**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the resident environment remained as free of accident hazards as possible and that each resident received adequate supervision and assistance devices to prevent accidents for 1 out of 1 resident (Resident #2) reviewed for adequate supervision. The facility failed to provide adequate supervision to prevent Resident #2 from eloping from the facility at 2:05 a.m. on 5/6/25 .The noncompliance was identified as Past Non-Compliance. The IJ began on 5/6/25 and ended on 6/6/25 . The facility had corrected the noncompliance before the survey began. The failure placed residents with wander guards at risk of serious harm or death. Findings included:Record review of Resident #2's face sheet dated 7/9/2025, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including Unspecified Dementia (group of symptoms affecting memory, thinking and social abilities), Muscle Wasting and Atrophy (decrease in size), and Other Abnormalities of Gait (a person's manner of walking) and Mobility. Record review of Resident #2's annual MDS dated [DATE], section C revealed a BIMS score of 6 that indicated severe cognitive impairment. Section E revealed Resident #2 had exhibited wandering daily but did not place him at significant risk of getting to a potentially dangerous place or significantly intrude on the privacy or activities of others. Section GG regarding Resident #2's Functional Abilities revealed he needed partial/moderate assistance for oral hygiene, toileting hygiene, showering/bathing, dressing, putting on/taking off footwear and substantial/maximal assistance for personal hygiene. Section V regarding Care Area Assessments revealed Resident #2 was reviewed for risks in the following areas: Cognitive Loss/Dementia (dated 4/11/2025), Communication (dated 4/11/2025), ADL Functional/Rehabilitation Potential (dated 4/11/2025), Urinary Incontinence and Indwelling Catheter (dated 4/11/2025), Behavioral Symptoms with care plan ongoing, Falls (dated 4/11/2025), and Psychotropic Drug Use (dated 4/11/2025). Record review revealed Resident #2 had an Elopement Risk Assessment completed on 2/27/25 that indicated Resident #2 was at risk of elopement. Record review of Resident #2's Care Plan revealed Resident #2 was care planned for being at risk for elopement related to wandering with date of initiation on 4/2/24. Resident #2 was also care planned regarding being noncompliant with wearing the wander guard and removing the wander guard after being applied. Interventions included wander guard with initiation date of 4/2/24with placement and function to be assessed every shift. Interventions added after the incident included Resident #2's family looking at 2 secure facilities due to noncompliance with wander guard with initiation date of 5/6/25 , and 1:1 (continuous observation) close monitoring with initiation date of 5/6/25 . Record review of Resident #2's MAR and TAR for May 2025 revealed from 5/1-5/6/25 that his wander guard was checked every shift with no documentation for night shift of 5/1/25 and sleeping was documented for night shift from 10 p.m. to 6 a.m. of 5/5/25 and 5/6/25 with no specific time documented . Wander guard was checked every four hours from 5/13/25 at 4 p.m. through 5/31/25 at 8 p.m. with no documentation for 5/21/25 at 12 p.m., 5/26 at 12 p.m. and 5/29/25 at 8 p.m. Wander guard was checked every night from 5/14-5/31/25. Safety checks were also documented every 30 minutes from 5/7-5/31/25. Record review of Resident #2's nursing progress note dated 5/6/25 at 12:01 a.m. by LVN B revealed, Resident observed not in bed during rounds. After searching around the unit and the neighborhood without finding resident. Facility management notified hence elopement protocol activated. Resident Responsible party notified. 911 called with police response. Physician also notified.Record review of statement written by CNA G on 5/6/25 revealed CNA G saw Resident #2 between 11:00 p.m. to 11:30 p.m. when CNA G took a snack to Resident #2, and he was asleep in his bed at that time and was not seen during the rest of CNA G's shift. Record review of statement written by LVN B on 5/6/25 revealed during shift report at 10:00 p.m. on 5/5/25 they were advised the door alarm in the Magnolia room (large sitting room) was going off. LVN B stated that about 12 midnight they made rounds on the unit and Resident #2 was not in his bed. LVN B stated that when they made rounds and Resident #2 was not in the center, they checked the Magnolia door, and it showed a green light (the door was operational) , and the door was secured and locked but could not recall the exact time this occurred. LVN B stated they notified CNA G at 12:15 a.m. to help look for Resident #2 and notified the other units to help search as well. Then 1 a.m. after still not being able to find Resident #2, LVN B drove to the nearby streets and neighborhood to search for him. LVN B returned to the facility at 1:45 a.m. and notified the administrator around 2 a.m. that Resident #2 was missing. LVN B notified the local Police Department and Resident #2's Responsible Party at 3:33 a.m.Record review of written statement, RN C revealed on 5/6/25 when they came on duty at 10 p.m. the alarm in the Magnolia room was going off. RN C stated that LVN B came to them at approximately 2 a.m. and told them that Resident #2 was no longer at the facility and then started a search inside and outside the facility. RN C stated the Administrator called them at 2:33 a.m. and had tried to reach LVN B but they were out looking for Resident #2. Record review of written statement, LVN C revealed there was a buzzing sound to the Magnolia door when they arrived for the 10 p.m. to 6 a.m. shift on 5/5/25. LVN C stated they checked the door at approximately 10:30 p.m. and it was secured. LVN C stated that LVN B notified them around midnight that Resident #2 was not at the facility, and they helped with an internal and external search of the facility but was unable to find Resident #2. Record review of written statement dated 5/12/25, CNA H stated they were notified that Resident #2 was missing about 1:30 a.m. but could not recall who notified them. CNA H stated they had gone to the Magnolia area and the door was unsecured. Per interview on 7/9/25 at 5:09 p.m., the Administrator said CNA H was no longer employed by the facility and was terminated for an unrelated offense and was angry. Record review of skin audit dated 5/6/25 but not timed revealed complete head to toe assessment with no wounds noted and vital signs were within normal limits. Record review of the Provider Investigation Report dated 5/12/25 regarding the elopement incident on 5/6/25 with Resident #2 revealed provider response included staff completed an audit of the elopement book for pictures and care plans to assure that all residents who were at risk had been included. Staff checked proper functioning/positioning of all Code Alert bracelets and all functioned as designed. Door checks to be conducted daily to assure proper function. Elopement drills for all three shifts on 5/6-6/7/25. In-services were immediately implemented for resident safety and Code Alerts during power loss and abuse, neglect, prevention of accidents and supervisions of residents. Ad Hoc QAPI was held with the medical director. Record review of facility's Elopement Binder revealed 1:1 logs for Resident #2 from 5/6-6/6/25 when it was documented per the log that Resident #2 was discharged [DATE]. The 1:1 logs showed documentation who was assigned to Resident #2 while he was under continuous monitoring. There was no documentation on the 1:1 logs from 10 p.m. on 5/10/25 to 6 a.m. on 5/11/25, from 2 p.m. on 5/23/25 to 6 a.m. on 5/24/25 (duplicate documentation from 2 p.m. to 6 a.m. noted on 5/23/25), from 2:10 p.m. to 5 p.m. on 5/27/25, from 6 a.m. to 8:30 a.m. on 5/28/25, from 10 p.m. on 5/28/25 to 6 a.m. on 5/29/25, from 2 p.m. to 5 p.m. on 5/30/25, from 10 p.m. on 6/4/25 to 8:30 a.m. on 6/5/25 and 6 a.m. to 7 a.m. on 6/6/25. Record review of facility's Elopement Binder revealed facility's audits for proper function and placement for code alert (wander guard) from 5/14 through 6/27/25, door checks from 4/28/25 through 7/4/25and elopement risk binders from 5/12/25 through 6/20/25 . Record review of facility's Elopement Binder revealed in services for Elopement, Response to Power Off on Exit Doors , Abuse and Neglect with objective staff will check wander guard placement every shift dated 5/6/25. The Elopement in-service included the objection to enhance staff monitoring and supervision by establishing protocols for appropriate staff supervision levels based on residents' risk assessments, encouraging regular observations and interactions. The Elopement in-service also included to implement individualized care plans. The Abuse and Neglect in-service included the objective staff will check wander guard placement every shift. All departments were included in the in-services with 130 staff members in-serviced regarding Elopement, 126 staff members in-serviced regarding Response to Power Off on Exit Doors and 136 staff members in-serviced regarding Abuse and Neglect. Record review of list of residents at risk of elopement provided during the investigation on 7/9/25 revealed there were four current residents at risk of elopement: Resident #3, Resident #4, Resident #5 and Resident #6. During interview on 7/9/25 at 11:06 a.m., LVN B said that they last saw Resident #2 between 11:00 p.m. to 12:00 a.m. and he was in bed and was wearing the wander guard. LVN B said Resident #2 was not in bed when they were making rounds around 12 a.m. but could not remember the exact time of the rounds. LVN B said they notified the administrator after searching inside and outside the facility. LVN B stated one of the doors had the alarm going off when they were searching for Resident #2 so that was when they thought he exited the building. LVN B said Resident #2 was not found before their shift ended at 6 a.m. LVN B said she had in-services regarding elopement that included to check the rooms, check the exit doors, and if the resident was missing then notify the administrator immediately. LVN B said Resident #2 had not tried to exit the facility before during their shift. During interview on 7/9/25 at 11:49 a.m., the Administrator said she was notified at 2:18 a.m. on 5/6/25 by LVN B of the elopement of Resident #2. The Administrator said that the Magnolia door was inspected on 5/6/25 after the incident and no issues were found. The Administrator said that Resident #2 was found by the Activities Director and Business Office after they started searching at 8 a.m. on 5/6/25 in addition to other staff members that were already searching for Resident #2. The Administrator said when Resident #2 was returned to the facility they replaced the wander guard and Resident #2 was placed on 1:1 supervision until he was transferred to the behavioral hospital. The Administrator said that staff should notify the Administrator and DON immediately when they realize a resident cannot be accounted for after performing a search of the facility. The