facility for 8 years. Resident #6 stated CNA A had provided care to her and was rough with her when helping her out of the bed. Resident #6 stated she told CNA A it hurt, and he said, so what. Resident #6 said she did not tell anyone, and when asked why Resident #6 stated, I don't know. Resident #6 stated CNA A had helped her with her showers, and never had a problem. Resident #6 stated she had heard CNA A say mean and hateful things. Resident #6 stated she did not remember who he was talking to at the time. On 6/6/24 at 2:21 p.m. and 4:11 p.m. two attempts were made to contact LVN L. No response was received to voicemail left. During an interview on 6/10/24 at 9:45 a.m. the DON stated she was working as a floor nurse on the day of Resident #1's incident on 5/29/24. DON stated she had talked with Resident #1 after the incident and said Resident #1 apologized for being so upset. Resident #1 stated she did not want CNA A in the shower with her. CNA A was out doing a transport at that time but was suspended as soon as he returned to the facility. DON stated she had not had any staff or resident come to her with any concerns with CNA A. DON stated she was not aware of any write-ups on CNA A since she had started working in the facility in April of this year. During an interview on 6/10/24 at 9:56 a.m. the ADON stated that on 5/29/24, she had gone to talk with Resident #1 after the incident. ADON stated Resident #1 was crying and would not talk with her. ADON stated she had looked at Resident #1's ribs, and there were no bruises. ADON stated the DON told her that she had sent CNA A to take Resident #1 to the shower after an incontinent episode. ADON stated Resident #1 was weak and needed assistance. ADON was asked if there were any specific documents she could provide regarding what was covered in the abuse trainings that were done or any documents that talked about what was discussed. ADON stated the abuse/neglect in-service was generic and covered the abuse policy. During a follow up interview on 6/10/24 at 10:16 a.m. Resident #1, stated that on the date of the incident with CNA A, she did not request that a female showered her, she just told CNA A you are not going into the shower with me. You are a kid and a male. Resident #1 stated she thought that was enough. Resident #1 stated CNA A stated, you're not yourself, you don't know what you are saying. Resident #1 stated she was so upset she did not remember if CNA A had helped wash her, but he must have washed some parts because he asked if I wanted to wash my own rosebud. Resident #1 stated she felt CNA A forced her to have that shower. Resident #1 stated she felt at peace now that CNA A was gone, and won't be doing this to anyone else, but I am not at peace after what happened and why it happened. Resident #1 stated, he made me feel so disgraced, and the more I think about it the madder I get. Resident #1 stated she did not feel bad that CNA A got fired. Resident #1 stated, at the time of the incident I kept thinking why isn't there a female in here. I was so busy thinking what is happening and why, I was not able to take the next step of getting him out of the shower. Everything happened so fast, and I was worried about getting covered up and getting him out. I told CNA A to stop and get out, over and over. Resident #1 stated she had chronic back pain and CNA A kept twisting and pulling under her arms and she thought he had broken her ribs which he didn't. Resident #1 stated CNA A lifted her from her rollator walker. (rollators have wheels on all legs, making them easier to push without lifting)to a shower chair, and she had always stood to take her showers. Resident #1 stated today was the first day I could take a shower. I was afraid to go into the shower since the incident. Resident #1 stated that she was a logical person, and knew it would not happen again, but it's kind of like PTSD. Resident #1 stated that she hated that she was still thinking about this incident and did not want to keep bringing it up. Resident #1 stated she felt that she can eventually put it out of her mind, and that it will just take a while. Resident #1 stated she was able to shower on this date by herself, and that two employees checked on her. Resident #1 stated it felt good to get a shower. Resident #1 stated, I know logically, CNA A is not here, but I still have thoughts of my shorts, underwear, shirt and sports bra all being removed by CNA A. Resident #1 stated she felt absolutely comfortable talking with the Administrator and DON if she felt she needed any counseling. Resident #1 stated, despite this incident, I am very happy to

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents the right to be free from abuse and/or neglect for 1 of 8 residents reviewed for abuse and/or neglect. (Resident #1) The facility failed to prevent CNA A from verbally, physically and mentally abusing Resident #1 while giving Resident #1 a shower on 5/29/24. The noncompliance was identified as PNC. The Immediate Jeopardy began on 5/29/24 and ended on 5/31/24. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of emotional harm, abuse/neglect, humiliation, intimidation, fear, shame, agitation, degradation, and decreased quality of life. Findings included: Record review of an admission Record dated 6/4/24 indicated Resident #1 was a [AGE] year-old female admitted to the facility on [DATE]. Diagnoses included lymphedema (a condition that results in swelling of the leg or arm. It occurs due to blockage in the lymphatic system which is part of the immune system), hypertension (high blood pressure), diabetes (a disease that occurs when blood glucose, also called blood sugar, is too high), and peripheral vascular disease (a disorder of the blood vessels outside the heart that affects blood flow to the limbs). Record review of the most recent MDS assessment dated [DATE] indicated Resident #1 was able to make herself understood and was able to understand others. She had a BIMS score of 11, which indicated moderately impaired cognition. Resident #1 required partial to moderate assistance with showering (helper doing less than half the effort). Resident #1 had no physical, verbal, or other behavioral symptoms directed towards others. Record review of a care plan with a revision date of 4/26/24 indicated Resident #1 had a self-care/mobility focus with a goal to maintain functional abilities. Interventions included, Resident #1 will maintain the ability to bathe self, including washing, rinsing, and drying self. The Resident requires assistance set up supervision with bathing/showering, as necessary. Resident #1 had bladder incontinence, with interventions to ensure Resident #1 had unobstructed pathway to the bathroom, and to monitor/document/report to physician possible medical causes of incontinence. Record Review of Resident #1's Nurses Progress Notes dated 5/29/24 at 11:23 a.m. and signed off by ADON indicated Resident #1 reportedly had an incontinent episode this morning which is unlike the resident. Resident was brought to shower per CNA A and resident was displaying weakness not able to wash self. Resident #1 is yelling/cursing at staff, crying, and not able to be consoled. This is not baseline for resident. Call placed to MD with new order for UA with C &S (urinalysis with culture and sensitivity). Will continue to monitor and assess as allowed. Record review of the facility's provider investigation report dated 6/2/24 indicated the following: date of incident 5/30/24 at 12:14 p.m. Resident #1 was independently ambulatory, interviewable and had the capacity to make informed decisions. Resident #1 had no history of combativeness, similar incidents, wandering, sexual misconduct, verbal aggression, or physical aggression. CNA A was named as the alleged perpetrator and had a history of similar allegations. The agency immediate response, Resident #1 was independent and did not want assistance in showering. Expressed to CNA A she did not want him in the shower room or in her room. Investigation findings were inconclusive. Agency action post investigation, The fact that there were two incidents that were involving CNA A, we determined that in the interest of the residents, it be best if we parted ways with CNA A. Record review of a Grievance/Complaint Report dated 4/7/24 indicated that Resident #2 had reported to a hospital case manager that CNA A was rough in the shower and when transferring her. Document indicated ADON was designated to take action on this concern. Date assigned was 4/8/24. Actions taken included Abuse and neglect in-service, for all staff and in-service CNA A on using a lighter touch when showering. Resolution of grievance/complaint included a written warning was done with CNA A regarding shower techniques, abuse, and neglect. Form signed off by Administrator/grievance officer. Record review of a Verbal Warning Record dated 4/8/24 indicated CNA A indicated ADON educated CNA A on lighter touch while in shower and also proper transfer techniques. Record review of an unnamed document provided by facility dated 4/9/24 indicated CNA A received sensitivity training on abuse and neglect (different forms of abuse), baths, attitude, transfers, and assignments. Document was signed by ADON, and CNA A. Record review of a Grievance/Complaint Report dated 5/30/24 indicated CNA A was neglecting Resident #1's rights to shower. Resident #1 expressed her feeling like her rights had been violated because CNA A would not allow her to independently bathe. Document indicated the ADON and DON were designated to take action on this concern. Date assigned was 5/30/24. Actions taken included in services on abuse and neglect, safe surveys done on residents under the care of CNA A and emotional monitoring done with Residents. Resolution of grievance/complaint included reporting incident to the State, in-services completed, safe surveys completed, emotional monitoring on Resident #1. CNA A was terminated. Document signed by Administrator/Grievance officer and dated 6/4/24. Record review of a witness statement from CNA A dated 5/30/24 indicated the following, On 5/29 resident was sitting on edge of bed and had an incontinent episode, large amount of urine on the floor. Resident was confused and weak and trembling. The DON notified me of the resident and told me to take resident to the shower. Resident usually bathes self but due to confusion and weakness she could not perform task herself. Resident never stated she felt uncomfortable with me performing shower. Resident kept saying she could do it herself but was falling over in the chair. Resident was upset that she had to have help in the shower and requested this CNA not to go in her room. On 5/30 I left Resident's tray on the cart at breakfast. Resident asked nurse where her tray was. I told nurse the resident requested me not to go in her room, so I left it on the food cart. Resident said she would get it herself. Record review of a witness statement from ADON dated 5/30/24 indicated the following, This nurse heard Resident #1 hollering and cussing in the hallway. Resident #1 was upset that CNA A had to help her in the shower. This nurse tried to talk to Resident #1 and let her know that for her safety in the shower she needed assistance due to new weakness. Resident #1 remains crying and yelling that she was told she could shower alone. This nurse let her know that she always needs to be accompanied by staff in case something happens. Resident becomes more agitated stating she has been lied to that she was told before she came she did not have to be accompanied. Resident exits room to therapy yelling you can all kiss my ass. Record review of an undated form titled Associate Separation Report indicated CNA A's date of hire was 2/23/23 and date of separation was 5/31/24. Reasons for separation included violating federal or state care standards, conduct or neglect of duties determined by management to be detrimental to the welfare of patients, resident, co-workers, the workplace of employer, and must follow all resident care guidelines including but not limited to on-time meals, care and medication and accurate detailed charting. Resident #1 forged a complaint against CNA A regarding her feeling like she was treated with disrespect. CNA A was assisting in resident shower and resident had a history of being independent in showers and she did not feel she needed assistance. The resident was found to have low blood sugar and a UTI, and was not at her baseline, so CNA A expressed that it was his obligation to assist due to her instability. Once the shower was complete, Resident #1 expressed her discontent that she was unable to shower by herself. The next day she lodged a complaint with the Ombudsman regarding CNA A and stated she felt abused. The investigation resulted in showing that abuse was found. Document was signed by Administrator. Record review of an undated online training report indicated CNA A received training on preventing, recognizing, and reporting abuse on 2/26/23 when hired. During an interview with the complainant on 6/3/24 at 4:52 p.m. she stated she had received a call on 5/30/24 sometime between midnight and 3:00 a.m. from LVN L, night shift nurse who told her that Resident #1 was upset over the way she was manhandled by CNA A during her shower on 5/29/24. Complainant stated she could hear Resident #1 in the background crying. Complainant stated she went into the facility on 5/31/24 to talk with Resident #1. Complainant stated Resident #1 told her she thought she had soiled her brief and asked CNA A to help her to the bathroom. CNA A told her get up you're going straight to the shower; I am not going to change you. Resident #1 told him she did not want to be in the shower by herself with a male, and CNA A told her you don't have a choice. Resident #1 stated CNA A kept telling her you're acting crazy, you are not making logical sense. Your blood sugar is low that is why you can't think. Resident #1 then told complainant CNA A forced her into the chair and took her to the shower. Resident #1 stood up and CNA A pushed her up against the shower wall and removed her blouse. Resident #1 told him No, stop, but CNA A continued to remove her blouse. CNA A then shoved Resident #1 down into the shower chair forcefully. Complainant stated Resident #1 told her she felt very afraid and intimidated by CNA A because he was so mean and angry with her. Complainant stated Resident #1 asked for her shampoo and CNA A told her no, you're going to use the shampoo I tell you to use. Resident #1 managed to get her own shampoo and get some in her hair. Complainant stated Resident #1 was very upset, and said she felt embarrassed, and felt that she was assaulted, and did not know what to do about it. Resident #1 told complainant that she refused to go the hospital because she was concerned, they would throw her out of the facility. Resident #1 stated that she liked being there but if they did not do something about that man, she would leave and go to another facility. During an interview on 6/4/24 at 11:50 a.m. Resident #1 stated she had lived in the facility since that last week of April 2024. Resident #1 stated she loved CNA A taking care of her, up until the date of the incident. Resident #1 stated she had been warned by other residents that he was mean and could turn on you real quick. Resident #1 stated that on 5/29/24 CNA A woke her up by slamming her breakfast tray on the table and yelling her name. Resident #1 stated that it startled her and she wet herself. Resident #1 stated she was a bit confused at the time because CNA A woke her up out of a dead sleep. Resident #1 stated CNA A asked her did you pee at church?, you're not yourself. Resident #1 stated CNA A kept getting louder and louder saying I wasn't myself over and over. Resident #1 stated she told CNA A to leave her alone. Resident #1 stated that before she moved into the facility it was a top priority for her to be able to shower herself. Resident #1 stated she called the facility prior to moving in and was told she could shower herself, and it was explained to her the shower room was a separate room in the facility. Resident #1 did not remember who she had talked with. Resident #1 stated she was very modest. Resident #1 stated that CNA A said, come on we're going to the shower, and that CNA A kept twisting me to get my clothes off, and I'm trying to stop him. Resident #1 stated CNA A told her, you are not yourself. Resident #1 stated I told him I'm not getting undressed in front of you, and CNA A continued to take her clothes off. Resident #1 stated he kept trying to get her to sit in a shower chair with a hole in the middle and kept pushing her into the chair. Resident #1 stated she asked CNA A to go behind the privacy curtain and CNA stated, No. This is my job, you want to wash your rosebud by yourself? Resident #1 stated that rosebud referred to her vagina. Resident #1 stated that CNA A kept forcing her to sit in the chair. CNA A put shampoo on her head and would not let her use her own shampoo. Resident #1 stated she unwrapped her Unna boots, (compression dressings made by wrapping layers of gauze around the leg and foot. It is often used to protect an ulcer or open wound. The compression of the dressing helps improve blood flow in your lower leg. Compression also helps decrease swelling and pain), and she begged CNA A to go behind the privacy screen again. Resident #1 stated, I felt like dirt. Resident #1 stated she had always showered by herself prior to this incident. Resident #1 stated she told CNA A you are hurting me. I'm humiliated please go behind the privacy screen. Resident #1 stated she kept repeating it and begged him to go behind the privacy screen, and CNA A did not go behind the screen. Resident #1 stated she did not feel comfortable in the shower chair and that it was slippery. Resident #1 stated CNA A stated, sit there, and stop acting like this. Resident #1 stated with all the commotion, no one came in to check on her. Resident #1 stated she had some bruises on her arms, but she got them while in the hospital, and said she had not seen any other bruises. Resident #1 stated that she was a bit disoriented when she woke up, but CNA A had startled her. I was confused when he kept asking if I peed myself at church. I don't know what he was talking about. Resident #1 said when CNA A brought her back to her room, he picked out some clothes for her to wear, and she told him she did not want to wear what he picked out, and he did not listen to her. Resident #1 stated, what really pissed me off was when we got back to my room, he took my wet towel and started mopping up the floor, like I had peed all over the place. It was a small spot. Resident #1 stated after she got dressed, the ADON came in her room, and said she wanted to talk to her while she was upset. Resident #1 stated the ADON was baby talking to her asking why are you mad, and why are your unna boots off? Are you upset because we care? Resident #1 stated the ADON told her we never told you that you could shower alone, and that there was not one resident in the facility that showers by themselves. Resident #1 stated she did not know why the ADON said that because she knew a lot of Residents that showered by themselves, and that she had showered by herself 3 times a week before this incident. Resident #1 stated that she asked the ADON to leave at that time, and the ADON replied, I still want to get to the bottom of why you are mad and why your unna boots are off. Resident #1 stated she told the ADON again she wanted her to leave, and the ADON stated she did not want to leave. Resident #1 stated she got up and went to the therapy department. Resident #1 stated she would take her unna boots off when she showered, a nurse would remove them, or she was capable of removing them herself. Resident #1 stated that one day, (did not know for sure what day it was), the Administrator came in and told her we need to talk. Resident #1 stated they went into her room and the Administrator said, CNA A is over enthusiastic and means well. Resident #1 stated the Administrator promised no one would go in the shower while she was in there. Resident #1 stated the Administrator apologized for the incident, and Resident #1 told her to