Administrator said that Resident #2 had a history of removing the wander guard but was never exit seeking. The Administrator said that Resident #2 would maneuver off the wander guard. The Administrator said Resident #2 had no injuries or signs of distress when he was found. The Administrator said at the time of the incident on 5/6/25 all cameras were outside the facility and located in the Magnolia area which was the second lobby, one area of the dining room and the porch. During interview on 7/9/25 at 12:24 p.m., the Activities Director said they found Resident #2 around 9 a.m. sitting outside a car/mechanical shop at the intersection of two streets which was around a 25 minute walk from the facility per apple maps directions. The Activities Director said Resident #2 was tired and hungry when they found him but had no obvious injuries and was returned to the facility where an assessment by nursing was performed. On 7/9/25 at 12:52 p.m. all the exit doors to the facility were checked and sounded an alarm when tested. During interview on 7/9/25 at 1:20 p.m., the Administrator said Code Alert was the name for the wander guard they use. The Administrator said she did counsel LVN B who was the nurse involved in the elopement incident of Resident #2. Observation on 7/9/25 at 1:45 p.m. revealed the Administrator showing a video the Administrator stated was Resident #2 exiting the facility from the Magnolia door. An elderly man dressed in red clothing was seen walking away from the facility. The man was seen walking away from the building in the video at time stamp starting at 2:05:56 a.m. on Tuesday 5/6/25. During interview on 7/9/25 at 4:46 p.m., the Senior Maintenance said he checked the Magnolia door the day after the incident with Resident #2. The Senior Maintenance said he checked the wander guard system, keypad and everything locked down normally and everything was functioning as it should. The Senior Maintenance said that there were no prior problems with the door that he was aware of. The Senior Maintenance said the facility had done the life safety survey recently and all doors locked down with wander guard, released keypad and opened within the 15 second regulations. Observation on 7/10/25 at 9:09 a.m. revealed Resident #4's wander guard was intact on their left ankle. Observation on 7/10/25 at 9:11 a.m. revealed Resident #6's wander guard was intact on their left ankle. Observation on 7/10/25 at 9:16 a.m. revealed Resident #3's wander guard was intact on their left leg. Observation on 7/10/25 at 9:19 a.m. revealed Resident #5's wander guard was intact on their right ankle. During interview on 7/10/25 at 1:11 p.m. , CNA I stated the facility was using Code Orange for elopements. CNA I stated elopement procedures included that someone would print the census and check all the halls to make sure everyone was accounted for including to check all the rooms and doors including bathrooms and closets. CNA I said someone would also go around the premises to search. CNA I said also the Administrator and DON should be notified immediately regarding a resident elopement. During interview on 7/10/25 at 11:17 a.m. the Administrator provided documents with information regarding elopements and if residents remove wander guards. The Administrator said if she and the DON were notified that a resident removed the wander guard, they would implement the documents provided . Record review of the documents provided on 7/10/25 at 11:17 a.m. revealed an Elopement policy if there was a resident that removed their Code Alert (wander guard) the following measures would be implemented: notification by the Charge Nurse to Administrator and DNS, Notification to Family/RP, Notification to Attending Physician and/or NP, Care Plan Conference with resident and/or RP for a secure care consult (consult for a secured/locked unit), Code Alert will be reimplemented until alternative placement, Immediate placement on one-on-one until alternative placement achieved with a secure unit and Notifications to Area Director of Operations and Regional Compliance Nurse. During interview on 7/10/25 at 11:55 a.m., LVN D denied any problems with Resident #5 removing her wander guard and said she had worked with Resident #5 since Resident #5 had arrived at the facility which had been over six months. LVN D said the nurses would monitor residents who removed their wander guard and would start a 1:1 with the resident and notify the administrator. LVN D said they had training regarding this information about two months ago in May. LVN D said how they would monitor a resident who was removing their wander guard was that whoever was on a 1:1 with the resident always had eyes on the resident. LVN D said Resident #5 was the only resident with a wander guard she had at this time. During interview on 7/10/25 at 12:00 p.m., the DON said she started at the facility on 5/27/25 so she was not working at the time of the incident of Resident #2's elopement on 5/6/25. The DON said the nurses would monitor residents if they were removing the wander guard and should notify the DON and Administrator. The DON said that they only have four residents currently with wander guards and none of the four current residents with wander guards have behaviors with removing the wander guard. The DON said staff had follow up training regarding wander guards yesterday 7/9/25. During interview on 7/10/25 at 12:00 p.m., the Administrator also agreed none of the four current residents with wander guard have behaviors of removing the wander guard. The Administrator said staff was trained regarding what to do if residents remove wander guards in May.During interview on 7/10/25 at 12:08 p.m., LVN E said he usually works with Resident #3 and Resident #6 and are the only residents at his station with wander guards. LVN E said neither Resident #3 nor Resident #6 tried to remove the wander guard. LVN E said the nurses are who monitor the residents who attempt to remove the wander guards because they are supposed to be checked every shift. LVN E said that the CNAs are supposed to tell the nurses if they see the residents remove the wander guard . LVN E said if the resident was trying to remove the wander guard, then they are to notify the administrator and the DON. LVN E said that they did trainings regarding residents removing the wander guards in May and had an update 7/9/25. LVN E said residents are monitored are through 1:1 observation and this was usually done by a CNA. During interview on 7/10/25 at 12:18 p.m., LVN C said she normally works night shift at the station with Resident #3 and Resident #6. LVN C said that neither Resident #3 nor Resident #6 have problems with trying to remove the wander guards. LVN C said if residents attempted to remove the wander guard, they did 1:1 observation and redirection. LVN C said they checked for placement to make sure the wander guards were functioning correctly and in place. LVN C said that if a resident removes the wander guard, they notify the Administrator and the DON immediately. LVN C said that all staff would participate in monitoring if a resident were removing the wander guard or trying to elope. LVN C said regarding residents removing wander guards they received training a couple a months ago because they had a resident who was removing the wander guards and then a follow up 7/9/25. LVN C said the training included what to do if they hear an alarm, stand at the doors, full census sweep, 1:1 if the resident was known, make sure the wander guard is in place, safety monitoring and notify the DON/Administrator if the residents was continuing to try and exit. LVN C said the priority is the residents' safety. LVN C said she was working the night of 5/5/25 from 10 p.m. to 6 a.m. LVN C said they heard the alarm going off when she was getting report about 10:15-10:20 p.m. LVN C said she went to the Magnolia door with a couple of CNAs and checked the alarm for proper functioning. LVN C said she pushed the door open and the secondary alarm above the door went off. LVN C said she did a census and told the other nurses to do a census at that time. LVN C said that was when the nurse on Station 4 said she could not find her resident, but LVN C said she could not remember what time that occurred. LVN C said then they completed a search and notified the administrator. LVN C said that on the night of 5/5/25 there was a female resident who was sitting by the door who was wearing a wander guard and LVN C said she thought the female resident had touched the door. LVN C said that the female resident was transferred out to a secured unit and was no longer at the facility. LVN C said that after she checked the door the alarm was no longer going off and did not go off the rest of the night. During interview on 7/10/25 at 12:40 p.m., LVN B said she usually works 10 p.m. to 6 a.m. on the #400 hallway. LVN B said Resident #4 is the only resident on her hallway with a wander guard and Resident #4 has never tried to remove the wander guard. LVN B said that if a resident attempted or removed the wander guard , they initiate a 1:1. LVN B said the nurses or CNA would have to be with the resident all the time if they were attempting to remove the wander guard. LVN B said if a resident was removing the wander guard, they would notify the administrator and DON immediately if a resident was placed on a 1:1. LVN B said that they had elopement training and drill about two months ago and then updated 7/9/25. LVN B said that the training included what they are expected to do if the residents remove the wander guard which included to initiate the 1:1, someone to be with the resident all the time until they can find a long term unit to transfer the resident to. LVN B said that she was working the night shift 10 p.m. to 6 a.m. on 5/5/25 when she saw the alarm to the door was going off. LVN B said then they printed the census and checked the residents, and she said she could not remember the exact time but was after 12 midnight. LVN B said the door was alarming about this time around 12 midnight. Observation on 7/10/25 at 1:42 p.m. revealed Resident #5 with wander guard to right ankle. On 7/10/25 at 2:44 p.m., the facility administrator was notified of past noncompliance IJ. An IJ template was provided to the administrator via email at 2:48 p.m. During interview on 7/11/25 at 11:04 a.m., the Administrator stated that potential adverse effects a resident that eloped could have would include physical dangers, health complications and psychological distress. Record review of facility's policy for Elopement dated April 2017 revealed All team members will be alerted to search in the center or grounds as soon as there is an awareness of the resident missing. The policy also stated, If the resident is not quickly located in center or on grounds a point person is designated to make the following notifications: Administrator and Director of Nursing, Designated guardian or resident representative and Police (once the search of center and grounds determines the resident is not here or sooner if there is good indication they will not be located during the search). The policy also