keep CNA A away from me, I'm humiliated. Resident stated the next day at breakfast time, CNA A was standing by the food cart and said, she (meaning Resident #1) don't want anything to do with me, she can get the damn tray herself. Resident #1 stated she asked the Administrator if she was going to get to eat if no one was going to bring her tray. Resident #1 stated that after CNA A twisted her all around in the shower, she could not stand very well. Resident #1 stated the facility called an ambulance and she was taken to the hospital where she found out she had pneumonia and flu and spent 3 days in the hospital. Resident #1 stated that the left side still hurt after CNA A manhandled her from the front trying to pick her up and put her in the shower chair. Resident #1 stated yes I was fighting him as he was pulling my clothes off. I had a sports bra on which was hard to get off. Everything came off, I had no say in what came off. Resident began to cry stating, I hate a young male kid seeing this fat person, maybe he was used to it, but I wasn't. It was just too much. Resident #1 stated she had heard other residents talk about CNA A in the smoking area calling him an asshole. Resident #1 stated after she heard these comments she did not want to judge CNA A by what other people said, but wanted to make her own decision about him, and they were right. Resident #1 stated she had no issues before this incident and had no issues with him taking care of her. Resident #1 stated CNA A had also gotten into it (verbal altercation) with the cook in the dining room in front of other residents. Resident #1 stated CNA A had also made Resident #3 cry twice. Resident#1 stated she loved living in the facility except for this incident. During an interview on 6/4/24 at 12:40 p.m. Resident #2 was lying in her bed. Resident #2 stated she had received care from CNA A. Resident #2 stated CNA A was yelling and was rough when moving me in bed. Resident #2 stated she did not remember when this occurred, and that she did not report it to anyone. During an interview on 6/4/24 at 12:50 p.m. Resident #3 was sitting outside in the smoking area. Resident #3 stated she had lived in the facility since December 2, 2023. Resident #3 stated CNA A was obnoxious and acted like a bully. Resident #3 stated CNA A talked very loud and had hurt her feelings a couple of times and made her cry. Resident #3 stated he mocked her in the hall in front of another employee. Resident #3 stated CNA A was a smart ass and very unprofessional, and it had gotten out of hand. Resident #3 stated CNA A was not very nice and was a smart ass bully. Resident #3 stated it was so bad, she checked herself out of the facility for a week and went to her family member's house just to get away. Resident #3 stated she checked out about 3 weeks after she had come to the facility, and then came back. Resident #3 stated CNA A hurt her feelings by making fun of her needing her medications. Resident #3 stated there was a day CNA A told her never raise your voice like that to me ever again yelling at the top of his lungs in front of all the smokers. Resident #3 did not remember all the details of the event. Resident #3 stated she did not report this to anyone but should have. During an interview on 6/4/24 at 1:24 p.m. MA B sated he had worked in the facility since November 2023. CMA B stated that CNA A was a hard worker, but horse-played (engaging in activities not related to task at hand) lot. MA B sated CNA A was rude and arrogant to residents as well as other staff. MA B stated on the day of the incident with Resident #1, CNA A had called for help to stand her up. MA B stated Resident #1 had a look of disgust on her face like, I can't believe this is happening. Resident #1 told MA B that she was told by the facility that she could shower by herself. MA B stated Resident #1 had told CNA A to stand behind the privacy curtain, and he did not. Resident #1 was crying when she came out of the shower, and her face was red. Resident #1 stated CNA A had hurt her feelings. MA B stated, whatever happened in that shower room, CNA A never looked the same ., and could not make eye contact with Resident #1. MA B stated CNA A had no respect for his peers or for any woman. MA B stated CNA A had said things to other staff such as your mom is a whore, and you are a crack baby. MA B stated he told CNA A that he had victimized Resident #1. MA B stated that looking at Resident #1, he could see so many emotions in the lady's face. MA B stated he knew that CNA A had been banned from a lot of facilities around the area. MA B stated CNA A told him, I don't know if this job is for me. Every facility I go to I get fired. I don't know what I want to do. During an interview on 6/4/24 at 2:30 p.m. CNA E said he had worked with CNA A a few times. CNA E stated he personally had no problems with CNA A, but he had heard from some residents that CNA A was rough with them. CNA E stated the only resident he could remember was Resident #6. During an interview on 6/4/24 at 2:42 p.m. Resident #4 stated she had been in the facility for about a month. Resident #4 stated she had known CNA A for many years when he was working at another facility. Resident #4 stated she felt CNA A had caused a lot of problems in the facility. Resident #4 stated CNA A had inappropriately touched some ladies . Resident #4 stated Resident #1 was one of them. Resident #4 stated she could not remember any other names and that most of the ladies that he had touched had left the facility because of him. Resident #4 stated CNA A grabs the top and in the middle during showers. Resident #4 stated CNA A did not belong giving ladies showers, and Resident #1 was very upset. Resident #4 stated CNA A tried to do it with ladies because he can get away with it. CNA A has cursed at women and was very disrespectful. CNA A had never touched me as he knows better. Some ladies need help with their showers, but not by him. Resident #4 stated she showered by herself. During an interview on 6/6/24 at 9:10 a.m. LVN F stated she had worked in the facility for 3 years. LVN F stated she was not working the day of Resident #1's incident, but that Resident #1 had told her CNA A had startled her on the morning of the incident waking her up, and that CNA A told her she had to go take a shower and she told him no, as she tried to keep her shirt down as he was pulling it off and hurt her ribs. LVN F stated CNA A had a tendency to blow up verbally and slam doors and had no problems getting in your face . During an interview on 6/6/24 at 10:55 a.m. Resident #5 stated that she showered by herself. Resident #5 stated CNA A acted like a child. Resident #5 stated she had never witnessed any abuse with him but wouldn't doubt it. Resident #5 stated CNA A was mean to other staff bullying them, and his mouth was always running and he talked very loud. Resident #5 stated she got mad at CNA A because every time she would be walking around in the facility, CNA A kept saying we're going to find you a boyfriend. He would say how bout that one, or that one, and kept pointing at different men. Resident #5 stated she asked him to please not do that as I was embarrassed. During an interview on 6/6/24 at 10:15 a.m. Rehab employee G stated CNA A did not have a good bedside manner. CNA A would joke a lot and did not realize it could hurt feelings. Rehab employee G stated she felt CNA A meant well and was always in a joking mood. Rehab employee G stated she had become close to Resident #1 and helped her get into the facility. Rehab employee G stated she told Resident #1 that therapy would always be a safe place for her to come to if she needed to. Rehab employee G stated Resident #1 told her CNA A had been rough in the shower, and that she was leaning forward in her chair and CNA A grabbed her around the chest area to sit her up, as he was afraid she was going to fall. Rehab employee G stated Resident #1 told her that CNA A put his arms across her chest to sit her up and hurt her ribs when pulling her back in the chair. Rehab employee G stated Resident #1 talked to her the day of the incident. Rehab employee G stated Resident #1 was hysterical when she came to the department, to the point they closed the door for her privacy. Rehab employee G stated Resident #1 was crying. Rehab employee G stated that Resident #1 stayed in the department for about 2 hours. Rehab employee G stated they let her lay down and gave her a heating pad for her back and applied Bio freeze to her shoulders. Rehab employee G stated the day after the incident Resident #1 had told her that CNA A would not bring her breakfast tray to her, and that she could get her own damn tray. Rehab employee G stated she had heard hearsay that CNA A had touched women prior to coming here, but it was just hearsay and she had never witnessed it. During an interview on 6/6/24 at 10:48 a.m. CNA H stated she had worked in the facility since 2012. CNA H said she would sometimes pick up a shift on CNA A's rotation but did not like to work with him. CNA H stated CNA A was different but could not explain how. CNA H stated she had never witnessed any abuse by CNA A. CNA H stated Resident #1 had always showered by herself. CNA H stated Resident #1 told her CNA A roughed her up and that she did not want him in the shower with her, and that he kept pulling her shirt off and pulled her sports bra down. During an interview on 6/6/24 at 11:50 a.m. CNA K stated she had not worked with CNA A very often but that he was playful, arrogant, rude to coworkers and a smart butt. During an interview on 6/6/24 at 12:20 p.m. the DON stated she had worked in the facility since April 1 of this year. DON stated Resident #1 was under the impression that she could shower alone, and due to Resident #1's state of mind, all showers had to be supervised. DON stated Resident #1 had a fall on 5/31/24 and complained of rib pain the next day and did not want x-rays done. DON stated that when Resident #1 was in the shower with CNA A , when Resident #1 said stop, CNA A should have stopped. DON stated the Ombudsman came to visit that day and was told of the situation. During an interview on 6/6/24 at 1:00 p.m. the Administrator stated that when Resident #1 said stop, CNA A should have stopped. Administrator stated she did grievances and had not received any from any staff member regarding CNA A. Administrator stated she did not have a copy of the provider investigator report that was submitted with all training documentation . During an interview on 6/6/24 at 1:00 p.m. ADON stated she talked with Resident #1 the day of her incident with CNA A. ADON stated Resident #1 was crying and stating, I'm humiliated. ADON told Resident #1 she could not take a shower by herself. ADON stated Resident #1 did not want to speak with her and wanted her out of her room. ADON stated every resident is to have assistance in the shower, and she had instructed the staff about it. ADON said she spoke to CNA A after the incident and wrote up what had happened. DON stated CNA A said Resident #1 felt humiliated that he had to bathe her, and CNA A told Resident #1 that for her safety he needed to be there. ADON stated that when Resident #1 said stop, he should have stopped. ADON stated she got a statement from CNA A on 5/30/24 and CNA A was sent home during the investigation and was terminated. ADON said she had not received any grievances from staff regarding CNA A. During an interview on 6/6/24 at 2:11 p.m. Resident #6 stated she had lived in the facility for 8 years. Resident #6 stated CNA A had provided care to her and was rough with her when helping her out of the bed. Resident #6 stated she told CNA A it hurt, and he said, so what. Resident #6 said she did not tell anyone, and when asked why Resident #6 stated, I don't know. Resident #6 stated CNA A had helped her with her showers, and never had a problem. Resident #6 stated she had heard CNA A say mean and hateful things. Resident #6 stated she did not remember who he was talking to at the time. On 6/6/24 at 2:21 p.m. and 4:11 p.m. two attempts were made to contact LVN L. No response was received to voicemail left. During an interview on 6/10/24 at 9:45 a.m. the DON stated she was working as a floor nurse on the day of Resident #1's incident on 5/29/24. DON stated she had talked with Resident #1 after the incident and said Resident #1 apologized for being so upset. Resident #1 stated she did not want CNA A in the shower with her. CNA A was out doing a transport at that time but was suspended as soon as he returned to the facility. DON stated she had not had any staff or resident come to her with any concerns with CNA A. DON stated she was not aware of any write-ups on CNA A since she had started working in the facility in April of this year. During an interview on 6/10/24 at 9:56 a.m. the ADON stated that on 5/29/24, she had gone to talk with Resident #1 after the incident. ADON stated Resident #1 was crying and would not talk with her. ADON stated she had looked at Resident #1's ribs, and there were no bruises. ADON stated the DON told her that she had sent CNA A to take Resident #1 to the shower after an incontinent episode. ADON stated Resident #1 was weak and needed assistance. ADON was asked if there were any specific documents she could provide regarding what was covered in the abuse trainings that were done or any documents that talked about what was discussed. ADON stated the Abuse/Neglect in-service was generic and covered the abuse policy. During a follow up interview on 6/10/24 at 10:16 a.m. Resident #1, stated that on the date of the incident with CNA A, she did not request that a female showered her, she just told CNA A you are not going into the shower with me. You are a kid and a male. Resident #1 stated she thought that was enough. Resident #1 stated CNA A stated, you're not yourself, you don't know what you are saying. Resident #1 stated she was so upset she did not remember if CNA A had helped wash her, but he must have washed some parts because he asked if I wanted to wash my own rosebud. Resident #1 stated she felt CNA A forced her to have that shower. Resident #1 stated she felt at peace now that CNA A was gone, and won't be doing this to anyone else, but I am not at peace after what happened and why it happened. Resident #1 stated, he made me feel so disgraced, and the more I think about it the madder I get. Resident #1 stated she did not feel bad that CNA A got fired. Resident #1 stated, at the time of the incident I kept thinking why isn't there a female in here. I was so busy thinking what is happening and why, I was not able to take the next step of getting him out of the shower. Everything happened so fast, and I was worried about getting covered up and getting him out. I told CNA A to stop and get out, over and over. Resident #1 stated she had chronic back pain and CNA A kept twisting and pulling under her arms and she thought he had broken her ribs which he didn't. Resident #1 stated CNA A lifted her from her rollator walker. (rollators have wheels on all legs, making them easier to push without lifting) to a shower chair, and she had always stood to take her showers. Resident #1 stated today was the first day I could take a shower. I was afraid to go into the shower since the incident. Resident #1 stated that she was a logical person, and knew it would not happen again, but it's kind of like PTSD . Resident #1 stated that she hated that she was still thinking about this incident and did not want to keep bringing it up. Resident #1 stated she felt that she can eventually put it out of her mind, and that it will just take a while. Resident #1 [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to immediately consult with the physician of a significant change in the resident's physical, mental, psychosocial status; or a need to alter treatment significantly for 1 (Resident #186) of 1 resident reviewed for notification of change. The facility failed to immediately consult with the resident's physician when Resident #186 had a significant decline in condition as evidenced by pupil changes and behavior changes, which resulted in his death. An Immediate Jeopardy (IJ) situation was identified on 07/12/23 at 11:15 am. The IJ template was provided to the facility on [DATE] at 11:30 am. While the IJ was removed on 07/13/23, the facility remained out of compliance at a severity level of actual harm with a scope of isolated due to the facility's need to monitor and evaluate the effectiveness of their plan of removal and corrective actions. This failure could place residents at the risk of not receiving appropriate medical interventions timely and effectively, which could result in severe illness, hospitalization or even death. Findings include: Record review of facility face sheet dated 7/12/23 for Resident #186 indicated that he was a [AGE] year-old male admitted to the facility on [DATE] with subsequent readmission on [DATE] with diagnoses including: right sided hemiplegia and hemiparesis following cerebral infarction (right sided weakness/paralysis due to a stroke), aphasia (problems speaking), dysphagia (trouble swallowing), and type 2 diabetes. Record review of a comprehensive MDS dated [DATE] for Resident #186 indicated that BIMS was not done due to resident being rarely/never understood. Also indicated that he required supervision of 1 person for transfers, and extensive assist of 1 person for toileting. Record review of physician orders dated 7/12/23 for Resident #186 indicated that resident was receiving Aspirin 81mg 1 tablet 1 time per day and Clopidogrel Bisulfate 75mg 1 tablet 1 time per day (medications that can thin the blood causing easy bleeding and increasing risk for internal bleeding). Record review of electronic medical record for Resident #186 indicated that he was a DNR and had been receiving hospice services since 11/2/2022 for diagnosis of CVA (stroke). Record review of incident report dated 1/16/23 for Resident #186 indicated that he had suffered an unwitnessed fall resulting in large gash above right eye and swelling and bruising to right eye. Record review of a care plan, undated, for Resident #186 indicated he was at risk for bleeding and injury associated with daily use of anti-platelet medications (Clopidogrel). Care plan also indicated that he had an actual fall on1/16/23 with injury and interventions included to monitor, document, and report to MD any signs/symptoms of pain, such as bruises, change in mental status, or agitation. Record review of a facility 24-hour report dated 7/12/23 for the dates of 1/16/23 through 1/17/23 indicated that resident had fallen on 1/16/23 and neurological assessments were initiated immediately after fall. 24-hour report indicated that Resident #186's neurological assessment on 1/16/23 at 5:41 pm his CGS was 15 indicating mild head injury. At 6:12 pm on 1/16/23, his score was a 10, indicating a moderate head injury. There was no documentation of physician notification regarding this decline. Record review of hospital paperwork in Resident #186's electronic medical record indicated that Resident #186 was admitted to ICU on 1/17/23 at 5:40 pm. Record review of progress note dated 1/19/23 indicated that Resident #186 readmitted to facility with diagnoses: right frontal intraparenchymal hemorrhage (a bleed that occurs within the brain parenchyma, the functional tissue in the brain); right temporal horn IVH (a bleeding into the brain's ventricular system, where the cerebrospinal fluid is produced and circulates through towards the subarachnoid space. It can result from physical trauma); bilateral subdural hematomas (a dangerous condition where blood collects under the skull, putting pressure on the brain and causing damage or death); left temporal horn IVH (a bleeding into the brain's ventricular system, where the cerebrospinal fluid is produced and circulates through towards the subarachnoid space. It can result from physical trauma). Record review of a progress note dated 1/21/23 for Resident #186 indicated that he passed away on 1/21/23 at 9:23 am. During an interview with DON on 7/11/23 at 4:00 pm, she said that she was not employed by this facility at that time but that she was employed by hospice services on 1/16/23. She said that she had started as the