stated, Document condition notifications and times of actions deployed. Record review of the facility's undated Elopement policy if there was a resident that removed their Code Alert (wander guard) the following measures would be implemented: notification by the Charge Nurse to Administrator and DNS, Notification to Family/RP, Notification to Attending Physician and/or NP, Care Plan Conference with resident and/or RP for a secure care consult (consult for a secured/locked unit), Code Alert will be reimplemented until alternative placement, Immediate placement on one-on-one until alternative placement achieved with a secure unit and Notifications to Area Director of Operations and Regional Compliance Nurse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to implement their written policies and procedures that prohibit and prevent abuse and neglect for 1 of 8 residents (CR#1) reviewed for abuse and neglect. The facility failed to conduct a thorough investigation and report to State Survey agency when CR #1, who was a total care resident, sustained a supra condylar femur fracture and required surgical procedure. The facility failed to protect CR #1 for over 24 hours while awaiting results of his suspicious injury of unknown origin. The facility failed to ensure their Abuse/Neglect policy was implemented and effective to prevent the further decline of CR #1. An Immediate Jeopardy (IJ) situation was identified on 9/8/2023 at 5:37 p.m. While the IJ was removed on 9/12/2023 at 1:09 p.m., the facility remained out of compliance at a scope of isolated with actual harm due to the facility's need to evaluate the effectiveness of the corrective system. This failure could place residents at risk of serious injuries requiring hospitalization or surgical intervention, and/or death. Findings Included: Record review of the facility's abuse, neglect policy, dated 1/2019, revealed the purpose is to prohibit and prevent abuse, neglect and exploitation of resident property and to ensure reporting and investigation of alleged violations (to include injuries of unknown source, mistreatment and involuntary seclusion) in accordance with Federal and State Laws. Definitions: Injuries of Unknown origin source: When both criteria are met: the source of the injury was not observed, or the source could not be explained by the resident and the injury is suspicious because of the extent of the injury or the location of the injury (i.e. the injury is located in an area not generally vulnerable to trauma). Protection: First and foremost, the resident/patient will be immediately assessed and removed from any potential harm. The results of all investigations must be reported to the Administrator, designee to the appropriate state agency, as required by state law, within five (5) working days of alleged violation. Record review of CR #1's face sheet revealed a [AGE] year-old male who was admitted to the facility on [DATE]. CR #1 had diagnoses which included: Quadriplegia (paralysis of all four limbs), injury of cervical spinal cord, contracture of left and right hand(condition that causes one or more fingers to bend towards the palm of the hand), contracture of muscle(a fixed tightening of muscle, tendons or ligaments), acute respiratory failure with hypoxia (impairment of gas exchange between the lungs and the blood), flexion deformity(the inability to straighten or extend the knee), stage 4 pressure ulcer on spine(injury to skin and underlying tissue resulting from prolonged pressure on the skin) and epilepsy(disorder of the brain). Record review of CR #1's quarterly MDS assessment, dated 6/17/23, indicated the following: Section B0600- Speech clarity- (2) no speech B0700- Ability to make self-understood (3)-Rarely or never. B0800- Ability to understand others (3)-Rarely or never Section C500- Brief Interview of Mental Status was unscored. Section G0110- Activities of Daily Living (ADL's) included: bathing, toileting, grooming and hygiene) revealed the following: A. Bed Mobility - total dependence (4) required full staff performance every time during 7-day period with support (2)- (one-person physical assist), B. Transfer (4-total dependence) support (3) (two-person assist), C. Walk in room by self- 8 (never happened), toilet use -total dependence (4) support -(1-person assist), Bathing (4-total dependence)- support (1-person assist) Section G0130- Functional Status revealed CR #1 was dependent - helper did all effort. Resident did none of the effort to complete activity for eating, oral hygiene, toileting hygiene, shower/bathe, upper body dressing, lower body dressing, and putting on or taking off footwear. Section G0170- Mobility revealed CR #1 was dependent on staff (01) for roll left and right, sit to lying, lying to sitting on side of bed, chair/bed, chair transfer and sit to stand. Code 01- dependent- Helper does all of the effort. Resident did none of the effort to complete the activity. Toilet transfer, car transfer, and walk 10 feet were coded (88) for not attempted due to medical condition or safety concerns. Section H0300 - Urinary Incontinence revealed CR #1 was (3) always incontinent of bowel and bladder. Record review of care plan, dated 6/17/23, revealed CR #1 had an ADL self-care performance deficit r/t traumatic brain injury and spinal cord injury. Interventions were transferring required total assistance with mechanical lift and two-person staff assistance and bed mobility required extensive assistance by (2) staff to turn and reposition. Record review of CR#1 facesheet, careplan dated 6/17/2023 and MDS dated [DATE], revealed that CR#1 had no diagnosis of Osteoarthritis and no care plan interventions for the disease. Record review of progress note #1, dated 8/1/23 at 6:37 p.m., LVN A wrote: CNA A reported CR #1's knee was swollen, assessed and called MD. Record review of progress note dated 8/2/23 at 12:01p.m., RN A wrote: Called to follow up with local x-ray company on orders for bilateral patella X-ray and was informed that the order was in dispatch status. Record review of radiology results for CR #1, dated 8/2/23 at 2:19 p.m., revealed the resident had an impacted acute or subacute fracture of the supracondylar distal femur. Conclusion: Fracture of the distal right femur. Record review of progress note dated 8/2/23 at 9:34 p.m., revealed the results of the x-ray report showed a fracture femur, MD notified, ordered to send CR#1 to local hospital emergency room. Record review of progress note dated 8/2/23 at 10:16 p.m., CR#1 was transported to a local hospital via ambulance. Record review of the facility's abuse, neglect policy, dated 1/2019, revealed the purpose is to prohibit and prevent abuse, neglect and exploitation of resident property and to ensure reporting and investigation of alleged violations (to include injuries of unknown source, mistreatment and involuntary seclusion) in accordance with Federal and State Laws. Definitions: Injuries of Unknown origin source: When both criteria are met: the source of the injury was not observed, or the source could not be explained by the resident and the injury is suspicious because of the extent of the injury or the location of the injury (i.e. the injury is located in an area not generally vulnerable to trauma). Protection: First and foremost, the resident/patient will be immediately assessed and removed from any potential harm. The results of all investigations must be reported to the Administrator, designee to the appropriate state agency, as required by state law, within five (5) working days of alleged violation. Record review of punch detail report dated 8/1/23- 8/4/23 provided by HR revealed that LVN A, CNA A and CNA Z all worked on 8/1, 8/2 and 8/3 and had access to CR#1 for over 24 hours. Interview with the hospital charge nurse on 8/4/23 at 3:07 p.m., revealed the leg injury caused CR #1 to require a surgical procedure. She said he had a broken right femur, lateral collateral ligament (LCL) repair, washout, and open reduction internal fixation (process of putting pieces of a broken bone into place using surgery). She stated it was in her professional experience as a registered nurse that the resident was not capable of falling out of bed on his own. She said he was not able to move his limbs. She said whatever happened to him took force. She said that she was unable to say if it was abuse. She said the resident had not grimaced or shown any facial expressions since she had been observing him today (8/4/23). Interview with an anonymous nurse at the local hospital on 8/4/23 at 3:32 pm, revealed her to state that it appears that someone intentionally hurt him. She said, off the record, the charge nurse might not have said that, but everyone that has cared for him at the hospital felt like someone did this to him. She said as a mother this would be very upsetting to her. She said that she felt like he was abused. Interview with the FM on 8/4/23 at 8:11 p.m., revealed that she received a call from LVN A (8/2/23) concerning CR #1's knee being swollen and later a call from LVN A that the lab results confirmed the resident had a fractured femur. She stated she inquired about what happened to CR #1. She said LVN A stated she was not sure, but the first report of a swollen knee was on 8/1/23. She said LVN A refused to say anymore. She denied talking with any other administration or nursing staff concerning the injury. She said the surgeon told her the longest and strongest bone in the bone was broken along with ligaments in his knee had to be repaired. The FM stated the surgeon said whatever happened to him required force to break his femur. She said that the admitting physician told her that it is difficult to break this bone. She said that she believes that someone at the facility intentionally hurt him, and she is very upset about him being treated in this way. Interview with the Interim Administrator A on 8/5/23 at 12:11 p.m., revealed he was a traveling Administrator and his 1st day of work at the facility was on 8/3/23. He said that he was just made aware of the incident on 8/3/23. He stated he did not call in an incident to State Agency. He said that the Administrator is responsible for investigating and reporting incidents of unknown origin. However, the DON and ADON can investigate and call in an incident as well. He said that incidents not investigated or reported to State agency can leave residents vulnerable to abuse, neglect or exploitation. Interview with the Director of Clinical Operations on 8/5/23 at 2:03 p.m., revealed the lab results revealed CR #1 had osteoarthritis and his contractures made him vulnerable to losing bone density and thus could have caused his fracture. She denied investigating the incident of unknown origin because she said that it was not considered suspicious. She denied reporting the incident of unknown origin to the State Agency. Interview with the DON on 8/5/23 at 2:06 p.m., revealed LVN A reported CR #1's knee was swollen (8/1/23), and a S-Bar was put in on Wednesday (8/2/23) once the results came back and informed them of his fracture. She said the Director of Clinical Operation requested the test be