facility DON in February 2023. She said that she had come to the facility to assess Resident #186 on 1/16/23 and she noticed a change from his baseline, and he was unresponsive. She said that she was unable to reach a family member to see what they wanted to do, so she had him sent out to the emergency room. She said in cases where she could not reach family members regarding hospice residents, she would use nursing judgement and sent out for evaluation. She said that any resident that suffered a fall with possible head injury should be sent out for evaluation. During an interview with Resident #186's family member on 7/11/23 at 4:34 pm, she said that the facility did notify her of the fall on 1/16/23 and that she had told them to send him to the ER if they thought that he needed to go. She said that she was under the impression that the nurse would use her judgement to decide if he needed to go. She said that if she had known the severity of the situation, she would have insisted they send him out. She said that once he was in the ICU at the hospital, the doctors there told her that he had five brain bleeds and that there was nothing that they could do. She said that before the fall, he had been active and alert, he just was unable to speak due to a stroke. She said that she had him sent back to the nursing facility because the hospital said that they could not do anything for the bleeding on his brain. During an interview with physician office staff on 7/12/23 at 9:00 am, surveyor was informed the physician was not currently in office, but staff could take a message. Message left with return phone number for physician to call regarding incident on 1/16/23. No return call received from physician before exit from facility. During an interview with LVN L on 7/12/23 at 10:18 am, she said she had worked for the facility from November of 2022 to March of 2023. She said she had worked days in the unit and was working the day of the fall. She said she had been at the nurse's station and was notified by a CNA of the resident's fall. She said she did an assessment and took vital signs on Resident #186. She said around 3:30 pm, he was found laying on the floor and had been trying to get up on his own without assistance. She said that he fell in his room while ambulating unassisted, and he pointed to the bathroom to indicate he was trying to go to the bathroom. She said he had a gash on his forehead on the right side. She said she called the hospice nurse, and the DON at the time. She said the DON at that time came back to the unit and assessed the resident, cleaned his wound, and put steri-strips in place. She said he was not sent to the hospital. She said she was monitoring him every 30 minutes and the wound was still bleeding. She said she notified hospice again about the bleeding. She said she was doing neurological checks, checking pupils with her penlight, and checking his grips. She said his grips were strong. She said his pupils were not dilated; they were normal at 2mm. She said he was moving around a lot, acting restless, moaning, and groaning. She said she worked until 6 pm that evening. She said she had called and spoke to his wife and explained about the fall. She said their protocol was to notify hospice regarding incidents with any hospice residents and hospice would instruct on what to do. She said there were no in services done regarding the incident. During an interview with LVN C on 7/12/23 at 3:00 pm, she said she had called hospice the night that Resident #186 fell because she had wanted to send him to the emergency room because the wound continued to bleed, but hospice said that they were against sending him out unless the wife wanted to send him out. She said she spoke to the sister-in-law and notified her of his condition regarding the contusion and that it continued to bleed, but she said to just monitor him for now. She said she did not notify the physician because it was their policy to notify hospice for hospice residents. Record review of a facility policy titled Falls - Clinical Protocol dated 2001, with revision date of March, 2018, indicated .the nurse shall assess and document/report the following: .recent injury, especially fracture or head injury .neurological status . and .the physician will identify medical conditions .and the risk for significant complications of falls (for example .increased risk of bleeding in someone taking an anticoagulant) . and .The staff, along with the physician's guidance, will follow up on any fall with associated injury until the resident is stable and delayed complications such as .subdural hematoma have been ruled out or resolved . Record review of a facility policy titled Change in a Resident's Condition or Status dated 2001, with revision date of February 2021 indicated .the nurse will notify the resident's attending physician or physician on call when there has been a(an): .significant change in the resident's physical/emotional/mental condition . This was determined to be an Immediate Jeopardy (IJ) on 07/12/23 at 11:15 am. The Administrator was notified. The Administrator was provided with the IJ template on 07/12/23 at 11:30 am. The facility's plan of removal was accepted on 7/13/23 at 9:05 am and included: 1) All nursing staff will be in serviced over physician notification regarding change in assessment per policy and procedure. Inservice to include: 2) Notification-Change of Condition - in service completed by RDC (regional director of clinical and/or nursing administration designee once trained. All abnormal findings including change of vital signs, change of mobility, change of mental status, and/or decline in ADL's must be reported to the Medical Director (regardless of hospice physician notification), Director of Nursing, Assistant Director of Nursing, Administrator, and Responsible Representative/Emergency Contact immediately. Notification to physician regarding fall with or without injury. Notification to physician regarding blood thinners as applicable on active orders or medications with anticoagulant similarities on active orders. To assess baseline, the Charge Nurse may utilize previous assessment and/or the comprehensive care plan in Point Click Care. Progress notes must reflect the changes observed, interventions, and notification. Neuro Checks - RDC regional director of clinical and/or nursing administration designee once trained. Post fall neuros must be conducted for 30 hours. ? Q 15 minutes for a duration of 1 hour ? Q 30 minutes for a duration of 1 hour ? Q 1 hour for a duration of 4 hours ? Q 4 hours for a duration of 24 hours All neuros MUST be completed for falls with head injury and unwitnessed fall. Abnormal findings will be reported to Medical Director (regardless of hospice physician notification), Director of Nursing, and Assistant Director of Nursing; and will be extended for an additional 24 hours to be monitored Q 4 hours (unless otherwise directed by physician). Review & Reporting - -in-service completed by RDC (regional director of clinical) on 8/12/23. The Administrator and DON, along with IDT will review each incident in the Stand Up meeting to determine possible cause, interventions, documentation, follow-up, and reporting status according to HHSC reporting guidelines. All residents have the potential to be affected by this alleged deficient practice. The Medical Director was initially made aware of the immediate jeopardy 7/12/23 and has been involved in the development of the plan to removal. These conversations are considered a part of the QA process. To monitor for compliance the Administrator and/or designee will review all Accident/Incident reports and follow up accordingly. The IDT will review and assess the Accident/Incident to determine what further actions if needed are necessary. Members of this meeting are to include the Administrator, Director of Nursing, Assistant Director of Nursing, MDS Coordinator, Social Worker, and Therapy Representative. In addition, designated members of the corporate staff will review all Accident/Incidents daily for 6 months and reevaluate the need for continued review. Any negative findings will be forwarded to the Administrator and the QA committee. This plan was initially implemented 7/12/23 and will be monitored through completion by corporate and regional staff. Plan of Removal completion date is 7/12/23 by 8:00 pm with continued follow up for oncoming staff. Verification of POR: Verified MDS and Corporate MDS completed a review of all residents fall assessments completed in the last quarter for current interventions and effectiveness with completion date 7/12/23 at 8:00 pm Staff interviews 7/13/23 10:45 am-2:50 pm completed with DON, ADON, and RN F were able to verbalize the Fall/Interventions/Documentation policy including neuro checks, documentation of incident, notification to physician, specific interventions, and monitoring or resident condition; Resident assessment and fall documentation policy and procedure; Neuro checks policy including must be conducted for 30 hours, Q 15 minutes for 1 hour, Q 30 minutes for 1 hour, Q 1 hour for 4 hours, and Q 4 hours for 24 hours, abnormal findings will be reported to physician (regardless of hospice notification), DON, ADON, and will be monitored for an extended 24 hours; Notification of Change in residents condition to be reported to physician; notification to physician regarding blood thinners/anticoagulants as applicable. Admin, DON, ADON verbalized review and reporting procedures for daily stand-up meetings. Verified Medical director was notified of IJ and participated in POR. 7/12/23 QA meeting held with medical director and IDT members. On 7/13/23 at 3:35 pm, the facility was informed the IJ was removed. However, the facility remained out of compliance at a severity level of actual harm that is not immediate with a scope of isolated due to the facility's need to monitor and evaluate the effectiveness of their plan of removal and corrective actions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that residents 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 1 resident (Resident #186), reviewed for quality of care. The facility failed to promptly identify and intervene for an acute change in Resident #186 following a fall resulting in him being transported to the hospital with bilateral subdural hematomas, which resulted in his death. An Immediate Jeopardy (IJ) situation was identified on 07/12/23 at 11:15 am. The IJ template was provided to the facility on [DATE] at 11:30 am. While the IJ was removed on 07/13/23, the facility remained out of compliance at a severity level of actual harm that is not immediate with a scope of isolated due to the facility's need to monitor and evaluate the effectiveness of their plan of removal and corrective actions. This failure could place residents at the risk of not receiving appropriate medical interventions timely and effectively, which could result in severe illness, hospitalization or even death. Findings include: Record review of facility face sheet dated 7/12/23 for Resident #186 indicated that he was a [AGE] year-old male admitted to the facility on [DATE] with subsequent readmission on [DATE] with diagnoses including: right sided hemiplegia and hemiparesis following cerebral infarction (right sided weakness/paralysis due to a stroke), aphasia (problems speaking), dysphagia (trouble swallowing), and type 2 diabetes. Record review of a comprehensive MDS dated [DATE] for Resident #186 indicated that BIMS was not done due to resident being rarely/never understood. Also indicated that he required supervision of 1 person for transfers, and extensive assist of 1 person for toileting. Record review of physician orders dated 7/12/23 for Resident #186 indicated that resident was receiving Aspirin 81mg 1 tablet 1 time per day and Clopidogrel Bisulfate 75mg 1 tablet 1 time per day (medications that can thin the blood causing easy bleeding and increasing risk for internal bleeding). Record review of electronic medical record for Resident #186 indicated that he was a DNR and had been receiving hospice services since 11/2/2022 for diagnosis of CVA (stroke). Record review of incident report dated 1/16/23 for Resident #186 indicated that he had suffered an unwitnessed fall resulting in large gash above right eye and swelling and bruising to right eye. Record review of a care plan, undated, for Resident #186 indicated he was at risk for bleeding and injury associated with daily use of anti-platelet (blood-thinning) medications (Clopidogrel). Record review of a facility 24-hour report dated 7/12/23 for the dates of 1/16/23 through 1/17/23 indicated that resident had fallen on 1/16/23 and neurological assessments were initiated immediately after fall. 24-hour report indicated that Resident #186's neurological assessment on 1/16/23 at 5:41 pm his CGS was 15 indicating mild head injury. At 6:12 pm on 1/16/23, his score was a 10, indicating a moderate head injury. There was no documentation of physician notification regarding this decline. Resident remained in facility and received no interventions. Record review of hospital paperwork in Resident #186's electronic medical record indicated that Resident #186 was admitted to ICU on 1/17/23 at 5:40 pm. Record review of progress note dated 1/19/23 indicated that resident readmitted to facility with diagnoses: right frontal intraparenchymal hemorrhage (a bleed that occurs within the brain parenchyma, the functional tissue in the brain); right temporal horn IVH (a bleeding into the brain's ventricular system, where the cerebrospinal fluid is produced and circulates through towards the subarachnoid space. It can result from physical trauma); bilateral subdural hematomas (a dangerous condition where blood collects under the skull, putting pressure on the brain and causing damage or death); left temporal horn IVH (a bleeding into the brain's ventricular system, where the cerebrospinal fluid is produced and circulates through towards the subarachnoid space. It can result from physical trauma). Record review of a progress note dated 1/21/23 for Resident #186 indicated that he passed away on 1/21/23 at 9:23 am. During an interview with DON on 7/11/23 at 4:00 pm, she said that she was not employed by this facility at that time but that she was employed by hospice services on 1/16/23. She said she had started as the facility DON in February 2023. She said she had come to the facility to assess Resident #186 on 1/16/23 and she noticed a change from his baseline, and he was unresponsive. She said she was unable to reach a family member to see what they wanted to do, so she had him sent out to the emergency room. She said in cases where she could not reach family members regarding hospice residents, she would use nursing judgement and sent out for evaluation. She said that any resident that suffered a fall with possible head injury should be sent out for evaluation. During an interview with Resident #186's family member on 7/11/23 at 4:34 pm, she said that the facility did notify her of the fall on 1/16/23 and that she had told them to send him to the ER if they thought he needed to go. She said she was under the impression that the nurse would use her judgement to decide if he needed to go. She said if she had known the severity of the situation, she would have insisted they send him out. She said once he was in the ICU at the hospital, the doctors there told her that he had five brain bleeds and there was nothing they could do. She said before the fall, he had been active and alert, he just was unable to speak due to a stroke. She said she had him sent back to the nursing facility because the hospital said they could not do anything for the bleeding on his brain. During an interview with physician office staff on 7/12/23 at 9:00 am, surveyor was informed that physician was not currently in office, but staff could take a message. Message left with return phone number for physician to call regarding incident on 1/16/23. No return call received from physician before exit from facility. During an interview with LVN L on 7/12/23 at 10:18 am, she said she had worked for the facility from November of 2022 to March of 2023. She said she had worked days in the unit and was working the day of the fall. She said she had been at the nurse's station and was notified by a CNA of the resident's fall. She said she did an assessment and took vital signs on Resident #186. She said around 3:30 pm, he was found laying on the floor and had been trying to get up on his own without assistance. She said that he fell in his room while ambulating unassisted, and he pointed to the bathroom to indicate he was trying to go to the bathroom. She said he had a gash on his forehead on the right side. She said she called the hospice nurse, and the DON at the time. She said the DON at that time came back to the unit and assessed the resident, cleaned his wound, and put steri-strips in place. She said he was not sent to the hospital. She said she was monitoring him every 30 minutes and the wound was still bleeding. She said she notified hospice again about the bleeding. She said she was doing neurological checks, checking pupils with her penlight, and checking his grips. She said his grips were strong. She said his pupils were not dilated; they were normal at 2mm. She said he was moving around a lot, acting restless, moaning, and groaning. She said she worked until 6 pm that evening. She said she had called and spoke to his wife and explained about the fall. She said their protocol was to notify hospice regarding incidents with any hospice residents and hospice would instruct on what to do. She said there were no in services done regarding the incident. During an interview with LVN C on 7/12/23 at 3:00 pm, she said she had called the hospice the night Resident #186 fell because she had wanted to send him to the emergency room due to the wound continuing to bleed, but hospice said that they were against sending him out unless the wife wanted to send him out. She said she spoke to a family member and notified them of his condition regarding the contusion and that it continued to bleed, but she said to just monitor him for now. She said she did not notify the physician because it was their policy to just notify hospice for hospice residents. Record review of a facility policy titled Falls - Clinical Protocol dated 2001, with revision date of March, 2018, indicated .the nurse shall assess and document/report the following: .recent injury, especially fracture or head injury .neurological status . and .the physician will identify medical conditions .and the risk for significant complications of falls (for example .increased risk of bleeding in someone taking an anticoagulant) . and .The staff, along with the physician's guidance, will follow up on any fall with associated injury until the resident is stable and delayed complications such as .subdural hematoma have been ruled out or resolved . Record review of a facility policy titled Change in a Resident's Condition or Status dated 2001, with revision date of February 2021 indicated .the nurse will notify the resident's attending physician or physician on call when there has been a(an): .need to transfer the resident to a hospital/treatment center . This was determined to be an Immediate Jeopardy (IJ) on 07/12/23 at 11:15 am. The Administrator was notified. The Administrator was provided with the IJ template on 07/12/23 at 11:30 am. On 7/13/23 at 3:35 pm, the facility was informed the IJ was removed. However, the facility remained out of compliance at a severity level of actual harm with a scope of isolated due to the facility's need to monitor and evaluate the effectiveness of their plan of removal and corrective actions. The facility's plan of removal was accepted on 7/13/23 at 9:05 am and included: 1) MDS and Corporate MDS completed a review all residents fall assessments completed in the last quarter for current interventions and effectiveness with completion date 7/12/23 at 8:00 pm. 2) The in-services are as follows completed by RDC (regional director of clinical) and/or administrative nursing designee once trained. Falls/Interventions/Documentation Neuro checks must follow any unwitnessed fall or evidence of head