done stat due to his co-morbidities, but they believed his fracture was due to his osteoarthritis. She said he was sent to the emergency room for care. She said there were no reports of CR #1 falling or trauma. She denied an investigation because she said they investigated when an injury was suspicious. She stated she had not called the State Agency because she was not sure if the former Administrator had called it in. She said the Administrator was not the only person who could call in an incident of unknown origin. She said, I guess any nurse could have called the incident in to State agency. Interview with CNA A on 8/8/23 at 3:23 p.m., revealed she had been off three days prior to 8/1/23. She stated upon her return to work she was doing rounds and noticed CR #1 right knee was swollen. She said it was like a large grapefruit. She said she immediately called LVN A into the room to observe. She said she had not tried to transfer or change the resident. She said she checked his brief to see if the previous shift had changed him and that is when she saw his knee as she pulled back the covers. She denied witnessing him fall or any trauma. Interview with Interim Administrator B on 9/8/23 at 5:47p.m., revealed her to state that when she first learned about the incident, she was told that CR#1 had co-morbidities that could have caused the injury, but that the DON started an investigation. She stated that she did not think any staff had been suspended. Subsequent interview with DON on 9/8/23 at 5:50pm, she stated that she did conduct an interview she stated that she did start the investigation process by getting statements from staff. She did not call in CR#1 injury of unknown origin because she said that it was not suspicious. She stated that she should have called it in to the State because now she understands how it was could have been considered suspicious. She denied staff being suspended pending an investigation. She said that she had no evidence to accuse anyone. She stated that she does understand that she was supposed to protect CR#1 while investigating. Interview with LVN A on 9/10/23 at 12:29pm, revealed her to state that she worked on 8/1 (day CNA reported CR#1 swollen knee), 8/2/23 (day results confirmed fracture) and worked Hall 100 (where CR#1 resided) on both days. She admitted that she had not been sent home or suspended. She was not aware of an investigation, but she said she wrote a statement and documented the progress note as they are required to do. Subsequent interview with DON on 9/11/23 at 2:10pm, revealed her to state that she started an investigation on 8/2/23, she learned that nobody saw anything and CNA A reported the swelling on 8/1/23. She said no one was suspended. What did she do to protect CR#1 during her investigation she responded, He was already gone, we sent him to the ER after getting the results. She was asked if the same staff (LVNA, CNA A and CNA P had access to CR#1 and she responded, she was not sure without looking at the schedule. But, she should have suspended the CNA that worked overnight 10p-6a(7/31/23), CNA P (worked 6-2pm shift on 8/1 and 8/2) , CNA A (reported the swollen knee 2-10pm shift on 8/2). She was unable to say why she did not protect CR#1 as their policy requires. Subsequent interview with Interim Administrator B on 9/11/23 at 2:16pm, revealed her to state that she was not working here at the time, but she began an investigation of her own. She stated that because of his osteoarthritis no one suspected abuse. She said that she can understand how this incident could be viewed as suspicious and thus called for a thorough investigation and reporting. She said she would report the incident to State agency immediately. Interview with HR on 9/11/23 at 2:25pm revealed her to state that she was not informed to suspend any employees due to CR#1's injury. She stated that the ADM or DON would be the two managers that would suspend employees if there was an investigation and determined that staff were going to be investigated. She stated that she had been employed with the company since May 2023. Record review of the DON's, undated, job description responsibilities states: (1) DON assumes responsibility of facility in absence of Administrator. (2) Works in collaboration with the center; ensures education and understanding by all team members of abuse recognition, protecting and reporting responsibilities; responds swiftly to any allegation of abuse, neglect or misappropriation by protecting, investigating and making any required reporting. Record review of TULIP on 8/9/23 and 9/9/23 revealed no incident report was found concerning CR #1's injury of unknown origin. The Interim Administrator B and DON was notified of an Immediate Jeopardy (IJ) on 9/8/2023 at 5:37p.m., due to the above failures, the Interim Administrator B was given a copy of the IJ template and a Plan of Removal (POR) was requested. The following Plan of Removal submitted by the facility was accepted on 9/9/23 at 3:20pm Immediate action to ensure residents were not in jeopardy and threat of harm: On 9/8/23, the Administrator and the DNS immediately took the following actions to address the citation to prevent any additional residents from experiencing an adverse outcome. On 9/8/23, the DNS and her designee conducted medical record reviews of all residents to identify which residents were interview able verse those that could not be interviewed. BIMS scores were collected to determine those residents that could be interviewed verses those that were considered non interviewable. On 9/8/23, the DNS and her designees completed physical assessments of all residents with a BIMS score of less than 11 to determine if there was evidence or abuse or injury of unknown origin. Assessments of these resident revealed no such evidence of abuse or injury of unknown origin. Documentation of these assessments was captured on an assessment tool and placed in the survey binder. This action was completed on 9/8/23. On 9/8/23, the DNS and her designees interviewed each resident with a BIMS of 11 or higher to assure they had not been abused or experienced an injury of unknown origin. Interview of these residents was captured on an interview tool and placed in the survey binder. Neither evidence of abuse nor injury of unknown origin was identified through interviews or body audits. This action was completed on 9/8/23. If evidence of abuse or injury of unknown origin had been identified, the Administrator would have suspended any accused staff and reported the incidents to the state and law enforcement in accordance with the State law and licensing agency requirements. A detailed investigation would have been prepared and submitted within 5 days of the negative findings. On 9/8/23, the Regional [NAME] President and the Senior Director of Clinical Operations provided training for the interim administrator and the Director of Nurses regarding abuse identification, protection, conducting a thorough investigation and reporting requirements. This action was completed on 9/8/23. Following the Adm and DNS training on 9/8/23, training on the center's abuse and neglect policy was initiated by DNS and her designee to include identification of abuse, protections of residents, investigation and reporting requirements. The DNS completed training on the morning of 9/9/23 for all staff that were working on the evening and night shifts. This training will continue until all staff are training. Employees will not be allowed to work until they have received this training. Facilities Plan to ensure compliance quickly by the following actions: All federal and State protocols will be followed going forward to include investigating and reporting abuse and injury of unknown origin allegations. The ADM is designated as the Abuse Coordinator . The Administrator was in-serviced on abuse identification, protection, conducting a thorough investigation and reporting requirements by RVP and Senior Director of Clinical Operations. This action was completed on 9/8/23. On 9/8/23, Residents with BIMS scores of 11 or higher were interviewed by the DNS and her designees to identify in they felt safe and if they had experienced abuse while living at the center. No concerns were identified. These interviews were completed on 9/8/23. On 9/8/23, the Abuse policy was reviewed by the Regional [NAME] President and the Senior Director of Clinical Operations. This review was completed on 9/8/23. No updates were necessary. On 9/8/23, Interim Administrator implemented an abuse investigation checklist to ensure investigations will be initiated and completed thoroughly. On 9/8/23, the DNS and her designee educated all staff on abuse prevention and reporting. This education was completed on 9/8/23. Going forward, any staff that were not present on 9/8/23 will not be allowed to work until they have been trained. On 9/9/23, the Activities Director will hold a Resident Council meeting in which the residents will be educated on the facility's abuse policies. This council meeting will conclude on 9/9/23. The Administrator or designee will continue to interview residents with a BIMS score of 11 or greater on a monthly basis to ensure they have not experienced abuse. 5 residents per week will be interviewed for 3 months starting the week of 9/11/23. The Director of Nursing or designee will conduct physical assessments on 5 residents per week with BIMS score of less than 11 to determine if there is evidence of abuse or injury of unknown origin for 3 months starting the week of 9/11/23. The findings of these interviews and physical assessments will be presented in QAPI as a PIP project. On 9/9/23, the Regional Director of Maintenance will conduct an environmental safety concern assessment of the center. This assessment will be completed by the center's maintenance director or the administrator on a weekly basis for 3 months beginning the week of 9/11/23. The findings of these assessments will be presented in QAPI as a PIP project. Competency of staff related to the Abuse/Neglect training will be captured by a competency test after each training. These competencies will continue until all are trained and deemed competent. Monitoring of the plan of removal included the following: Record review of in-services revealed that abuse, neglect, expliotation, including injuries of unknown origin, turning and repostioning, lift and transfers, customer service, reporting incidents and abuse coordinator acknowledgements were conducted. Interview with the Interim Administrator B on 9/10/23 at 11:24am, revealed her to state that BIM scores were pulled from MDS and she compared with the census to ensure every resident was either deemed interviewable (BIM score above 11) or required a body audit if BIM score was under 11. She provided a list of the residents that were interviewed and those that they conducted body audits on. Interview with Activity Director on 9/10/23 at 12:02p.m., revealed her to state that she conducted a resident council meeting with the residents, and none of the residents had any concerns about abuse, neglect or misappropriations. She said that she had a training and in-service on abuse and neglect, professionalism, transfers, smoking policy. Interview with two housekeepers on 9/10/23 at 12:07p.m., revealed them to state that they had an in-service on abuse, neglect, reporting if they see someone mistreating the residents to report it to the Administrator or DON. Interview with Maintenance and Regional Maintenance on 9/10/23 at 12:12pm, revealed them to state that on a daily basis they are checking the building for safety hazards such as: fire extinguishers, doors, outlets, hoyer lifts and checking for any safety issues in the facility. Interviews with CNA's on all three shifts, LVN A, two housekeepers, one floor tech, one MA, two charge nurses and maintenance and they all stated that they had been in-serviced on abuse, neglect and exploitation, reporting abuse and told if they had witnessed abuse they would report it to the Administrator. The Interim Administrator B was informed the Immediate Jeopardy was removed on 9/12/23 at 1:09pm. The facility remained out of compliance at a severity level of actual harm that is not IJ and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to develop and implement policies and procedures for ensuring the reporting of reasonable suspicion of a crime for 1 (CR #1) of 8 residents who was total care and sustained a femur fracture. 