trauma. Documentation of incident must be charted in the incident report, and must contain investigation of cause of fall, interventions to prevent further falls, assessment summary including injuries, vitals, and initiation of neuros indicated. Notification to physician regarding fall with or without injury. Notification to physician regarding blood thinners as applicable on active orders or medications with anticoagulant similarities on active orders. Specific interventions will be determined by the Charge Nurse and IDT team. These interventions will be reviewed, and the Care plan will be updated to reflect changes by MDS Nurse. The Administrator and IDT will review each fall, possible cause, and interventions for effectiveness-and change accordingly if not effectual. Nurse to monitor and document resident response to interventions on the Incident Report, and the MDS Nurse will update the Care Plan. Changes to be reported to Medical Director, Director of Nursing, Assistant Director of Nursing, Administrator, and Responsible Representative/Emergency Contact. Intervention review occurs daily in the morning Stand Up Meeting; and weekly in Standards of Care (SOC) with IDT. Changes will be noted in the progress note by the nurse; as well as the Stands of Care document. Residents at risk for fall will be identified utilizing the Fall Risk Assessment tool in Point Click Care (PCC) that is completed after any fall occurs, and quarterly. Resident Assessment - in service completed by RDC (regional director of clinical) and/or nursing administration once trained After all incidents the licensed nurse will completely fill out the incident report to include all portions of areas completed: o Nursing Description o Resident Description if applicable o Description of immediate action taken o Injuries observed o Pain Assessment o Mental status, o Mobility status, o Environmental factors, o Predisposing physiological factors, o Witness statements if applicable, o Agencies and people notified o Fall nurses note, o Fall risk assessment, o Neuros if applicable, o Administration of blood thinners review o Complete set of Vital Signs in the fall nurse note o Administer first aid if applicable. Change of Condition All abnormal findings including change of vital signs, change of mobility, change of mental status, and/or decline in ADL's must be reported to the Medical Director, Director of Nursing, Assistant Director of Nursing, Administrator, and Responsible Representative/Emergency Contact immediately. To assess baseline, the Charge Nurse may utilize previous assessment and/or the comprehensive care plan in Point Click Care. Progress notes must reflect the changes observed, interventions, and notification. Neuro Checks Post fall neuros must be conducted for 30 hours. ? Q 15 minutes for a duration of 1 hour ? Q 30 minutes for a duration of 1 hour ? Q 1 hour for a duration of 4 hours ? Q 4 hours for a duration of 24 hours All neuros MUST be completed for falls with head injury and unwitnessed fall. Abnormal findings will be reported to Medical Director (regardless of hospice physician notification), Director of Nursing, and Assistant Director of Nursing; and will be extended for an additional 24 hours to be monitored Q 4 hours (unless otherwise directed by physician). Review & Reporting-in-service completed by RDC (regional director of clinical) on 8/12/23. The Administrator and DON, along with IDT will review each incident in the Stand-Up meeting to determine possible cause, interventions, documentation, follow-up, and reporting status according to HHSC reporting guidelines. All residents have the potential to be affected by this alleged deficient practice. The Medical Director was initially made aware of the immediate jeopardy 7/12/23 and has been involved in the development of the plan to removal. These conversations are considered a part of the QA process. To monitor for compliance the Administrator and/or designee will review all Accident/Incident reports and follow up accordingly. The IDT will review and assess the Accident/Incident to determine what further actions if needed are necessary. Members of this meeting are to include the Administrator, Director of Nursing, Assistant Director of Nursing, MDS Coordinator, Social Worker, and Therapy Representative. In addition, designated members of the corporate staff will review all Accident/Incidents daily for 6 months and reevaluate the need for continued review. Any negative findings will be forwarded to the Administrator and the QA committee. This plan was initially implemented 7/12/23 and will be monitored through completion by corporate and regional staff. Plan of Removal completion date is 7/12/23 8:00 pm with continued follow up for oncoming staff. Verification of POR: Verified MDS and Corporate MDS completed a review of all residents fall assessments completed in the last quarter for current interventions and effectiveness with completion date 7/12/23 at 8:00 pm Staff interviews 7/13/23 10:45 am-2:50 pm completed with DON, ADON, and RN F were able to verbalize the Fall/Interventions/Documentation policy including neuro checks, documentation of incident, notification to physician, specific interventions, and monitoring or resident condition; Resident assessment and fall documentation policy and procedure; Neuro checks policy including must be conducted for 30 hours, Q 15 minutes for 1 hour, Q 30 minutes for 1 hour, Q 1 hour for 4 hours, and Q 4 hours for 24 hours, abnormal findings will be reported to physician (regardless of hospice notification), DON, ADON, and will be monitored for an extended 24 hours; Notification of Change in residents condition to be reported to physician; notification to physician regarding blood thinners/anticoagulants as applicable. Admin, DON, ADON verbalized review and reporting procedures for daily stand-up meetings. Verified Medical director was notified of IJ and participated in POR. 7/12/23 QA meeting held with medical director and IDT members. On 7/13/23 at 3:35 pm, the facility was informed the IJ was removed. However, the facility remained out of compliance at a severity level of actual harm that is not immediate with a scope of isolated due to the facility's need to monitor and evaluate the effectiveness of their plan of removal and corrective actions.

**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 4 of 10 residents (Resident #12, Resident #184, Resident #185, and Resident #186) reviewed for Resident Abuse. 1. The facility failed to protect Resident #185 from abuse by Resident #2. On 11/22/2022 Resident #185 wandered by Resident #2's door on the secured unit, and Resident #2 grabbed Resident #185's arm and struck her in the upper chest. 2. The facility failed to protect Resident #185 from abuse by Resident #2. On 12/05/2022 Resident #185 wandered into Resident #2's room on the secured unit, and Resident #2 punched Resident #185 in the face causing an abrasion to her left check . 3. The facility failed to protect Resident #186 from abuse by Resident #2. On 01/15/2023 Resident #2 grabbed and yanked Resident #186's arm backwards. 4. The facility failed to protect Resident # 184 from abuse by Resident #2. On 03/04/2023 Resident #2 hit Resident #184 with an open hand on the left side of his face . 5. The facility failed to protect Resident # 12 from abuse by Resident #2. On 03/09/2023 Resident #12 wandered by Resident #2's door on the secured unit. and Resident #2 grabbed Resident #12's right arm pulling her to the floor. 6. The facility failed to protect Resident # 184 from abuse by Resident #2. On 04/27/2023 Resident #184 wandered into Resident #2's room on the secured unit and Resident #2 hit Resident #184 in the mouth . An IJ (immediate jeopardy) was identified on 07/11/2023 at 4:13 PM. The IJ template was provided to the facility on [DATE] at 4:13 PM. While the IJ was removed on 07/13/2023 at 3:35 PM, the facility remained out of compliance at a severity level of actual harm that is not immediate with a scope of pattern due to the facility's need to monitor and evaluate the effectiveness of their plan of removal and corrective actions. These failures placed all residents at risk of physical harm, mental anguish, emotional distress, or death. Findings included: 1. Record review of facility face sheet dated 7/11/2023 indicated Resident #2 was a [AGE] year-old male admitted to the facility on [DATE] with a primary diagnosis of bipolar disorder (mood disorder), psychosis (mental disorder), and anxiety. Record review of comprehensive MDS dated [DATE] indicated Resident #2 had a BIMS of 99 indicating Resident #2 was unable to complete interview. Section C for cognition indicated Resident #2 had disorganized thinking. Section E for behaviors indicated Resident #2 had verbal behaviors directed toward others and resident had wandered. Record review of care plan dated 05/08/2023 indicated Resident #2 required psychotropic medications for diagnosis of behavior management, bipolar disorder, and psychosis. Resident #2 had impaired cognitive function and dementia or impaired thought processes related to dementia and psychosis and required the secured unit due to risk of elopement and wandering. Resident #2 had physical behaviors towards residents and staff with interventions added on 03/04/2023 to separate from resident and redirect to room, 3/09/2023 Seroquel increased, and 4/27/2023 resident #2 was sent to a Behavioral Hospital for evaluation and treatment. Record review of physician orders dated 7/11/2023 indicated Resident #2 had order for behavior monitoring, lorazepam 1 mg by mouth as needed for anxiety and Seroquel 100mg by mouth at bedtime. Record review of facility incident report dated 11/23/2022 revealed a resident-to-resident altercation that occurred between Resident # 2 and Resident #185. Resident #185 wandered by Resident #2's door on the secured unit, and Resident #2 grabbed Resident #185's arm and struck her in the upper chest. Resident #185 was removed from area, the responsible parties, physician, and administrator was notified. Record review of facility progress note dated 11/22/2023 at 6:18 pm stated LVN P was called to Resident #2's room by the aide working on the unit and the aide reported Resident #185 was walking by Resident #2's room when he grabbed Resident #185's arm and hit her in the chest before the aide was able to intervene. The aide separated the resident's and nurse notified the administrator. The administrator said an incident report was not needed due to resident's mental status. Record review of a facility progress note dated 12/05/2022 at 3:14 pm LVN L stated Resident #185 entered Resident #2's room, stooped down towards his face and Resident#2 punched Resident #185 on the left side of the face. Resident #185 was redirected and continue to monitor for behaviors. Record review of incident report log from November 2022 to present date and no incident recorded on 12/05/2022 regarding incident between Resident #2 and Resident #185. Record review of incident report dated 01/15/2023 stated Resident #2 rolled up to Resident #186 at the dining table and Resident #2 pulled, twisted, and yanked Resident #186's right arm. CNA A attempted to separate the residents and Resident #2 punched CNA A in the jaw. Administrator and physician were notified. Record review facility progress note dated 01/15/2023 at 11:33 am LVN P stated upon entering the unit, was notified Resident #2 had attacked Resident #186 and CNA A. Record review of incident report dated 03/04/2023 stated Resident #2 hit Resident#184 with an open hand on the left side of the face. Residents were separated and head to toe assessment completed. DON, physician, and families notified. Record review of progress note dated 03/05/2023 at 2:54 am stated LVN C was notified by RA assigned to the unit; Resident #2 had hit Resident #184 with an open hand to the left side of the face when Resident #184 had gotten to close to Resident #2. RA was advised to do frequent monitoring and hallway checks. Record review of incident report dated 03/09/2023 stated Resident #2 grabbed Resident #12 by the right arm and pulled her to the floor in the hallway. Head to toe assessment complete, physician, DON, and families notified. Record review of progress note dated 03/09/2023 at 4:36 am stated LVN C was notified by RA assigned to the unit Resident #12 was on the floor. RA reported that Resident #2 was sitting in the hallway when Resident #12 attempted to wander into Resident #2's room. Resident #2 grabbed Resident #12 by the right forearm pulling her to the floor. Head to toe assessment completed with no injuries noted to Resident #12. Resident #2 was redirected into his room and assisted to bed. Record review of incident report dated 4/27/2023 stated Resident #2 hit Resident #184. Resident #2 was noted to have two skin tears on his right knuckle. The CNA assigned to the unit reports when she was coming up the hall she noticed Resident #184 was no longer at the dining table. She then heard Resident #2 yelling from his room and when she entered the Resident #2's room, Resident #184 was sitting in a chair and had blood coming from his mouth on the left side. Both residents separated, assessed for injuries, Resident #2 placed on every 15-minute checks and referral sent to a behavioral hospital. Physician, Administrator, DON and families notified. 2. Record review of facility face sheet dated 7/11/2023 indicated Resident #12 was a [AGE] year-old female admitted to the facility 9/19/2020 with the diagnosis of Alzheimer's disease. Record review of quarterly MDS dated [DATE] indicated Resident #12 had a BIMS of 99 indicating Resident #12 was unable to complete the interview. Section E for behaviors indicated Resident #12 wandered daily. Record review of comprehensive care plan dated 4/25/2023 indicated Resident #12 required secured unit placement due to elopement risk and Resident #12 had potential to demonstrate physical behaviors with interventions to analyze what deescalates behavior and document and intervene before agitation escalates. Record review of incident report dated 03/09/2023 stated Resident #12 was grabbed by the right arm and pulled to the floor by Resident #2 in the hallway. Head to toe assessment complete, physician, DON, and families notified. Record review of progress note dated 03/09/2023 at 5:20 am stated LVN C was notified by RA assigned to the unit Resident #12 was on the floor. RA reported that Resident #12 attempted to wander into Resident #2's room. Resident #2 grabbed Resident #12 by the right forearm pulling her to the floor. Head to toe assessment completed with no injuries noted to Resident #12. 3.Record review of facility face sheet dated 7/12/2023 indicated Resident #184 was an [AGE] year-old male admitted to the facility on [DATE] with a diagnosis of Alzheimer's disease. Record review of admission MDS dated [DATE] indicated Resident #184 had a BIMS of 99 indicating Resident #184 was unable to complete the interview. Section E for behaviors indicated verbal behaviors directed towards others and wandered daily. Record review of comprehensive care plan dated 02/26/2023 indicated Resident # 184 had a potential to demonstrate physical behaviors with interventions to analyze triggers and what de-escalates behaviors and document and was an elopement risk requiring a secured unit. Record review of nurse progress note dated 3/05/2023 at 2:15 am stated LVN C was notified by RA assigned to the unit Resident #184 had been hit to the left side of the face with an open hand by Resident #2. CNA was advised to do frequent checks on Resident #184 and monitor the hallway. Responsible party, DON, ADON and physician notified. Record review of nurse progress note dated 4/28/2023 at 3:57 pm stated ADON was alerted by CNA assigned to the unit that Resident #2 had hit Resident #184. ADON entered the unit and Resident #184 was standing in the hall with the CNA and had a gash and blood to left side of his mouth. 4. Record review of facility face sheet dated 7/12/2023 indicated Resident #185 was a [AGE] year-old female admitted to the facility on [DATE] with diagnosis of Alzheimer's disease. Record review of admission MDS dated [DATE] indicated Resident #185 had a BIMS of 01 indicating severe cognitive deficit. Section E for behaviors indicated Resident # 185 had physical behavioral symptoms directed towards others and had wandered. Record review of comprehensive care plan dated 11/16/2022 indicated Resident #185 had potential for psychosocial problem and required secured unit and was an elopement risk for wandering. Record review of nurse progress note dated 11/23/22 at 8:28 pm stated on 11/22/2023 LVN P was notified by the aide working the secured unit that Resident #185 was attempting to wander into Resident #2's room. Resident #2 grabbed Resident #185 by the arm and struck her in the chest twice before the aide could stop him. One on one care being provided to keep resident from wandering back into Resident #2's room until Resident #185 can be transferred to an all-female secured unit on Monday 11/28/2022. Record review of electronic health record for Resident #185 indicated no documentation of one-on-one monitoring initiated after incident on 11/22/2022. Record review of nurse progress note dated 12/2/2023 at 5:08 pm LVN C stated Resident #185 was hit in the face by Resident #2 causing an abrasion to her left cheek. On review, the dates documented for the incident for Resident #185 and Resident #2 do not match. No record of incident report found in the electronic health record. 5. Record review of facility face sheet dated 7/12/2023 indicated Resident # 186 was a [AGE] year-old male admitted to the facility on [DATE] with diagnosis of hemiplegia following cerebral infarction (paralysis following a stroke). Record review of admission MDS 12/12/2022 indicated Resident #186 had moderately impaired cognition requiring supervision and wandered. Record review of comprehensive care plan dated 12/20/2022 indicated Resident # 186 had a communication problem and to provide a safe environment. Record review of Resident #186's electronic health record with no documentation related to altercation with Resident #2 on 01/15/2023. During an observation on 07/10/23 at 09:12 am CNA A and CNA B were present on the secured unit that housed 10 residents. During an observation on 7/10/2023 at 12:10 pm Resident #2 was up in his wheelchair in his room eating lunch. Resident #2 propels self in wheelchair and resides in a private room. During an interview on 07/10/2023 at 12:15 pm CNA A stated she had worked at the facility for 8 months and primarily was assigned to the secured unit. She stated the residents on the unit need supervision as they wander and get into things. She stated Resident #2 had been at the facility a long time and had a history of being aggressive if other residents entered his space. She stated she tried to keep everyone else away from him. She stated there was an incident when Resident #2 pulled another resident's arm in the dining room and when she intervened Resident #2 hit her. She stated the nurse was notified and Resident #2 returned to his room. She stated she had training on caring for residents with behaviors and incidents or abuse as to be reported to the nurse and administrator. During an interview on 07/10/20023 at 12:40 pm CNA B stated she had worked at the facility almost 2 years and worked the secured unit. She stated that during the day there are 2 CNAs on the unit and the nurse comes on and off the unit throughout the day. She stated that the residents on the unit have behaviors and she had been trained on how to control outburst but it does not always work. She stated Resident #2 did have some issues a few months ago but in the last few months had been better. She stated as long as no one messes with him he was fine. She stated there had not been any special interventions for Resident #2 and she just tried to keep an eye on him and prevent the other residents from going around him. During an interview on 7/11/2023 at 10:11 AM the RA stated he had been employed at the facility for 3 months part time. He said when he worked he worked all over the facility. He stated Resident #2 was on the secured unit and stayed in a wheelchair usually in his doorway of his room. He stated the incident with Resident #2 and Resident #184 he had worked that night and witnessed the incident. He stated Resident #184 walked up to Resident #2's wheelchair and Resident #2 hit Resident #184 in the face. He said he reported to the nurse LVN C and immediately separated both residents. He stated LVN C told him to write a witness statement and she called the hospice nurse. He stated he stayed in the hallway in the secured unit and put Resident #184 back to bed. He stated Resident #184 was a wanderer and he did not go back into the room of Resident #2. He stated LVN C checked on Resident #184 but could not recall any in-services or other interventions following that incident. He stated the incident with Resident #2 and Resident #12 was witnessed by him. He stated Resident #2 was sitting in the doorway of his room and Resident #12 went into his room but by the time he made it there, Resident #2 had already grabbed her by the arm and she fell to her knees. He stated Resident #12 jumped back up and he called to the nurse station to notify LVN C. He stated LVN C came and provided first aide to Resident 12's arm because she had a skin tear. He stated he was instructed by the nurse to write out a witness statement but no other special instructions were given. He said he had received training on abuse/neglect. He stated Resident #2 liked to sit in the doorway of his room and did not like other residents going in his room. He stated he was told by facility staff prior to working on the secured unit to monitor Resident #2 to ensure no residents entered his room. He stated at the time of both incidents, he was the only staff on the secured unit. He stated both incidents occurred on the night shift and usually there was only 1 aide on the unit at night. He stated the nurse stayed at the nurse station outside of the unit and they would come to the unit about 2-3 times a night. Attempted phone interviews on 7/11/2023 with LVN C at 10:34 am and at 4:43 pm with no answer and voicemail messages were left for a return phone call. During an interview on 7/11/2023 at 11:01 am the DON stated she had started as the facility DON in February 2023. She stated that when she first started she was told that resident to resident altercations was not abuse if it occurred between residents on the secured unit that had cognitive delays and did not have to be investigated or reported to the state unless the other resident suffered a significant injury. She stated she had knowledge of the altercations regarding Resident #2 and the nurse had notified her with each incident but had missed that the altercations were abuse. She stated the administrator was aware and he did not treat the altercations as abuse either. She stated that with each incident the aide separated the residents, the nurse was notified, and the victim was assessed. She stated she knew the facilities policy on abuse and the process of investigation and reporting but with the incidents that occurred since she had been DON with Resident #2 were missed. She stated in April her regional nurse notified her that all resident-to-resident altercations were to be investigated, reported and followed through to prevent further abuse. She stated by not following the abuse program the risk to the residents could be significant. During an interview on 7/12/23 at 7:32 am CNA D stated she had been a CNA for 6 years and employed at the facility for 2 months. She stated she worked all units and shifts. She stated on the night shift there was only 1 CNA and the nurse came back and forth as needed. She stated if a resident-to-resident altercation occurred on her shift she would report it to the nurse and separate the residents. She stated she was aware of each resident and their moods and Resident #2 prefers to stay to himself and no one be in his space. She stated at night when she worked on the unit by herself, if she was in another resident's room, she just tried to listen for any noise indicating a resident had gotten up or needed help. She stated she had not had any issues with any residents on the unit since starting to work at the facility. During an interview on 7/12/2023 at 7:48 am Resident #2 stated he did not remember any incidents occurring between him and another resident. He stated he was not sure how long he had been at the facility but there were a lot of people who lived there. He stated if someone were to come in his room that would be just fine but if they messed with him or his stuff he was not sure what he would do. He stated he was not a mean person and tried to get along with everyone. He stated he stayed in his room and kept to himself. During an interview on 7/12/2023 at 7:53 am CNA E stated she had been a CNA for 21 years and employed at the facility 6 months. She stated she was not working during any of the incidents with Resident # 2. She stated when she was hired she had to go through a full training program on the facilities computer-based training program before she could start to work. She stated the training included signs of abuse, types of abuse and reporting abuse to the administrator. She stated there was training on behavior monitoring and if there was an altercation between residents that they were to be separated and monitored to make sure the incident did not occur again. She stated the nurse was informed and the nurse did a report. She stated when she had worked the unit there were 2 CNA's working during the day. She stated if she and the other CNA were busy she would ask the nurse to come to the unit and help supervise if it was needed. She stated that if residents are not properly supervised and the abuse program was not followed a resident could get hurt. During an interview on 07/12/2023 at 8:01 am RN F stated she was new to the facility as of 2 weeks but had worked in long term care for over 20 years. She stated abuse training was completed when she was hired through the facilities online training program. She stated resident to resident altercations are to be reported to the abuse coordinator. The residents were to be separated, the victim assessed, and the perpetrator should be monitored 1 on 1 if needed. She stated she worked the secured unit and was on and off the unit throughout her shift and as needed by the CNA. During an interview on 7/12/2023 at 9:44 am, the Psychiatrist stated that residents that received hospice services were not typically seen by psychiatric services, but he did follow them if it was requested by the doctor or hospice. He stated he did complete an evaluation on Resident #2 on 7/11/2023 and with coordination of the son was able to develop a past history and adjust his diagnosis. He stated he did a medication review and made some adjustments with dose times of his antipsychotic and anxiety medications. He stated he would continue to monitor for any symptoms and make other adjustments if needed. He stated the facility had put in place one on one monitoring to monitor for any negative outcomes to his interventions. He stated he was going to provide the facility staff with more in-depth training today 7/12/2023 on how to care for aggressive residents, behavior monitoring and interventions, pharmacological interventions, and regulations for abuse. During an interview on 7/12/2023 at 10:05 am, the Administrator stated he had been at the facility since mid-December 2022 and was aware of each incident regarding Resident #2. He stated he monitored all incidents that occurred in the facility through the morning meetings. He stated he did not recognize that the incidents were abuse and because of that did not follow the facility abuse program in all aspects. At the time he did not see any risk to the residents but looking back now he could see the risk of injury to the other residents on the unit. He stated going forward he would follow the abuse program. During a phone interview on 7/12/2023 at 3:08 pm, LVN C stated she had been employed at the facility about 9 months but no longer was working at the facility. She stated she remembered the incidents between Resident #2 and Resident #184 and Resident #12. She stated Resident #2 was territorial and the staff tried to keep other residents out of Resident #2's room but at times she and the aides were busy with other task and could not keep their eyes on him all the time. She stated when Resident #2 hit Resident #184 she was notified by the CNA working the hall and she assessed both residents and there were no injuries. She stated she called the doctor, DON and each residents responsible person and notified them of the incident but did not do any special monitoring. She stated when Resident #2 grabbed and pulled Resident #12 to the ground, the CNA got her that time as well. She stated she assessed each resident and called the doctor, DON, and each residents responsible person. She stated Resident #2 and Resident #12 were separated and no other special monitoring was done. She stated the nights she worked at the facility there was only 1 CNA on the secured unit and she would go to the unit if needed. She stated she knew the types of abuse and resident to resident altercations was abuse. She stated when she was hired she was trained on abuse and to report abuse to the DON or abuse coordinator. Record review of facility in-service sign in sheet dated 1/15/2023 indicated a training on abuse and neglect and on 3/6/2023 training on abuse and neglect, types, reporting, policy, and abuse coordinator. Record review of facility policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program dated April 2021 indicated, .Residents have the right to be free from abuse. 1. protect residents from abuse, 2. develop and implement policies and protocols to prevent and identify abuse, 3. ensure adequate staffing, 8. identify and investigate all possible incidents of abuse, 9. Investigate and report any allegations within timeframe required by federal requirements, 10. protect residents from any further harm. Record review of facility policy titled Protection of Residents During Abuse Investigations dated April 2021 indicated, .3. if the alleged abuse involves another resident, there may be restrictions on the accused resident's freedom to visit other resident rooms unattended, 5. The victim is evaluated for safety, measures are taken such as more supervision. Record review of facility policy titled Identifying Types of Abuse dated April 2021 indicated, .5. Physical abuse includes but is not limited to hitting, slapping, punching. Record review of facility policy titled Abuse and Neglect Clinical Protocol dated March 2018 indicated, .The staff will investigate alleged abuse, the facility management will institute measures to address the needs of residents and minimize the possibility of abuse, the management will address situations of suspected or identified abuse and report them in a timely manner, and the staff and physician will monitor individuals who have been abused to address any issues regarding their medical condition, mood and function. Record review of facility policy titled Coordinating/Implementing Abuse, Neglect and Exploitation indicated, .the administrator is responsible for the overall coordination and implementation of the facility's policies and procedures against abuse. 1. Policies are in place that: a. prohibit and prevent resident abuse, b. establish processes to investigate such allegations, 2. policies address the following as part of abuse: c. prevention, d. identification of violations, e. investigative processes, f. protection of residents during investigations, g. reporting of and response to investigations, 3. the administrator has the overall responsibility for the coordination and implementation for facility's policies and procedures. Record review of facility policy titled Resident-to-Resident Altercations dated September 2022 indicated, .1.facility staff monitor residents for aggressive behaviors towards other residents, 3. Occurrences of such incidents are promptly reported to the nurse supervisor, DON, and administrator. The administrator will report the incident in accordance with the criteria established under Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, 4. If two residents are involved in an altercation staff: a. separate the residents b. identify what happened c. notify each resident's representative and the attending physician d. review the event with the DON e. consult the attending physician f. make changes to care plan if necessary g. document in the resident's clinical record h. consult psychiatric services as needed i. complete a report of Incident/Accident form j. report the incident, findings and corrective actions to appropriate agencies.5. Inquiries concerning resident-to resident altercations are referred to the DON or the administrator. Record review of facility policy titled Abuse, Neglect, Exploitation or misappropriation - Reporting and Investigating dated April 2021 indicated .All reports of resident abuse are reported to local, state and federal agencies and thoroughly investigated by facility management. 1. Resident abuse must be reported immediately to the administrator and to other officials according to state law, 3. Immediately is defined as within 2 hours of allegation involving abuse, 6. Upon receiving any abuse allegation the administrator is responsible for determining what actions are needed for the protection of residents. The facility Administrator was notified on 07/11/2022 at 4:13 PM that an Immediate Jeopardy situation had been identified due to the above failures and the IJ template was given at that time. The facility's plan of removal was accepted on 07/13/2022 at 3:35 PM and included: The facility will in-service all staff on abuse policy and procedure. To include types of abuse, reporting abuse, prevention of abuse, resident protection during abuse allegations and incidents, and signs and symptoms of abuse. Staff will be trained in de-escalation techniques and interventions to prevent resident to resident altercations. The facility will assess all residents on the secured unit for changes in their behavior monitoring or notations of emotional distress. The facility will in-service all staff on providing an environment free of hazards. The facility will have psychiatric service provider in-service the DON/ADON/RDC (regional director of clinical) on de-escalation techniques and protecting residents to provide to all staff. The facility will in-service all staff on abuse policy-protection, protecting residents from abuse from residents with history of multiple physical incidents and recognizing patterns of behaviors. The facility will in-service any agency staff on all related in-services before being permitted to work. The facility will complete an elopement assessment on Resident #2 to ensure that the resident still needed a secure unit. Resident #2 will be placed on Q15 monitoring until psychiatric telehealth review could be achieved. Resident #2 will be assessed via psychiatric telehealth services and placed on 1:1 to initiate nursing assessment review of psychiatric medication changes regarding behavior changes or safety measures because of these changes. A 30-day discharge will be initiated due to IDT determination. The facility will assign 1:1 designated staff to Resident #2 x 3 days following psychiatric evaluation. The facility will adjust staffing with the day shift having 2 nurse aides assigned to the secured unit and night shift having 1 nurse aide and 1 nurse assigned to the secured unit. Facility will complete weekly QAPI review pertaining to abuse/neglect and accident and incidents. The RDO (regional director of operations) will complete an in-service with the administrator and DON regarding abuse policy and procedure for types of abuse, reporting and investigating according to facility policies. The facility administrator or designee will monitor and review all Accident/Incident reports and follow up accordingly. The IDT will review and assess each Accident/incident to determine any further actions needed. IDT members to include the administrator, DON, ADON, MDS coordinator, Social Worker, and therapy representative. The corporate staff will review all incident/accidents daily for 6 months and reevaluate the need for continued review. On 07/13/2023, the surveyors confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy by: During an observation on 7/12/2023 at 7:40 am Resident #2 was up in his wheelchair eating breakfast with a facility staff present in room for 1 on 1 monitoring. During an interview on 7/12/2023 at 7:43 am laundry aide O stated she worked at the facility in laundry but was asked to sit and provide 1 on 1 supervision to Resident #2 to prevent any altercations with other residents. During an observation on 7/12/23 at 3:10 pm 1:1 sitter present with Resident #2 in his room. During an observation on 7/13/23 at 7:25 am and 1:10 pm 1:1 sitter present with Resident #2. Staff interviews on 7/13/2023 10:45-2:50 pm completed with Administrator, DON, ADON, BOM, Activity Director, Housekeeping Supervisor, MDS coordinator, Maintenance supervisor, DM, dietary cook, CNA A, CNA E, CNA I, CNA N, Restorative aide, transportation aide, LVN J, LVN M, RN F, HSK K, and laundry aide H was able to verbalize the abuse policy and procedure, de-escalation techniques, interventions to prevent resident to resident altercations, providing environment free of hazards, protecting residents and recognizing patterns of behaviors. The DON and administrator verbalized abuse policy, reporting and investigating per facility policies, and agency staff permitted to work after in-services received. During a phone interview on 7/13/2023 at 2:35 pm LVN M stat[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews, the facility failed to implement written policies and procedures that prohibit abuse/neglect for 4 of 10 residents (Resident #12, Resident #184, Resident #185, and Resident #186) ) reviewed for incidents. The facility failed to implement their abuse policy and program to prevent abuse when Resident #2 abused Resident #12, Resident #184, Resident #185, and Resident #186. An IJ (immediate jeopardy) was identified on 07/11/2023 at 4:13 PM. The IJ template was provided to the facility on [DATE] at 4:13 PM. While the IJ was removed on 07/13/2023 at 3:35 PM, the facility remained out of compliance at a severity level of actual harm that is not immediate with a scope of pattern due to the facility's need to monitor and evaluate the effectiveness of their plan of removal and corrective actions. These deficient practices affected all residents and contributed to further abuse. Findings included: 1. Record review of facility face sheet dated 7/11/2023 indicated Resident #2 was a [AGE] year-old male admitted to the facility on [DATE] with a primary diagnosis of bipolar disorder (mood disorder), psychosis (mental disorder), and anxiety. Record review of comprehensive MDS dated [DATE] indicated Resident #2 had a BIMS of 99 indicating Resident #2 was unable to complete interview. Section C for cognition indicated Resident #2 had disorganized thinking. Section E for behaviors indicated Resident #2 had verbal behaviors directed toward others and resident had wandered. Record review of care plan dated 05/08/2023 indicated Resident #2 required psychotropic medications for diagnosis of behavior management, bipolar disorder, and psychosis. Resident #2 had impaired cognitive function and dementia or impaired thought processes related to dementia and psychosis and required the secured unit due to risk of elopement and wandering. Resident #2 had physical behaviors towards residents and staff with interventions added on 03/04/2023 to separate from resident and redirect to room, 3/09/2023 Seroquel increased, and 4/27/2023 resident #2 was sent to a behavioral hospital for evaluation and treatment. Record review of physician orders dated 7/11/2023 indicated Resident #2 had order for behavior monitoring, lorazepam 1 mg by mouth as needed for anxiety and Seroquel 100mg by mouth at bedtime. Record review of facility incident report dated 11/23/2022 revealed a resident-to-resident altercation that occurred between Resident # 2 and Resident #185. Resident #185 wandered by Resident #2's door on the