1. The facility failed to thoroughly investigate and report to State Survey agency that CR #1, who was a total care resident, sustained a supra condylar femur fracture and required surgical procedure.On 8/2/23 the resident was sent to the hospital and it was confirmed to be a supracondylar acute or subacute fracture. This suspicious injury of unknown origin should have been reported to the Administrator immediately. Interim Administrator A was not made aware of the incident until 8/3/23 a day later. Meanwhile the staff that had assisted CR#1 continued to work and no investigation was started. Interim Administrator A did not conduct an investigation. 2. The facility failed to ensure all allegations involving abuse, neglect, exploitation, or mistreatment including injuries of unknown origin were reported to State Agency for 1 (CR #1) of 8 reviewed for abuse and neglect. This failure could have placed 101 residents at risk of abuse and neglect. An Immediate Jeopardy (IJ) situation was identified on 9/8/2023 at 5:37 p.m. While the IJ was removed on 9/12/2023 at 1:09 p.m., the facility remained out of compliance at a scope of isolated with actual harm due to the facility's need to evaluate the effectiveness of the corrective system. Findings Included: Record review of census provided on 8/4/2023, revealed a census of 101 residents. Record review of CR #1's face sheet revealed a [AGE] year-old male who was admitted to the facility on [DATE]. CR #1 had diagnoses which included: Quadriplegia(paralysis of all four limbs), injury of cervical spinal cord, contracture of left and right hand(condition that causes one or more fingers to bend towards the palm of the hand), contracture of muscle(a fixed tightening of muscle, tendons or ligaments), acute respiratory failure with hypoxia (impairment of gas exchange between the lungs and the blood), flexion deformity(the inability to straighten or extend the knee), stage 4 pressure ulcer on spine(injury to skin and underlying tissue resulting from prolonged pressure on the skin) and epilepsy(disorder of the brain). Record review of CR #1's quarterly MDS assessment, dated 6/17/23, indicated the following: Section B0600- Speech clarity- (2) no speech B0700- Ability to make self-understood (3)-Rarely or never. B0800- Ability to understand others (3)-Rarely or never Section C500- Brief Interview of Mental Status was unscored. Section G0110- Activities of Daily Living (ADL's) included: bathing, toileting, grooming and hygiene) revealed the following: A. Bed Mobility - total dependence (4) required full staff performance every time during 7-day period with support (2)- (one-person physical assist), B. Transfer (4-total dependence) support (3) (two-person assist), C. Walk in room by self- 8 (never happened), toilet use -total dependence (4) support -(1-person assist), Bathing (4-total dependence)- support (1-person assist) Section G0130- Functional Status revealed CR #1 was dependent - helper did all effort. Resident did none of the effort to complete activity for eating, oral hygiene, toileting hygiene, shower/bathe, upper body dressing, lower body dressing, and putting on or taking off footwear. Section G0170- Mobility revealed CR #1 was dependent on staff (01) for roll left and right, sit to lying, lying to sitting on side of bed, chair/bed, chair transfer and sit to stand. Code 01- dependent- Helper does all of the effort. Resident did none of the effort to complete the activity. Toilet transfer, car transfer, and walk 10 feet were coded (88) for not attempted due to medical condition or safety concerns. Section H0300 - Urinary Incontinence revealed CR #1 was (3) always incontinent of bowel and bladder. Record review of care plan, dated 6/17/23, revealed CR #1 had an ADL self-care performance deficit r/t traumatic brain injury and spinal cord injury. Interventions were transferring required total assistance with mechanical lift and two-person staff assistance and bed mobility required extensive assistance by (2) staff to turn and reposition. Record review of progress note #1, dated 8/1/23 at 6:37 p.m. LVN A wrote: CNA A reported CR #1's knee was swollen, assessed and contracted physician. Record review of progress note dated 8/2/23 at 12:01p.m., RN A wrote: Called to follow up with local x-ray company on orders for bilateral patella X-ray and was informed that the order was in dispatch status. Record review of radiology results for CR #1, dated 8/2/23 at 2:19 p.m., revealed the resident had an impacted acute or subacute fracture of the supracondylar distal femur. Conclusion: Fracture of the distal right femur. Record review of progress note dated 8/2/23 at 9:34 p.m., revealed the results of the x-ray report showed a fracture femur, MD notified, ordered to send CR#1 to local hospital emergency room. Record review of progress note dated 8/2/23 at 10:16p.m., CR#1 was transported to a local hospital via ambulance. Record review of CR#1 facesheet, careplan dated 6/17/2023 and MDS dated [DATE], revealed that CR#1 had no diagnosis of Osteoarthritis and no care plan interventions for the disease. Record review of the facility's abuse, neglect policy, dated 1/2019, revealed the purpose is to prohibit and prevent abuse, neglect and exploitation of resident property and to ensure reporting and investigation of alleged violations (to include injuries of unknown source, mistreatment and involuntary seclusion) in accordance with Federal and State Laws. Definitions: Injuries of Unknown origin source: When both criteria are met: the source of the injury was not observed, or the source could not be explained by the resident and the injury is suspicious because of the extent of the injury or the location of the injury (i.e. the injury is located in an area not generally vulnerable to trauma). Protection: First and foremost, the resident/patient will be immediately assessed and removed from any potential harm. The results of all investigations must be reported to the Administrator, designee to the appropriate state agency, as required by state law, within five (5) working days of alleged violation. Record review of punch detail report dated 8/1/23- 8/4/23 provided by HR revealed that LVN A, CNA A and CNA Z all worked on 8/1, 8/2 and 8/3 and had access to CR#1 for over 24 hours. Interview with the Interim Administrator A on 8/5/23 at 12:11 p.m., revealed he was a traveling Administrator and his 1st day of work at the facility was on 8/3/23. He said that he was just made aware of the incident on 8/3/23. He stated he did not call in an incident to State Agency. He said that the Administrator is responsible for investigating and reporting incidents of unknown origin. However, the DON and ADON can investigate and call in an incident as well. He said that incidents not investigated or reported to State agency can leave residents vulnerable to abuse, neglect or exploitation. Interview with the Director of Clinical Operations on 8/5/23 at 2:03 p.m., revealed the lab results revealed CR #1 had osteoarthritis and his contractures made him vulnerable to losing bone density and thus could have caused his fracture. She denied investigating the incident of unknown origin because she said that it was not considered suspicious. She denied reporting the incident of unknown origin to the State Agency. Interview with the DON on 8/5/23 at 2:06 p.m., revealed LVN A reported CR #1's knee was swollen (8/1/23), and a S-Bar was put in on Wednesday (8/2/23) once the results came back and informed them of his fracture. She said the Director of Clinical Operation requested the test be done stat due to his co-morbidities, but they believed his fracture was due to his osteoarthritis. She said he was sent to the emergency room for care. She said there were no reports of CR #1 falling or trauma. She denied an investigation because she said they investigated when an injury was suspicious. She stated she had not called the State Agency because she was not sure if the former Administrator had called it in. She said the Administrator was not the only person who could call in an incident of unknown origin. She said, I guess any nurse could have called the incident in to State agency. Interview with CNA A on 8/8/23 at 3:23 p.m., revealed she had been off three days prior to 8/1/23. She stated upon her return to work she was doing rounds and noticed CR #1 right knee was swollen. She said it was like a large grapefruit. She said she immediately called LVN A into the room to observe. She said she had not tried to transfer or change the resident. She said she checked his brief to see if the previous shift had changed him and that is when she saw his knee as she pulled back the covers. She denied witnessing him fall or any trauma. Interview with Interim Administrator B on 9/8/23 at 5:47 p.m., revealed her to state that when she first learned about the incident, she was told that CR#1 had co-morbidities that could have caused the injury, but that the DON started an investigation. She stated that she did not think any staff had been suspended. Subsequent interview with DON on 9/8/23 at 5:50 p.m., she stated that she did conduct an interview she stated that she did start the investigation process by getting statements from staff. She did not call in CR#1 injury of unknown origin because she said that it was not suspicious. She stated that she should have called it in to the State because now she understands how it was could have been considered suspicious. She denied staff being suspended pending an investigation. She said that she had no evidence to accuse anyone. She stated that she does understand that she was supposed to protect CR#1 while investigating. Interview with LVN A on 9/10/23 at 12:29 p.m., revealed her to state that she worked on 8/1 (day CNA reported CR#1 swollen knee), 8/2/23 (day results confirmed fracture) and worked Hall 100 (where CR#1 resided) on both days. She admitted that she had not been sent home or suspended. She was not aware of an investigation, but she said she wrote a statement and documented the progress note as they are required to do. Subsequent interview with DON on 9/11/23 at 2:10 p.m., revealed her to state that she started an investigation on 8/2/23, she learned that nobody saw anything and CNA A reported the swelling on 8/1/23. She said no one was suspended. What did she do to protect CR#1 during her investigation she responded, He was already gone, we sent him to the ER after getting the results. She was asked if the same staff (LVNA, CNA A and CNA P had access to CR#1 and she responded, she was not sure without looking at the schedule. But, she should have suspended the CNA that worked overnight 10p-6a (7/31/23), CNA P (worked 6-2pm shift on 8/1 and 8/2) , CNA A (reported the swollen knee 2-10pm shift on 8/2). She was unable to say why she did not protect CR#1 as their policy requires. Subsequent interview with Interim Administrator B on 9/11/23 at 2:16 p.m., revealed her to state that she was not working here at the time, but she began an investigation of her own. She stated that because of his osteoarthritis no one suspected abuse. She said that she can understand how this incident could be viewed as suspicious and thus called for a thorough investigation and reporting. She said she would report the incident to State agency immediately. Interview with HR on 9/11/23 at 2:25 p.m. revealed her to state that she was not informed to suspend any employees due to CR#1's injury. She stated that the ADM or DON would be the two managers that would suspend employees if there was an investigation and determined that staff were going to be investigated. She stated that she had been employed with the company since May 2023. Record review of the DON's, undated, job description responsibilities states: (1) DON assumes responsibility of facility in absence of Administrator. (2) Works in collaboration with the center; ensures education and understanding by all team members of abuse recognition, protecting and reporting responsibilities; responds swiftly to any allegation of abuse, neglect or misappropriation by protecting, investigating and making any required reporting. Record review of TULIP on 8/9/23 and 9/9/23 revealed no incident report was found concerning CR #1's injury of unknown origin.The Interim Administrator B and DON was notified of an Immediate Jeopardy (IJ) on 9/8/2023 at 5:37p.m., due to the above failures, the Interim Administrator B was given a copy of the IJ template, and a Plan of Removal (POR) was requested. The following Plan of Removal submitted by the facility was accepted on 9/9/23 at 3:20pm Immediate action to ensure residents were not in jeopardy and threat of harm: On 9/8/23, the Administrator and the DNS immediately took the following actions to address the citation to prevent any additional residents from experiencing an adverse outcome. On 9/8/23, the DNS and her designee conducted medical record reviews of all residents to identify which residents were interview able verses those that could not be interviewed. BIMS scores were collected to determine those residents that could be interviewed verses those that were considered non interview able. On 9/8/23, the DNS and her designees completed physical assessments of all residents with a BIMS score of less than 11 to determine if there was evidence or abuse or injury of unknown origin. Assessments of these resident revealed no such evidence of abuse or injury of unknown origin. Documentation of these assessments was captured on an assessment tool and placed in the survey binder. This action was completed on 9/8/23. On 9/8/23, the DNS and her designees interviewed each resident with a BIMS of 11 or higher to assure they had not been abused or experienced an injury of unknown origin. Interview of these residents was captured on an interview tool and placed in the survey binder. Neither evidence of abuse nor injury of unknown origin was identified through interviews or body audits. This action was completed on 9/8/23. If evidence of abuse or injury of unknown origin had been identified, the Administrator would have suspended any accused staff and reported the incidents to the state and law enforcement in accordance with the State law and licensing agency requirements. A detailed investigation would have been conducted and the results submitted within 5 days of the negative findings. On 9/8/23, the Regional [NAME] President and the Senior Director of Clinical Operations provided training for the interim administrator and the Director of Nurses regarding abuse identification, protection, conducting a thorough investigation and reporting requirements. This action was completed on 9/8/23. Following the Adm and DNS training on 9/8/23, training on the center's abuse and neglect policy was initiated by DNS and her designee to include identification of abuse, protections of residents, investigation and reporting requirements. The DNS completed training on the morning of 9/9/23 for all staff that were working on the evening and night shifts. This training will continue until all staff are training. Employees will not be allowed to work until they have received this training. Facilities Plan to ensure compliance quickly by the following actions: All federal and State protocols will be followed going forward to include investigating and reporting abuse and injury of unknown origin allegations. The ADM is designated as the Abuse Coordinator. The Administrator was in-serviced on abuse identification, protection, conducting a thorough investigation and reporting requirements by RVP and Senior Director of Clinical Operations. This action was completed on 9/8/23. On 9/8/23, Residents with BIMS scores of 11 or higher were interviewed by the DNS and her designees to identify in they felt safe and if they had experienced abuse while living at the center. No concerns were identified. These interviews were completed on 9/8/23. On 9/8/23, the Abuse policy was reviewed by the Regional [NAME] President and the Senior Director of Clinical Operations. This review was completed on 9/8/23. No updates were necessary. On 9/8/23, Interim Administrator implemented an abuse investigation checklist to ensure investigations will be initiated and completed thoroughly. On 9/8/23, the DNS and her designee educated all staff on abuse prevention and reporting. This education was completed on 9/8/23. Going forward, any staff that were not present on 9/8/23 will not be allowed to work until they have been trained. On 9/9/23, the Activities Director will hold a Resident Council meeting in which the residents will be educated on the facility's abuse policies. This council meeting will conclude on 9/9/23. The Administrator or designee will continue to interview residents with a BIMS score of 11 or greater on a monthly basis to ensure they have not experienced abuse. 5 residents per week will be interviewed for 3 months starting the week of 9/11/23. The Director of Nursing or designee will conduct physical assessments on 5 residents per week with BIMS score of less than 11 to determine if there is evidence of abuse or injury of unknown origin for 3 months starting the week of 9/11/23. The findings of these interviews will be presented in QAPI as a PIP project. On 9/9/23, the Regional Director of Maintenance will conduct an environmental safety concern assessment of the center. This assessment will be completed by the center's maintenance director or the administrator on a weekly basis for 3 months beginning the week of 9/11/23. The findings of these assessments will be presented in QAPI as a PIP project. Competency of staff related to the Abuse/Neglect training will be captured by a competency test after each training. These competencies will continue until all are trained and deemed competent. Monitoring of the plan of removal included the following: Record review of in-services revealed that abuse, neglect, expliotation, including injuries of unknown origin, turning and repostioning, lift and transfers, customer service, reporting incidents and abuse coordinator acknowledgements were conducted. Interview with the Interim Administrator B on 9/10/23 at 11:24 a.m., revealed her to state that BIM scores were pulled from MDS and she compared with the census to ensure every resident was either deemed interviewable (BIM score above 11) or required a body audit if BIM score was under 11. She provided a list of the residents that were interviewed and those that they conducted body audits on. Interview with Activity Director on 9/10/23 at 12:02p.m., revealed her to state that she conducted a resident council meeting with the residents, and none of the residents had any concerns about abuse, neglect or misappropriations. She said that she had a training and in-service on abuse and neglect, reporting incidents, professionalism, transfers, smoking policy. Interview with two housekeepers on 9/10/23 at 12:07p.m., revealed them to state that they had an in-service on abuse, neglect, reporting if they see someone mistreating the residents to report it to the Administrator or DON. Interview with Maintenance and Regional Maintenance on 9/10/23 at 12:12pm, revealed them to state that on a daily basis they are checking the building for safety hazards such as: fire extinguishers, doors, outlets, hoyer lifts and checking for any safety issues in the facility. Interviews with CNA's on all three shifts, LVN A, two housekeepers, one floor tech, one MA, two charge nurses and maintenance and they all stated that they had been in-serviced on abuse, neglect and exploitation, reporting abuse and told if they had witnessed abuse they would report it to the Administrator. The Interim Administrator B was informed the Immediate Jeopardy was removed on 9/12/23 at 1:09pm. The facility remained out of compliance at a severity level of actual harm that is not IJ and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. Record review of TULIP on 9/14/23 revealed a provider's report dated 9/12/23 with findings of inconclusive for the allegation of injury of unknown origin.