secured unit, and Resident #2 grabbed Resident #185's arm and struck her in the upper chest. Resident #185 was removed from area, the responsible parties, physician, and administrator was notified. Record review of facility progress note dated 11/22/2023 at 6:18 pm LVN P stated was called to Resident #2's room by the aide working on the unit and the aide reported Resident #185 was walking by Resident #2's room when he grabbed Resident #185's arm and hit her in the chest before the aide was able to intervene. The aide separated the resident's and nurse notified the administrator. The administrator said an incident report was not needed due to resident's mental status. Record review of a facility progress note dated 12/05/2022 at 3:14 pm LVN L stated Resident #185 entered Resident #2's room, stooped down towards his face and Resident#2 punched Resident #185 on the left side of the face. Resident #185 was redirected and continue to monitor for behaviors. Record review of incident report log and no incident recorded on 12/05/2022 regarding incident between Resident #2 and Resident #185. Record review of incident report dated 01/15/2023 stated Resident #2 rolled up to Resident #186 at the dining table and Resident #2 pulled, twisted, and yanked Resident #186's right arm. CNA A attempted to separate the residents and Resident #2 punched CNA A in the jaw. Administrator and physician were notified. Record review facility progress note dated 01/15/2023 at 11:33 am LVN P stated upon entering the unit, was notified Resident #2 had attacked Resident #186 and CNA A. Record review of incident report dated 03/04/2023 stated Resident #2 hit Resident#184 with an open hand on the left side of the face. Residents were separated and head to toe assessment completed. DON, physician, and families notified. Record review of progress note dated 03/05/2023 at 2:54 am LVN C stated was notified by RA assigned to the unit; Resident #2 had hit Resident #184 with an open hand to the left side of the face when Resident #184 had gotten to close to Resident #2. RA was advised to do frequent monitoring and hallway checks. Record review of incident report dated 03/09/2023 stated resident #2 grabbed Resident #12 by the right arm and pulled her to the floor in the hallway. Head to toe assessment complete, physician, DON, and families notified. Record review of progress note dated 03/09/2023 at 4:36 am LVN C stated notified by RA assigned to the unit resident #12 was on the floor. RA reported that Resident #2 was sitting in the hallway when Resident #12 attempted to wander into Resident #2's room. Resident #2 grabbed Resident #12 by the right forearm pulling her to the floor. Head to toe assessment completed with no injuries noted to Resident #12. Resident #2 was redirected into his room and assisted to bed. Record review of incident report dated 4/27/2023 stated Resident #2 hit Resident #184. Resident #2 was noted to have two skin tears on his right knuckle. The CNA assigned to the unit reports when she was coming up the hall she noticed Resident #184 was no longer at the dining table. She then heard Resident #2 yelling from his room and when she entered the Resident #2's room, Resident #184 was sitting in a chair and had blood coming from his mouth on the left side. Both residents separated, assessed for injuries, Resident #2 placed on every 15-minute checks and referral sent to Behavioral Hospital. Physician, Administrator, DON and families notified. 2. Record review of facility face sheet dated 7/11/2023 indicated Resident #12 was a [AGE] year-old female admitted to the facility 9/19/2020 with the diagnosis of Alzheimer's disease. Record review of quarterly MDS dated [DATE] indicated Resident #12 had a BIMS of 99 indicating Resident #12 was unable to complete the interview. Section E for behaviors indicated Resident #12 wandered daily. Record review of comprehensive care plan dated 4/25/2023 indicated Resident #12 required secured unit placement due to elopement risk and Resident #12 had potential to demonstrate physical behaviors with interventions to analyze what deescalates behavior and document and intervene before agitation escalates. Record review of incident report dated 03/09/2023 stated resident #12 was grabbed by the right arm and pulled to the floor by Resident #2 in the hallway. Head to toe assessment complete, physician, DON, and families notified. Record review of progress note dated 03/09/2023 at 5:20 am LVN C stated was notified by RA assigned to the unit Resident #12 was on the floor. RA reported that Resident #12 attempted to wander into Resident #2's room. Resident #2 grabbed Resident #12 by the right forearm pulling her to the floor. Head to toe assessment completed with no injuries noted to Resident #12. 3.Record review of facility face sheet dated 7/12/2023 indicated Resident #184 was an [AGE] year-old male admitted to the facility on [DATE] with a diagnosis of Alzheimer's disease. Record review of admission MDS dated [DATE] indicated Resident #184 had a BIMS of 99 indicating Resident #184 was unable to complete the interview. Section E for behaviors indicated verbal behaviors directed towards others and wandered daily. Record review of comprehensive care plan dated 02/26/2023 indicated Resident # 184 had a potential to demonstrate physical behaviors with interventions to analyze triggers and what de-escalates behaviors and document and was an elopement risk requiring a secured unit. Record review of nurse progress note dated 3/05/2023 at 2:15 am LVN C stated was notified by RA assigned to the unit Resident #184 had been hit to the left side of the face with an open hand by Resident #2. RA was advised to do frequent checks on Resident #184 and monitor the hallway. Responsible pat, DON, ADON and physician notified. Record review of nurse progress note dated 4/28/2023 at 3:57 pm ADON stated on 4/27/2023 at 5:18 pm was alerted by CNA assigned to the unit that Resident #2 had hit Resident #184. Nurse entered the unit and Resident #184 was standing in the hall with the CNA and had a gash and blood to left side of his mouth. 4. Record review of facility face sheet dated 7/12/2023 indicated Resident #185 was a [AGE] year-old female admitted to the facility on [DATE] with diagnosis of Alzheimer's disease. Record review of admission MDS dated [DATE] indicated Resident #185 had a BIMS of 01 indicating severe cognitive deficit. Section E for behaviors indicated Resident # 185 had physical behavioral symptoms directed towards others and had wandered. Record review of comprehensive care plan dated 11/16/2022 indicated Resident #185 had potential for psychosocial problem and required secured unit and was an elopement risk for wandering. Record review of nurse progress note dated 11/23/22 at 8:28 pm LVN P stated on 11/22/2023 at 3:30 pm nurse was notified by the aide working the secured unit that Resident #185 was attempting to wander into Resident #2's room. Resident #2 grabbed Resident #185 by the arm and struck her in the chest twice before the aide could stop him. One on one care being provided to keep resident from wandering back into Resident #2's room until Resident #185 can be transferred to an all-female secured unit on Monday 11/28/2022. Record review of electronic health record for Resident #185 indicated no documentation of one-on-one monitoring initiated after incident on 11/22/2022. Record review of nurse progress note dated 12/2/2023 at 5:09 pm LVN Q indicated Resident #185 was hit in the face by Resident #2 causing an abrasion to her left cheek. On review, the dates documented for the incident for Resident #185 and Resident #2 do not match. No record of incident report found in the electronic health record. 5. Record review of facility face sheet dated 7/12/2023 indicated Resident # 186 was a [AGE] year-old male admitted to the facility on [DATE] with diagnosis of hemiplegia following cerebral infarction (paralysis following a stroke). Record review of admission MDS 12/12/2022 indicated Resident #186 had moderately impaired cognition requiring supervision and wandered. Record review of comprehensive care plan dated 12/20/2022 indicated Resident # 186 had a communication problem and to provide a safe environment. Record review of Resident #186's electronic health record with no documentation related to altercation with Resident #2 on 01/15/2023. During an observation on 07/10/23 at 09:12 AM CNA A and CNA B were present on the secured unit that housed 10 residents. During an observation on 7/10/2023 at 12:10 pm Resident #2 was up in his wheelchair in his room eating lunch. Resident #2 propels self in wheelchair and resides in a private room. During an interview on 07/10/2023 at 12:15 pm CNA A stated she had worked at the facility for 8 months and primarily was assigned to the secured unit. She stated the residents on the unit need supervision as they wander and get into things. She stated Resident #2 had been at the facility a long time and had a history of being aggressive if other residents entered his space. She stated she tried to keep everyone else away from him. She stated there was an incident when Resident #2 pulled another resident's arm in the dining room and when she intervened Resident #2 hit her. She stated the nurse was notified and Resident #2 returned to his room. She stated she had training on caring for residents with behaviors and incidents or abuse as to be reported to the nurse and administrator. During an interview on 07/10/20023 at 12:40 pm CNA B stated she had worked at the facility almost 2 years and worked the secured unit. She stated that during the day there are 2 CNAs on the unit and the nurse comes on and off the unit throughout the day. She stated that the residents on the unit have behaviors and she had been trained on how to control outburst but it does not always work. She stated Resident #2 did have some issues a few months ago but in the last few months had been better. She stated as long as no one messes with him he is fine. She stated there had not been any special interventions for Resident #2 and she just tried to keep an eye on him and prevent the other residents from going around. During an interview on 7/11/2023 at 10:11 AM the RA stated he had been employed at the facility for 3 months part time. He said when he worked he worked all over the facility. He stated Resident #2 was on the secured unit and stayed in a wheelchair usually in his doorway of his room. He stated the incident with Resident #2 and Resident #184 he had worked that night and witnessed the incident. He stated Resident #184 walked up to Resident #2's wheelchair and Resident #2 hit resident #184 in the face. He said he reported to the nurse LVN C and immediately separated both residents. He stated LVN C told him to write a witness statement and she called the hospice nurse. He stated he stayed in the hallway in the secured unit and put Resident #184 back to bed. He stated Resident #184 was a wanderer and he did not go back into the room of Resident #2. He stated LVN C checked on Resident #184 but could not recall any in-services or other interventions following that incident. He stated the incident with Resident #2 and Resident #12 was witnessed by him. He stated Resident #2 was sitting in the doorway of his room and Resident #12 went into his room but by the time he made it there, Resident #2 had already grabbed her by the arm and she fell to her knees. He stated Resident #12 jumped back up and he called to the nurse station to notify LVN C. He stated LVNC came and provided first aide to Resident 12's arm because she had a skin tear. He stated he was instructed by the nurse to write out a witness statement but no other special instructions were given. He said he had received training on abuse/neglect. He stated Resident #2 liked to sit in the doorway of his room and did not like other residents going in his room. He stated he was told by facility staff prior to working on the secured unit to monitor Resident #2 to ensure no residents entered his room. He stated at the time of both incidents, he was the only staff on the secured unit. He stated both incidents occurred on the night shift and usually there was only 1 aide on the unit at night. He stated the nurse stayed at the nurse station outside of the unit and they would come to the unit about 2-3 times a night. A phone call was attempted to LVN C on 7/11/2023 at 10:34 am and 4:43 pm with no answer and voicemail left. During an interview on 7/11/2023 at 11:01 am the DON stated she had started as the facility DON in February 2023. She stated that when she first started she was told that resident to resident altercations was not abuse if it occurred between residents on the secured unit that had cognitive delays and did not have to be investigated or reported to the state unless the other resident suffered a significant injury. She stated she had knowledge of the altercations regarding Resident #2 and the nurse had notified her with each incident but had missed that the altercations were abuse. She stated the administrator was aware and he did not treat the altercations as abuse either. She stated that with each incident the aide separated the residents, the nurse was notified, and the victim was assessed. She stated she knew the facilities policy on abuse and the process of investigation and reporting but with the incidents that occurred since she had been DON with Resident #2 were missed. She stated in April her regional nurse notified her that all resident-to-resident altercations were to be investigated, reported and followed through to prevent further abuse. She stated by not following the abuse program the risk to the residents could be significant. During an interview on 7/12/23 at 7:32 am CNA D stated she had been a CNA 6 years and employed at the facility 2 months. She stated she worked all units and shifts. She stated on the night shift there was only 1 CNA and the nurse came back and forth as needed. She stated if a resident-to-resident altercation occurred on her shift she would report it to the nurse and separate the residents. She stated she was aware of each resident and their moods and Resident #2 prefers to stay to himself and no one be in his space. She stated at night when she worked on the unit by herself, if she was in another resident's room, she just tried to listen for any noise indicating a resident had gotten up or needed help. She stated she had not had any issues with any residents on the unit since starting to work at the facility. During an interview on 7/12/2023 at 7:48 am Resident #2 stated he did not remember any incidents occurring between him and another resident. He stated he was not sure how long he had been at the facility but there were a lot of people who lived there. He stated if someone were to come in his room that would be just fine but if they messed with him or his stuff he was not sure what he would do. He stated he was not a mean person and tried to get alone with everyone. He stated he stayed in his room and kept to himself. During an interview on 7/12/2023 at 7:53 am CNA E stated she had been a CNA for 21 years and employed at the facility 6 months. She stated she was not working during any of the incidents with Resident # 2. She stated when she was hired she had to go through a full training program through the facilities computer-based training program before she could start to work. She stated the training included signs of abuse, types of abuse and reporting abuse to the administrator. She stated there was training on behavior monitoring and if there was an altercation between residents that they were to be separated and monitored to make sure the incident did not occur again. She stated the nurse was informed and the nurse did a report. She stated when she had worked the unit there were 2 CNA's working during the day. She stated if she and the other CNA were busy she would ask the nurse to come to the unit and help supervise if it was needed. She stated that if residents are not properly supervised and the abuse program was not followed a resident could get hurt. During an interview on 07/12/2023 at 8:01 am RN F stated she was new to the facility as of 2 weeks but had worked in long term care for over 20 years. She stated abuse training was completed when she was hired through the facilities Relias training program. She stated resident to resident altercations are to be reported to the abuse coordinator. The residents were to be separated, the victim assessed, and the perpetrator should be monitored 1 on 1 if needed. She stated she worked the secured unit and was on and off the unit throughout her shift and as needed by the CNA. During an interview on 7/12/2023 at 9:44 am the psychiatrist stated that residents that receive hospice services are not typically seen by psychiatric services but he did follow them if it was requested by the doctor or hospice. He stated he did complete an evaluation on Resident #2 7/11/2023 and with coordination of the son was able to develop a past history and adjust his diagnosis. He stated he did a medication review and made some adjustments with dose times of his antipsychotic and anxiety medications. He stated he will continue to monitor for any symptoms and make other adjustments if needed. He stated the facility has put in place 1 on 1 monitoring to monitor for any negative outcomes to his interventions. He stated he was going to provide the facility staff with more in-depth training today 7/12/2023 on how to care for aggressive residents, behavior monitoring and interventions, pharmacological interventions, and regulations for abuse. During an interview on 7/12/2023 at 10:05 am the administrator stated he had been at the facility since mid-December 2022 and was aware of each incident regarding Resident #2. He stated he monitors all incidents that occur in the facility through the morning meeting. He stated he did not recognize that the incidents were abuse and because of that did not follow the facility abuse program in all aspects . At the time he did not see any risk to the residents but looking back now he could see the risk of injury to the other residents on the unit. He stated going forward he would follow the abuse program. During a phone interview on 7/12/2023 at 3:08 pm LVN C stated she had been employed at the facility about 9 months but no longer was working at the facility. She stated she remembered the incidents between Resident #2 and Resident #184 and Resident #12. She stated Resident #2 was territorial and the staff tried to keep other residents out of Resident #2's room but at times she and the aides were busy with other task and could not keep their eyes on him all the time. She stated when Resident #2 hit Resident #184 she was notified by the CNA working the hall and she assessed both residents and there were no injuries. She stated she called the doctor, DON and each residents responsible person and notified them of the incident but did not do any special monitoring. She stated when Resident #2 grabbed and pulled Resident #12 to the ground, the CNA got her that time as well. She stated she assessed each resident and called the doctor, DON, and each residents responsible person. She stated Resident #2 and Resident #12 were separated and no other special monitoring was done. She stated the nights she worked at the facility there was only 1 CNA on the secured unit and she would go to the unit if needed. She stated she knew the types of abuse and resident to resident altercations was abuse. She stated when she was hired she was trained on abuse and to report abuse to the DON or abuse coordinator. Record review of facility in-service sign in sheet dated 1/15/2023 indicated a training on abuse and neglect and on 3/6/2023 training on abuse and neglect, types, reporting, policy, and abuse coordinator. Record review of facility policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program dated indicated, .Residents have the right to be free from abuse. 