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to thoroughly investigate and report an injury of unknown origin for 1 (CR #1) of 8 reviewed for abuse and neglect. The facility failed to thoroughly investigate CR #1 injury of unknown origin which was suspicious due him being a total care resident with an impacted acute or subacute fracture of the supracondylar distal femur and a diagnosis of Quadriplegia. The facility failed to implement interventions to ensure CR #1 was safe after learning that his knee was swollen and was total dependent on staff for care. The facility failed to report the results of all investigations to officials in accordance with state law, including to State agency within 5 working days of the incident. An Immediate Jeopardy (IJ) situation was identified on 9/8/2023 at 5:37 p.m. While the IJ was removed on 9/12/2023 at 1:09 p.m., the facility remained out of compliance at a scope of isolated with actual harm due to the facility's need to evaluate the effectiveness of the corrective system. This failure could have placed residents at risk of abuse and neglect. Finding Included: Record review of census provided on 8/4/2023, revealed a census of 101 residents. Record review of CR #1's face sheet revealed a [AGE] year-old male who was admitted to the facility on [DATE]. CR #1 had diagnoses which included: Quadriplegia(paralysis of all four limbs), injury of cervical spinal cord, contracture of left and right hand(condition that causes one or more fingers to bend towards the palm of the hand), contracture of muscle(a fixed tightening of muscle, tendons or ligaments), acute respiratory failure with hypoxia (impairment of gas exchange between the lungs and the blood), flexion deformity(the inability to straighten or extend the knee), stage 4 pressure ulcer on spine(injury to skin and underlying tissue resulting from prolonged pressure on the skin) and epilepsy(disorder of the brain). Record review of care plan, dated 6/17/23, revealed CR #1 had an ADL self-care performance deficit r/t traumatic brain injury and spinal cord injury. Interventions were transferring required total assistance with mechanical lift and two-person staff assistance and bed mobility required extensive assistance by (2) staff to turn and reposition. Record review of progress note #1, dated 8/1/23 at 6:37 PM, revealed CNA A reported CR #1's knee was swollen to LVN A. Record review of progress note dated 8/2/23 at 12:01p.m., RN A wrote: Called to follow up with local x-ray company on orders for bilateral patella X-ray and was informed that the order was in dispatch status. Record review of radiology results for CR #1, dated 8/2/23 at 2:19 p.m., revealed the resident had an impacted acute or subacute fracture of the supracondylar distal femur. Conclusion: Fracture of the distal right femur. Record review of progress note dated 8/2/23 at 9:34 p.m., revealed the results of the x-ray report showed a fracture femur, MD notified, ordered to send CR#1 to local hospital emergency room. Record review of progress note dated 8/2/23 at 10:16p.m., CR#1 was transported to a local hospital via ambulance. Record review of CR#1 facesheet, careplan dated 6/17/2023 and MDS dated [DATE], revealed that CR#1 had no diagnosis of Osteoarthritis and no care plan interventions for the disease. Record review of the schedule dated 8/1/23 and 8/2/23, revealed that LVN A was scheduled as the nurse for Hall 100, CNA B worked 6a-2pm shift on Hall 100, CNA A was scheduled to work Hall 100 (2pm-10pm shift). Record review of punch detail report dated 8/1/23- 8/4/23 provided by HR revealed that LVN A, CNA A and CNA B all worked on 8/1/23, 8/2/23 and 8/3/23 and had access to CR#1 for over 24 hours. Interview with the hospital charge nurse on 8/4/23 at 3:07 p.m., revealed the leg injury caused CR #1 to require a surgical procedure. She said he had a broken right femur, lateral collateral ligament (LCL) repair, washout, and open reduction internal fixation (process of putting pieces of a broken bone into place using surgery). She stated it was in her professional experience as a registered nurse that the resident was not capable of falling out of bed on his own. She said he was not able to move his limbs. She said whatever happened to him took force. She said that she was unable to say if it was abuse. She said the resident had not grimaced or shown any facial expressions since she had been observing him today (8/4/23). Interview with an anonymous nurse at the local hospital on 8/4/23 at 3:32 pm, revealed her to state that it appears that someone intentionally hurt him. She said, off the record, the charge nurse might not have said that, but everyone that has cared for him at the hospital felt like someone did this to him. She said as a mother this would be very upsetting to her. She said that she felt like he was abused. Interview with the FM on 8/4/23 at 8:11 p.m., revealed that she received a call from LVN A (8/2/23) concerning CR #1's knee being swollen and later a call from LVN A that the lab results confirmed the resident had a fractured femur. She stated she inquired about what happened to CR #1. She said LVN A stated she was not sure, but the first report of a swollen knee was on 8/1/23. She said LVN A refused to say anymore. She denied talking with any other administration or nursing staff concerning the injury. She said the surgeon told her the longest and strongest bone in the bone was broken along with ligaments in his knee had to be repaired. The FM stated the surgeon said whatever happened to him required force to break his femur. She said that the admitting physician told her that it is difficult to break this bone. She said that she believes that someone at the facility intentionally hurt him, and she is very upset about him being treated in this way. Interview with the Interim Administrator A on 8/5/23 at 12:11 p.m., revealed he was a traveling Administrator and his 1st day of work at the facility was on 8/3/23. He said that he was just made aware of the incident on 8/3/23. He stated he did not call in an incident to State Agency. He said that the Administrator is responsible for investigating and reporting incidents of unknown origin. However, the DON and ADON can investigate and call in an incident as well. He said that incidents not investigated or reported to State agency can leave residents vulnerable to abuse, neglect or exploitation. Interview with the Director of Clinical Operations on 8/5/23 at 2:03 p.m., revealed the lab results revealed CR #1 had osteoarthritis and his contractures made him vulnerable to losing bone density and thus could have caused his fracture. She denied investigating the incident of unknown origin because she said that it was not considered suspicious. She denied reporting the incident of unknown origin to the State Agency. Interview with the DON on 8/5/23 at 2:06 p.m., revealed LVN A reported CR #1's knee was swollen (8/1/23), and a S-Bar was put in on Wednesday (8/2/23) once the results came back and informed them of his fracture. She said the Director of Clinical Operation requested the test be done stat due to his co-morbidities, but they believed his fracture was due to his osteoarthritis. She said he was sent to the emergency room for care. She said there were no reports of CR #1 falling or trauma. She denied an investigation because she said they investigated when an injury was suspicious. She stated she had not called the State Agency because she was not sure if the former Administrator had called it in. She said the Administrator was not the only person who could call in an incident of unknown origin. She said, I guess any nurse could have called the incident in to State agency. Interview with Physician A on 8/8/23 at 3:05 p.m., revealed he received a call and/or text from LVN A on 8/1/23 concerning CR #1's swollen knee. He stated he ordered blood work to rule out gout and rheumatoid arthritis and an x-ray of right bilateral knee. He said the resident did not have evidence of gout or rheumatoid arthritis. He said osteoarthritis would not cause a fracture. He said given CR #1's age of 25, and the fact he did not have any diagnosis that would cause a fracture of the femur, he was baffled at how something like this could have happened. He stated CR #1 had been under his care since he was admitted to the facility (1/13/22) and have not had any seizures. Interview with CNA A on 8/8/23 at 3:23 p.m., revealed she had been off three days prior to 8/1/23. She stated upon her return to work she was doing rounds and noticed CR #1 right knee was swollen. She said it was like a large grapefruit. She said she immediately called LVN A into the room to observe. She said she had not tried to transfer or change the resident. She said she checked his brief to see if the previous shift had changed him and that is when she saw his knee as she pulled back the covers. She denied witnessing him fall or any trauma. Interview with the Orthopedic Surgeon on 8/9/23 at 1:29 p.m., he stated he conducted surgery on CR #1's femur and repaired ligaments on the outside of the patella on 8/3/23. He said he did not understand how the largest and strongest bone in your body could be fractured. He said especially since he was not ambulatory and was total care. He said CR #1 had a supra condylar femur fracture which is very complex fracture. He said that it required quite a bit of force to break. He said something traumatic happened to the resident for such as break to occur. He said he has osteoarthritis himself, but it would not cause this type of fracture. Interview with Interim Administrator B on 9/8/23 at 5:47p.m., revealed her to state that when she first learned about the incident, she was told that CR#1 had co-morbidities that could have caused the injury, but that the DON started an investigation. She stated that she did not think any staff had been suspended due to no staff admitting any falls or trauma. She said that it is also believed that if CR#1 had fallen he would have other injuries. Interview with DON on 9/8/23 at 5:50 p.m., she stated that she did conduct an interview she stated that she started the investigation process by getting statements from staff. She did not call in CR#1 injury of unknown origin to State agency because she said that it was not suspicious. She stated that she should have called it in to the State because now she understands how it was could have been considered suspicious. She stated that no staff had been suspended pending an investigation. She said that she had no evidence to accuse anyone. She stated that she does understand that she was supposed to protect CR#1 while investigating. Interview with LVN A on 9/10/23 at 12:29 p.m., revealed her to state that she worked on 8/1 (day CNA reported CR#1 swollen knee), 8/2/23 (day results confirmed fracture) and worked Hall 100 (where CR#1 resided) on both days. She admitted that she had not been sent home or suspended. She was not aware of an investigation, but she said she wrote a statement and documented the progress note as they are required to do. Subsequent interview with DON on 9/11/23 at 2:10 p.m., revealed her to state that her investigation revealed that no one saw anything. She said no one was suspended because she did not find that anyone intentionally hurt CR#1. When asked how did she protect CR#1 during her investigation, she responded, He was already gone, we sent him to the ER after getting the results. She was asked if the same staff (LVN A, CNA A and CNA P had access to CR#1 and she responded, she was not sure without looking at the schedule. But, she should have suspended the CNA that worked overnight 10p-6a on 7/31/23, CNA P (worked 6-2pm shift on 8/1 and 8/2) , CNA A (reported the swollen knee 2-10pm shift on 8/2). She was unable to say why she did not protect CR#1 as their policy requires. Subsequent interview with Interim Administrator B on 9/11/23 at 2:16 p.m., revealed her to state that she was not working here at the time, but she began an investigation of her own. She stated