1. protect residents from abuse, 2. develop and implement policies and protocols to prevent and identify abuse, 3. ensure adequate staffing, 8. identify and investigate all possible incidents of abuse, 9. Investigate and report any allegations within timeframe required by federal requirements, 10. protect residents from any further harm. Record review of facility policy titled Protection of Residents During Abuse Investigations dated April 2021 indicated, .3. if the alleged abuse involves another resident, there may be restrictions on the accused resident's freedom to visit other resident rooms unattended, 5. The victim is evaluated for safety, measures are taken such as more supervision. Record review of facility policy titled Identifying Types of Abuse dated April 2021 indicated, .5. Physical abuse includes but is not limited to hitting, slapping, punching. Record review of facility policy titled Abuse and Neglect Clinical Protocol dated March 2018 indicated, .The staff will investigate alleged abuse, the facility management will institute measures to address the needs of residents and minimize the possibility of abuse, the management will address situations of suspected or identified abuse and report them in a timely manner, and the staff and physician will monitor individuals who have been abused to address any issues regarding their medical condition, mood and function. Record review of facility policy titled Coordinating/Implementing Abuse, Neglect and Exploitation indicated, .the administrator is responsible for the overall coordination and implementation of the facility's policies and procedures against abuse. 1. Policies are in place that: a. prohibit and prevent resident abuse, b. establish processes to investigate such allegations, 2. policies address the following as part of abuse: c. prevention, d. identification of violations, e. investigative processes, f. protection of residents during investigations, g. reporting of and response to investigations, 3. the administrator has the overall responsibility for the coordination and implementation for facility's policies and procedures. Record review of facility policy titled Resident-to-Resident Altercations dated September 2022 indicated, .1.facility staff monitor residents for aggressive behaviors towards other residents, 3. Occurrences of such incidents are promptly reported to the nurse supervisor, DON, and administrator. The administrator will report the incident in accordance with the criteria established under Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, 4. If two residents are involved in an altercation staff: a. separate the residents b. identify what happened c. notify each resident's representative and the attending physician d. review the event with the DON e. consult the attending physician f. make changes to care plan if necessary g. document in the resident's clinical record h. consult psychiatric services as needed i. complete a report of Incident/Accident form j. report the incident, findings and corrective actions to appropriate agencies.5. Inquiries concerning resident-to resident altercations are referred to the DON or the administrator. Record review of facility policy titled Abuse, Neglect, Exploitation or misappropriation - Reporting and Investigating dated April 2021 indicated .All reports of resident abuse are reported to local, state and federal agencies and thoroughly investigated by facility management. 1. Resident abuse must be reported immediately to the administrator and to other officials according to state law, 3. Immediately is defined as within 2 hours of allegation involving abuse, 6. Upon receiving any abuse allegation the administrator is responsible for determining what actions are needed for the protection of residents. The facility Administrator was notified on 07/11/2022 at 4:13 PM that an Immediate Jeopardy situation had been identified due to the above failures and the IJ template was given at that time. The facility's plan of removal was accepted on 07/13/2022 at 03:35 PM and included: The facility will in-service all staff on abuse policy and procedure. To include types of abuse, reporting abuse, prevention of abuse, resident protection during abuse allegations and incidents, and signs and symptoms of abuse. Staff were trained in de-escalation techniques and interventions to prevent resident to resident altercations. The RDO will in-service facility administrator regarding reporting abuse and neglect according to Provider Letter 19-17 and federal regulations. The facility will assess all residents on the secured unit for changes in their behavior monitoring or notations of emotional distress. The RDO will in-service all administrative staff regarding reporting guidelines. The facility will in-service all staff on providing an environment free of hazards. The facility will have psychiatric service provider in-service the DON/ADON/RDC (regional director of clinical) on de-escalation techniques and protecting residents to provide to all staff. The facility will in-service any agency staff on all related in-services before being permitted to work. The facility will complete an elopement assessment on Resident #2 to ensure that the resident still needed a secure unit. Resident #2 will be placed on Q15 monitoring until psychiatric telehealth review could be achieved. Resident #2 will be assessed via psychiatric telehealth services and placed on 1:1 to initiate nursing assessment review of psychiatric medication changes regarding behavior changes or safety measures because of these changes. A 30-day discharge will be initiated due to IDT determination. The facility will assign 1:1 designated staff to Resident #2 x 3 days following psychiatric evaluation. The facility will adjust staffing with the day shift having 2 nurse aides assigned to the secured unit and night shift having 1 nurse aide and 1 nurse assigned to the secured unit. The RDC (regional director of clinical) will in-service all licensed nursing staff over accidents and incident policy and procedure including investigating and documentation of events per facility protocol. All IDT members will be in-serviced on 24-hour report required review during stand-up meeting. The administrator, DON and ADON will review every incident report during the stand-up to ensure investigation, interventions and documentation is appropriate for resident safety and resident needs as applicable to prevent re-occurrence and provide protection. The facility will complete weekly QAPI review pertaining to abuse/neglect and accident and incidents. The facility administrator or designee will monitor and review all Accident/Incident reports and follow up accordingly. The IDT will review and assess each Accident/incident to determine any further actions needed. IDT members to include the administrator, DON, ADON, MDS coordinator, Social Worker, and therapy representative. The corporate staff will review all incident/accidents daily for 6 months and reevaluate the need for continued review. On 07/13/2023, the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy by: During an observation on 7/12/2023 at 7:40 am Resident #2 was up in his wheelchair eating breakfast with a facility staff present in room for 1 on 1 monitoring. During an interview on 7/12/2023 at 7:43 am laundry aide stated she worked at the facility in laundry but was asked to sit and provide 1 on 1 supervision to Resident #2 to prevent any altercations with other residents. During an observation on 7/12/23 at 3:10 pm 1:1 sitter present with Resident #2 in his room. During an observation on 7/13/23 at 7:25 am and 1:10 pm 1:1 sitter present with Resident #2 in his room. Staff interviews on 7/13/2023 10:45-2:50 pm completed with Administrator, DON, ADON, BOM, Activity Director, Housekeeping Supervisor, MDS coordinator, Maintenance supervisor, DM, dietary cook, CNA A, CNA E, CNA I, CNA N, Restorative aide, transportation aide, LVN J, LVN M, RN F, HSK K, and laundry aide H was able to verbalize the abuse policy and procedure, de-escalation techniques, interventions to prevent resident to resident altercations, providing environment free of hazards, protecting residents and recognizing patterns of behaviors. The DON and administrator verbalized abuse policy, reporting and investigating per facility policies, and agency staff permitted to work after in-services received. During a phone interview on 7/13/2023 at 2:35 pm LVN M stated she worked the night shift and verbalized 1 CNA and 1 nurse were to reside on the unit at night. LVN M stated the other LVN was to cover the secured unit if she were to need to come off unit for a break. Record review of Resident #2's electronic health record indicated Resident #2 had an updated elopement risk completed, Q15 min checks were completed from 7/11/2023 at 4:30 pm until 7:00 pm and was seen by psychiatrist for evaluation on 7/11/23. Resident #2's medications were adjusted and 1 on 1 started 7/11/2023 at 7:15 pm to evaluate changes in behaviors and safety x 3 days. 1 on 1 to complete 7/15/23 with a reevaluation. Record review of psychiatric note dated 7/11/2023 indicated Resident #2 was evaluated[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to thoroughly investigate and take measures to prevent further potential abuse, neglect, exploitation or mistreatment while the investigation is in process, and failed to ensure corrective action was taken for 4 of 10 residents (Resident #12, Resident #184, Resident #185, and Resident #186) reviewed for abuse. 1.The facility failed to investigate allegations of abuse and ensure corrective actions were in place when Resident #2 hit Resident #185 in the chest on 11/22/2022. 2.The facility failed to investigate allegations of abuse and ensure corrective actions were in place when Resident #2 hit Resident #185 in the face causing an abrasion to her cheek on 12/05/2022. 3.The facility failed to investigate allegations of abuse and ensure corrective actions were in place when Resident #2 grabbed and yanked Resident #186's arm backwards on 01/15/2023. 4.The facility failed to investigate allegations of abuse and ensure corrective actions were in place when Resident #2 hit Resident #184 with an open hand on the left side of his face on 03/04/2023. 5.The facility failed to investigate allegations of abuse and ensure corrective actions were in place when Resident #2 grabbed Resident #12's right arm pulling her to the floor on 03/09/2023. An IJ was identified on 07/11/2023 at 4:13 PM. The IJ template was provided to the facility on [DATE] at 4:13 PM. While the IJ was removed on 07/13/2023 at 3:35 PM, the facility remained out of compliance at a scope of pattern and a severity level of actual harm that is not immediate with a scope of pattern due to the facility's need to monitor and evaluate the effectiveness of their plan of removal and corrective actions. These failures placed all residents at risk of increased abuse, major injury and decreased quality of life. Findings included: 1. Record review of facility face sheet dated 7/11/2023 indicated Resident #2 was a [AGE] year-old male admitted to the facility on [DATE] with a primary diagnosis of bipolar disorder (mood disorder), psychosis (mental disorder), and anxiety. Record review of comprehensive MDS dated [DATE] indicated Resident #2 had a BIMS of 99 indicating Resident #2 was unable to complete interview. Section C for cognition indicated Resident #2 had disorganized thinking. Section E for behaviors indicated Resident #2 had verbal behaviors directed toward others and resident had wandered. Record review of care plan dated 05/08/2023 indicated Resident #2 required psychotropic medications for diagnosis of behavior management, bipolar disorder, and psychosis. Resident #2 had impaired cognitive function and dementia or impaired thought processes related to dementia and psychosis and required the secured unit due to risk of elopement and wandering. Resident #2 had physical behaviors towards residents and staff with interventions added on 03/04/2023 to separate from resident and redirect to room, 3/09/2023 Seroquel increased, and 4/27/2023 resident #2 was sent to a Behavioral Hospital for evaluation and treatment. Record review of physician orders dated 7/11/2023 indicated Resident #2 had order for behavior monitoring, lorazepam 1 mg by mouth as needed for anxiety and Seroquel 100mg by mouth at bedtime. Record review of facility incident report dated 11/23/2022 revealed a resident-to-resident altercation that occurred between Resident # 2 and Resident #185. Resident #185 wandered by Resident #2's door on the secured unit, and Resident #2 grabbed Resident #185's arm and struck her in the upper chest. Resident #185 was removed from area, the responsible parties, physician, and administrator was notified. Record review of facility progress note dated 11/22/2023 at 6:18 pm LVN P stated the nurse was called to Resident #2's room by the aide working on the unit and the aide reported Resident #185 was walking by Resident #2's room when he grabbed Resident #185's arm and hit her in the chest before the aide was able to intervene. The aide separated the resident's and nurse notified the administrator. The administrator said an incident report was not needed due to resident's mental status. Record review of a facility progress note dated 12/05/2022 at 3:14 pm LVN L stated Resident #185 entered Resident #2's room, stooped down towards his face and Resident#2 punched Resident #185 on the left side of the face. Resident #185 was redirected and continue to monitor for behaviors. Record review of incident report log and no incident recorded on 12/05/2022 regarding incident between Resident #2 and Resident #185. Record review of incident report dated 01/15/2023 stated Resident #2 rolled up to Resident #186 at the dining table and Resident #2 pulled, twisted, and yanked Resident #186's right arm. CNA A attempted to separate the residents and Resident #2 punched CNA A in the jaw. Administrator and physician were notified. Record review facility progress note dated 01/15/2023 at 11:33 am LVN P stated upon entering the unit, was notified Resident #2 had attacked Resident #186 and CNA A. Record review of incident report dated 03/04/2023 stated Resident #2 hit Resident#184 with an open hand on the left side of the face. Residents were separated and head to toe assessment completed. DON, physician, and families notified. Record review of progress note dated 03/05/2023 at 2:54 am LVN C stated nurse was notified by RA assigned to the unit; Resident #2 had hit Resident #184 with an open hand to the left side of the face when Resident #184 had gotten to close to Resident #2. RA was advised to do frequent monitoring and hallway checks. Record review of incident report dated 03/09/2023 stated resident #2 grabbed Resident #12 by the right arm and pulled her to the floor in the hallway. Head to toe assessment complete, physician, DON, and families notified. Record review of progress note dated 03/09/2023 at 4:36 am LVN C stated nurse was notified by RA assigned to the unit resident #12 was on the floor. RA reported that Resident #2 was sitting in the hallway when Resident #12 attempted to wander into Resident #2's room. Resident #2 grabbed Resident #12 by the right forearm pulling her to the floor. Head to toe assessment completed with no injuries noted to Resident #12. Resident #2 was redirected into his room and assisted to bed. 2. Record review of facility face sheet dated 7/11/2023 indicated Resident #12 was a [AGE] year-old female admitted to the facility 9/19/2020 with the diagnosis of Alzheimer's disease. Record review of quarterly MDS dated [DATE] indicated Resident #12 had a BIMS of 99 indicating Resident #12 was unable to complete the interview. Section E for behaviors indicated Resident #12 wandered daily. Record review of comprehensive care plan dated 4/25/2023 indicated Resident #12 required secured unit placement due to elopement risk and Resident #12 had potential to demonstrate physical behaviors with interventions to analyze what deescalates behavior and document and intervene before agitation escalates. Record review of incident report dated 03/09/2023 stated resident #12 was grabbed by the right arm and pulled to the floor by Resident #2 in the hallway. Head to toe assessment complete, physician, DON, and families notified. Record review of progress note dated 03/09/2023 at 5:20 am LVN C stated nurse was notified by RA assigned to the unit Resident #12 was on the floor. RA reported that Resident #12 attempted to wander into Resident #2's room. Resident #2 grabbed Resident #12 by the right forearm pulling her to the floor. Head to toe assessment completed with no injuries noted to Resident #12. 3.Record review of facility face sheet dated 7/12/2023 indicated Resident #184 was a [AGE] year-old male admitted to the facility on [DATE] with a diagnosis of Alzheimer's disease. Record review of admission MDS dated [DATE] indicated Resident #184 had a BIMS of 99 indicating Resident #184 was unable to complete the interview. Section E for behaviors indicated verbal behaviors directed towards others and wandered daily. Record review of comprehensive care plan dated 02/26/2023 indicated Resident # 184 had a potential to demonstrate physical behaviors with interventions to analyze triggers and what de-escalates behaviors and document and was an elopement risk requiring a secured unit. Record review of nurse progress note dated 3/05/2023 at 2:15 am LVN C stated nurse was notified by RA assigned to the unit Resident #184 had been hit to the left side of the face with an open hand by Resident #2. RA was advised to do frequent checks on Resident #184 and monitor the hallway. Responsible parties , DON, ADON and physician notified. 4. Record review of facility face sheet dated 7/12/2023 indicated Resident #185 was a [AGE] year-old female admitted to the facility on [DATE] with diagnosis of Alzheimer's disease. Record review of admission MDS dated [DATE] indicated Resident #185 had a BIMS of 01 indicating severe cognitive deficit. Section E for behaviors indicated Resident # 185 had physical behavioral symptoms directed towards others and had wandered. Record review of comprehensive care plan dated 11/16/2022 indicated Resident #185 had potential for psychosocial problem and required secured unit and was an elopement risk for wandering. Record review of nurse progress note dated 11/23/22 at 8:28 pm LVN P stated on 11/22/2023 nurse was notified by the aide working the secured unit that Resident #185 was attempting to wander into Resident #2's room. Resident #2 grabbed Resident #185 by the arm and struck her in the chest twice before the aide could stop him. One on one care being provided to keep resident from wandering back into Resident #2's room until Resident #185 can be transferred to an all-female secured unit on Monday 11/28/2022. Record review of electronic health record for Resident #185 indicated no documentation of one-on-one monitoring initiated after incident on 11/22/2022. Record review of nurse progress note dated 12/2/2023 at 5:09 pm LVN Q indicated Resident #185 was hit in the face by Resident #2 causing an abrasion to her left cheek. On review, the dates documented for the incident for Resident #185 and Resident #2 do not match. No record of incident report found in the electronic health record. 5. Record review of facility face sheet dated 7/12/2023 indicated Resident # 186 was a [AGE] year-old male admitted to the facility on [DATE] with diagnosis of hemiplegia following cerebral infarction (paralysis following a stroke). Record review of admission MDS 12/12/2022 indicated Resident #186 had moderately impaired cognition requiring supervision and wandered. Record review of comprehensive care plan dated 12/20/2022 indicated Resident # 186 had a communication problem and to provide a safe environment. Record review of Resident #186's electronic health record with no documentation related to altercation with Resident #2 on 01/15/2023. During an observation on 07/10/23 at 09:12 AM CNA A and CNA B were present on the secured unit that housed 10 residents. During an observation on 7/10/2023 at 12:10 pm Resident #2 was up in his wheelchair in his room eating lunch. Resident #2 propels self in wheelchair and resides in a private room. During an interview on 07/10/2023 at 12:15 pm CNA A stated she had worked at the facility for 8 months and primarily was assigned to the secured unit. She stated the residents on the unit need supervision as they wander and get into things. She stated Resident #2 had been at the facility a long time and had a history of being aggressive if other residents entered his space. She stated she tried to keep everyone else away from him because of his behaviors. She stated there was an incident when Resident #2 pulled another resident's arm in the dining room and when she intervened Resident #2 hit her. She stated the nurse was notified and Resident #2 returned to his room. She stated she had training on caring for residents with behaviors and incidents or abuse as to be reported to the nurse and administrator. During an interview on 07/10/20023 at 12:40 pm CNA B stated she had worked at the facility almost 2 years and worked the secured unit. She stated that during the day there are 2 CNAs on the unit and the nurse comes on and off the unit throughout the day. She stated that the residents on the unit have behaviors and she had been trained on how to control outburst but it does not always work. She stated Resident #2 did have some issues a few months ago but in the last few months had been better. She stated as long as no one messes with him he is fine. She stated there had not been any special interventions for Resident #2 and she just tried to keep an eye on him and prevent the other residents from going around him. During an interview on 7/11/2023 at 10:11 AM the RA stated he had been employed at the facility for 3 months part time. He said when he worked he worked all over the facility. He stated Resident #2 was on the secured unit and stayed in a wheelchair usually in his doorway of his room. He stated the incident with Resident #2 and Resident #184 he had worked that night and witnessed the incident. He stated Resident #184 walked up to Resident #2's wheelchair and Resident #2 hit resident #184 in the face. He said he reported to the nurse LVN C and immediately separated both residents. He stated LVN C told him to write a witness statement and she called the hospice nurse. He stated he stayed in the hallway in the secured unit and put Resident #184 back to bed. He stated Resident #184 was a wanderer and he did not go back into the room of Resident #2. He stated LVN C checked on Resident #184 but could not recall any in-services or other interventions following that incident. He stated the incident with Resident #2 and Resident #12 was witnessed by him. He stated Resident #2 was sitting in the doorway of his room and Resident #12 went into his room but by the time he made it there, Resident #2 had already grabbed her by the arm and she fell to her knees. He stated Resident #12 jumped back up and he called to the nurse station to notify LVN C. He stated LVN C came and provided first aide to Resident 12's arm because she had a skin tear. He stated he was instructed by the nurse to write out a witness statement but no other special instructions were given to him regarding preventing Resident #2 from further harming any other resident on the unit. He said he had received training on abuse/neglect. He stated Resident #2 liked to sit in the doorway of his room and did not like other residents going in his room. He stated he was told by facility staff prior to working on the secured unit to monitor Resident #2 to ensure no residents entered his room. He stated at the time of both incidents, he was the only staff on the secured unit. He stated both incidents occurred on the night shift and usually there was only 1 aide on the unit at night. He stated the nurse stayed at the nurse station outside of the unit and they would come to the unit about 2-3 times a night. A phone call was attempted to LVN C on 7/11/2023 at 10:34 am and 4:43 pm with no answer and voicemail left. During an interview on 7/11/2023 at 11:01 am the DON stated she had started as the facility DON in February 2023. She stated that when she first started she was told that resident to resident altercations was not abuse if it occurred between residents on the secured unit that had cognitive delays and did not have to be investigated or reported to the state unless the other resident suffered a significant injury. She stated no actual measures or corrective actions had been in place to prevent Resident #2 for further harming the other residents on the unit until April when the regional nurse notified her that all resident-to-resident altercations are treated as abuse and had to be investigated. She stated the administrator was aware and he did not treat the altercations as abuse either. She stated that with each incident the aide separated the residents, the nurse was notified, and the victim was assessed. She stated she knew the facilities policy on abuse and the process of investigation and reporting but with the incidents that occurred before April 2023 the abuse policy was not followed. She stated by not following the abuse program the risk to the residents could be significant. During an interview on 7/12/23 at 7:32 am CNA D stated she had been a CNA 6 years and employed at the facility 2 months. She stated she worked all units and shifts. She stated on the night shift there was only 1 CNA and the nurse came back and forth as needed. She stated if a resident-to-resident altercation occurred on her shift she would report it to the nurse and separate the residents. She stated she was aware of each resident and their moods and Resident #2 prefers to stay to himself and no one be in his space. She stated at night when she worked on the unit by herself, if she was in another resident's room, she just tried to listen for any noise indicating a resident had gotten up or needed help. She stated she had not had any issues with any residents on the unit since starting to work at the facility. During an interview on 7/12/2023 at 7:48 am Resident #2 stated he did not remember any incidents occurring between him and another resident. He stated he was not sure how long he had been at the facility but there were a lot of people who lived there. He stated if someone were to come in his room that would be just fine but if they messed with him or his stuff he was not sure what he would do. He stated he was not a mean person and tried to get alone with everyone. He stated he stayed in his room and kept to himself. During an interview on 7/12/2023 at 7:53 am CNA E stated she had been a CNA for 21 years and employed at the facility 6 months. She stated she was not working during any of the incidents with Resident # 2. She stated when she was hired she had to go through a full training program on Relias before she could start to work. She stated the training included signs of abuse, types of abuse and reporting abuse to the administrator. She stated there was training on behavior monitoring and if there was an altercation between residents that they were to be separated and monitored to make sure the incident did not occur again. She stated the nurse was informed and the nurse did a report. She stated when she had worked the unit there were 2 CNA's working during the day. She stated if she and the other CNA were busy she would ask the nurse to come to the unit and help supervise if it was needed. She stated that if residents are not properly supervised and the abuse program was not followed a resident could get hurt. During an interview on 07/12/2023 at 8:01 am RN F stated she was new to the facility as of 2 weeks but had worked in long term care for over 20 years. She stated abuse training was completed when she was hired through the facilities Relias training program. She stated resident to resident altercations are to be reported to the abuse coordinator. The residents were to be separated, the victim assessed, and the perpetrator should be monitored 1 on 1 if needed. She stated she worked the secured unit and was on and off the unit throughout her shift and as needed by the CNA. During an interview on 7/12/2023 at 9:44 am the psychiatrist stated that residents that receive hospice services are not typically seen by psychiatric services but he did follow them if it was requested by the doctor or hospice. He stated he did complete an evaluation on Resident #2 7/11/2023 and with coordination of the son was able to develop a past history and adjust his diagnosis. He stated he did a medication review and made some adjustments with dose times of his antipsychotic and anxiety medications. He stated he will continue to monitor for any symptoms and make other adjustments if needed. He stated the facility has put in place 1 on 1 monitoring to monitor for any negative outcomes to his interventions. He stated he was going to provide the facility staff with more in-depth training today 7/12/2023 on how to care for aggressive residents, behavior monitoring and interventions, pharmacological interventions, and regulations for abuse. During an interview on 7/12/2023 at 10:05 am the administrator stated he had been at the facility since mid-December 2022 and was aware of each incident regarding Resident #2. He stated he monitors all incidents that occur in the facility through the morning meeting. He stated he did not recognize that the incidents were abuse and because of that did not follow the facility abuse program in all aspects. At the time he did not see any risk to the residents but looking back now he could see the risk of injury to the other residents on the unit. He stated going forward he would follow the abuse program. During a phone interview on 7/12/2023 at 3:08 pm LVN C stated she had been employed at the facility about 9 months but no longer was working at the facility. She stated she remembered the incidents between Resident #2 and Resident #184 and Resident #12. She stated Resident #2 was territorial and the staff tried to keep other residents out of Resident #2's room but at times she and the aides were busy with other task and could not keep their eyes on him all the time. She stated when Resident #2 hit Resident #184 she was notified by the CNA working the hall and she assessed both residents and there were no injuries. She stated she called the doctor, DON and each residents responsible person and notified them of the incident but did not do any special monitoring. She stated when Resident #2 grabbed and pulled Resident #12 to the ground, the CNA got her that time as well. She stated she assessed each resident and called the doctor, DON, and each residents responsible person. She stated Resident #2 and Resident #12 were separated and no other special monitoring was done. She stated the nights she worked at the facility there was only 1 CNA on the secured unit and she would go to the unit if needed. She stated she knew the types of abuse and resident to resident altercations was abuse. She stated when she was hired she was trained on abuse and to report abuse to the DON or abuse coordinator. Record review of facility in-service sign in sheet dated 1/15/2023 indicated a training on abuse and neglect and on 3/6/2023 training on abuse and neglect, types, reporting, policy, and abuse coordinator. Record review of facility policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program dated indicated, .Residents have the right to be free from abuse. 1. protect residents from abuse, 2. develop and implement policies and protocols to prevent and identify abuse, 3. ensure adequate staffing, 8. identify and investigate all possible incidents of abuse, 9. Investigate and report any allegations within timeframe required by federal requirements, 10. protect residents from any further harm. Record review of facility policy titled Protection of Residents During Abuse Investigations dated April 2021 indicated, .3. if the alleged abuse involves another resident, there may be restrictions on the accused resident's freedom to visit other resident rooms unattended, 5. The victim is evaluated for safety, measures are taken such as more supervision. Record review of facility policy titled Identifying Types of Abuse dated April 2021 indicated, .5. Physical abuse includes but is not limited to hitting, slapping, punching. Record review of facility policy titled Abuse and Neglect Clinical Protocol dated March 2018 indicated, .The staff will investigate alleged abuse, the facility management will institute measures to address the needs of residents and minimize the possibility of abuse, the management will address situations of suspected or identified abuse and report them in a timely manner, and the staff and physician will monitor individuals who have been abused to address any issues regarding their medical condition, mood and function. Record review of facility policy titled Coordinating/Implementing Abuse, Neglect and Exploitation indicated, .the administrator is responsible for the overall coordination and implementation of the facility's policies and procedures against abuse. 1. Policies are in place that: a. prohibit and prevent resident abuse, b. establish processes to investigate such allegations, 2. policies address the following as part of abuse: c. prevention, d. identification of violations, e. investigative processes, f. protection of residents during investigations, g. reporting of and response to investigations, 3. the administrator has the overall responsibility for the coordination and implementation for facility's policies and procedures. Record review of facility policy titled Resident-to-Resident Altercations dated September 2022 indicated, .1.facility staff monitor residents for aggressive behaviors towards other residents, 3. Occurrences of such incidents are promptly reported to the nurse supervisor, DON, and administrator. The administrator will report the incident in accordance with the criteria established under Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, 4. If two residents are involved in an altercation staff: a. separate the residents b. identify what happened c. notify each resident's representative and the attending physician d. review the event with the DON e. consult the attending physician f. make changes to care plan if necessary g. document in the resident's clinical record h. consult psychiatric services as needed i. complete a report of Incident/Accident form j. report the incident, findings and corrective actions to appropriate agencies.5. Inquiries concerning resident-to resident altercations are referred to the DON or the administrator. Record review of facility policy titled Abuse, Neglect, Exploitation or misappropriation - Reporting and Investigating dated April 2021 indicated .All reports of resident abuse are reported to local, state and federal agencies and thoroughly investigated by facility management. 1. Resident abuse must be reported immediately to the administrator and to other officials according to state law, 3. Immediately is defined as within 2 hours of allegation involving abuse, 6. Upon receiving any abuse allegation the administrator is responsible for determining what actions are needed for the protection of residents. The facility Administrator was notified on 07/11/2022 at 4:13 PM that an Immediate Jeopardy situation had been identified due to the above failures and the IJ template was given at that time. The facility's plan of removal was accepted on 07/13/2022 at 03:35 PM and included: The facility will in-service all staff on abuse policy and procedure. To include types of abuse, reporting abuse, prevention of abuse, resident protection during abuse allegations and incidents, and signs and symptoms of abuse. Staff were trained in de-escalation techniques and interventions to prevent resident to resident altercations. The facility will assess all residents on the secured unit for changes in their behavior monitoring or notations of emotional distress. The facility will in-service all staff on abuse policy-protection, protecting residents from abuse from residents with history of multiple physical incidents and recognizing patterns of behaviors. The facility will in-service any agency staff on all related in-services before being permitted to work. The facility will in-service all nursing staff over accident/incident policy and procedure including documentation of events per facility protocol with investigation and intervention review. All IDT members will be in-serviced on 24-hour report required review during stand-up meeting. The administrator, DON and ADON will review every incident report during the stand-up to ensure investigation, interventions and documentation is appropriate for resident safety and resident needs as applicable to prevent re-occurrence and provide protection. Facility will complete weekly QAPI review pertaining to abuse/neglect and accident and incidents. The RDO (regional director of operations) will complete an in-service with the administrator and DON regarding abuse policy and procedure for types of abuse, reporting and investigating according to facility policies. The facility administrator or designee will monitor and review all Accident/Incident reports and follow up accordingly. The IDT will review and assess each Accident/incident to determine any further actions needed. IDT members to include the administrator, DON, ADON, MDS coordinator, Social Worker, and therapy representative. The corporate staff will review all incident/accidents daily for 6 months and reevaluate the need for continued review. On 07/13/2023, the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy by: Staff interviews on 7/13/2023 10:45-2:50 pm completed with Administrator, DON, ADON, BOM, Activity Director, Housekeeping Supervisor, MDS coordinator, Maintenance supervisor, DM, dietary cook, CNA A, CNA E, CNA I, CNA N, Restorative aide, transportation aide, LVN J, LVN M, RN F, HSK K, and laundry aide H was able to verbalize the abuse policy and procedure, de-escalation techniques, interventions to prevent resident to resident altercations, providing environment free of hazards, protecting residents and recognizing patterns of behaviors. The DON and administrator verbalized abuse policy, reporting and investigating per facility policies, and agency staff permitted to work after in-services received. Record review of in-service dated 7/11/2023 presented by DON revealed topic of Abuse/Neglect, resident to resident altercations and reporting, emotional assessments, abuse/neglect policy and procedures. The attendees included management staff, nurses, nurse aides, dietary staff, activity director, and BOM (business office manager). Record review of in-service dated 7/11/2023 and 7/12/2023 presented by RDO revealed topic of reporting and investigating incidents of abuse. The attendees included administrator, DON, management staff, nurses, CNA's, housekeeping, activity director, laundry staff, dietary staff, and maintenance. Record review of in-service dated 7/11/2023 and 7/12/2023 presented by RDO revealed topic of environment free of hazards, accident and incident policy, and investigating and documentation. The attendees included management staff, nurses, aides, dietary staff, laundry staff, activity director, housekeeping staff, and BOM. Record review of in-service dated 7/11/2023 and 7/12/2023 presented by RDC revealed topic of 24-hour report review during morning meeting. The attendees included IDT members. Record review of in-service dated 7/11/2023 and 7/12/2023 presented by RDO revealed topic of investigating and protecting residents from abuse. The attendees included administrator, DON, management staff, nurses, CNA's, housekeeping, activity director, laundry staff, dietary staff, and maintenance. Record review of in-service dated 7/12/2023 presented by RDC (regional director of clinical) revealed topic of incidents and accidents are to be reviewed daily. The attendees included DON, ADON, and administrator. Record review of communication note dated 7/11/2023 indicated the medical director was notified of IJ and participated in plan of removal. Record review of quality assurance meeting sign in sheet indicated meeting was held 7/12/2023 with the medical director and IDT (interdisciplinary team) members. Record review of electronic health record indicated 11 of 11 residents residing on the secured unit were assessed for changes in their behaviors and monitoring. On 07/13/2023 at 03:35 PM, the facility was informed the IJ was removed. However, the facility remained out of compliance at severity level of actual harm [TRUNCATED]