that because of his osteoarthritis no one suspected abuse. She said that she can understand how this incident could be viewed as suspicious though and thus called for a thorough investigation and reporting. She said she would report the incident to State agency immediately. Interview with HR on 9/11/23 at 2:25 p.m. revealed her to state that she was not informed to suspend any employees due to CR#1's injury. She stated that the ADM or DON would be the two managers that would suspend employees if there was an investigation and determined that staff were going to be investigated. She stated that she had been employed with the company since May 2023. Record review of the DON's, undated, job description responsibilities states: (1) DON assumes responsibility of facility in absence of Administrator. (2) Works in collaboration with the center; ensures education and understanding by all team members of abuse recognition, protecting and reporting responsibilities; responds swiftly to any allegation of abuse, neglect or misappropriation by protecting, investigating and making any required reporting. Record review of the facility's abuse, neglect policy, dated 1/2019, revealed the purpose is to prohibit and prevent abuse, neglect and exploitation of resident property and to ensure reporting and investigation of alleged violations (to include injuries of unknown source, mistreatment and involuntary seclusion) in accordance with Federal and State Laws. Definitions: Injuries of Unknown origin source: When both criteria are met: the source of the injury was not observed, or the source could not be explained by the resident and the injury is suspicious because of the extent of the injury or the location of the injury (i.e. the injury is located in an area not generally vulnerable to trauma). Protection: First and foremost, the resident/patient will be immediately assessed and removed from any potential harm. The results of all investigations must be reported to the Administrator, designee to the appropriate state agency, as required by state law, within five (5) working days of alleged violation. Record review of TULIP on 9/14/23 revealed a provider's report dated 9/12/23 with findings of inconclusive for the allegation of injury of unknown origin. The Interim Administrator B and DON was notified of an Immediate Jeopardy (IJ) on 9/8/2023 at 5:37p.m., due to the above failures, the Interim Administrator B was given a copy of the IJ template, and a Plan of Removal (POR) was requested. The following Plan of Removal submitted by the facility was accepted on 9/9/23 at 3:20pm Immediate action to ensure residents were not in jeopardy and threat of harm: On 9/8/23, the Administrator and the DNS immediately took the following actions to address the citation to prevent any additional residents from experiencing an adverse outcome. On 9/8/23, the DNS and her designee conducted medical record reviews of all residents to identify which residents were interview able verses those that could not be interviewed. BIMS scores were collected to determine those residents that could be interviewed verses those that were considered non interview able. On 9/8/23, the DNS and her designees completed physical assessments of all residents with a BIMS score of less than 11 to determine if there was evidence or abuse or injury of unknown origin. Assessments of these resident revealed no such evidence of abuse or injury of unknown origin. Documentation of these assessments was captured on an assessment tool and placed in the survey binder. This action was completed on 9/8/23. On 9/8/23, the DNS and her designees interviewed each resident with a BIMS of 11 or higher to assure they had not been abused or experienced an injury of unknown origin. Interview of these residents was captured on an interview tool and placed in the survey binder. Neither evidence of abuse nor injury of unknown origin was identified through interviews or body audits. This action was completed on 9/8/23. If evidence of abuse or injury of unknown origin had been identified, the Administrator would have suspended any accused staff and reported the incidents to the state and law enforcement in accordance with the State law and licensing agency requirements. A detailed investigation would have been conducted and the results submitted within 5 days of the negative findings. On 9/8/23, the Regional [NAME] President and the Senior Director of Clinical Operations provided training for the interim administrator and the Director of Nurses regarding abuse identification, protection, conducting a thorough investigation and reporting requirements. This action was completed on 9/8/23. Following the Adm and DNS training on 9/8/23, training on the center's abuse and neglect policy was initiated by DNS and her designee to include identification of abuse, protections of residents, investigation and reporting requirements. The DNS completed training on the morning of 9/9/23 for all staff that were working on the evening and night shifts. This training will continue until all staff are training. Employees will not be allowed to work until they have received this training. Facilities Plan to ensure compliance quickly by the following actions: All federal and State protocols will be followed going forward to include investigating and reporting abuse and injury of unknown origin allegations. The ADM is designated as the Abuse Coordinator. The Administrator was in-serviced on abuse identification, protection, conducting a thorough investigation and reporting requirements by RVP and Senior Director of Clinical Operations. This action was completed on 9/8/23. On 9/8/23, Residents with BIMS scores of 11 or higher were interviewed by the DNS and her designees to identify in they felt safe and if they had experienced abuse while living at the center. No concerns were identified. These interviews were completed on 9/8/23. On 9/8/23, the Abuse policy was reviewed by the Regional [NAME] President and the Senior Director of Clinical Operations. This review was completed on 9/8/23. No updates were necessary. On 9/8/23, Interim Administrator implemented an abuse investigation checklist to ensure investigations will be initiated and completed thoroughly. On 9/8/23, the DNS and her designee educated all staff on abuse prevention and reporting. This education was completed on 9/8/23. Going forward, any staff that were not present on 9/8/23 will not be allowed to work until they have been trained. On 9/9/23, the Activities Director will hold a Resident Council meeting in which the residents will be educated on the facility's abuse policies. This council meeting will conclude on 9/9/23. The Administrator or designee will continue to interview residents with a BIMS score of 11 or greater on a monthly basis to ensure they have not experienced abuse. 5 residents per week will be interviewed for 3 months starting the week of 9/11/23. The Director of Nursing or designee will conduct physical assessments on 5 residents per week with BIMS score of less than 11 to determine if there is evidence of abuse or injury of unknown origin for 3 months starting the week of 9/11/23. The findings of these interviews will be presented in QAPI as a PIP project. On 9/9/23, the Regional Director of Maintenance will conduct an environmental safety concern assessment of the center. This assessment will be completed by the center's maintenance director or the administrator on a weekly basis for 3 months beginning the week of 9/11/23. The findings of these assessments will be presented in QAPI as a PIP project. Competency of staff related to the Abuse/Neglect training will be captured by a competency test after each training. These competencies will continue until all are trained and deemed competent. Monitoring of the plan of removal included the following: Record review of in-services revealed that abuse, neglect, expliotation, including injuries of unknown origin, turning and repostioning, lift and transfers, customer service, reporting incidents and abuse coordinator acknowledgements were conducted. Interview with the Interim Administrator B on 9/10/23 at 11:24 a.m., revealed her to state that BIM scores were pulled from MDS and she compared with the census to ensure every resident was either deemed interviewable (BIM score above 11) or required a body audit if BIM score was under 11. She provided a list of the residents that were interviewed and those that they conducted body audits on. Interview with Activity Director on 9/10/23 at 12:02p.m., revealed her to state that she conducted a resident council meeting with the residents, and none of the residents had any concerns about abuse, neglect or misappropriations. She said that she had a training and in-service on abuse and neglect, reporting incidents, professionalism, transfers, smoking policy. Interview with two housekeepers on 9/10/23 at 12:07p.m., revealed them to state that they had an in-service on abuse, neglect, reporting if they see someone mistreating the residents to report it to the Administrator or DON. Interview with Maintenance and Regional Maintenance on 9/10/23 at 12:12pm, revealed them to state that on a daily basis they are checking the building for safety hazards such as: fire extinguishers, doors, outlets, hoyer lifts and checking for any safety issues in the facility. Interviews with CNA's on all three shifts, LVN A, two housekeepers, one floor tech, one MA, two charge nurses and maintenance and they all stated that they had been in-serviced on abuse, neglect and exploitation, reporting abuse and told if they had witnessed abuse they would report it to the Administrator. The Interim Administrator B was informed the Immediate Jeopardy was removed on 9/12/23 at 1:09pm. The facility remained out of compliance at a severity level of actual harm that is not IJ and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure the resident environment remained as free of accident hazards as possible and each resident received adequate supervision and assistance devices to prevent accidents for 1 of 8 residents (CR #1) reviewed for accidents and supervision and to the facility failed to establish policies, in accordance with applicable Federal, State, and local laws and regulations, regarding smoking areas, and smoking safety that also take into account nonsmoking residents for 3 of 23 residents (Resident #4, Resident #5 and Resident #6) reviewed for smoking policies. The facility failed to ensure CR #1 was free of accidents and injuries causing him to sustain a impacted acute or subacute fracture of the supracondylar distal femur that required surgical procedure. Physician A and Orthopedic Surgeon said that it would require force to break and stated that something traumatic happened to the resident. 1. The facility failed to ensure Resident #4 did not have smoking materials on his person and in his room. 2. The facility failed to ensure Resident #5 did not have smoking materials in her room. 3. The facility failed to ensure Resident #7 was supervised and wore a smoking apron while smoking. These deficient practices could place residents at risk for an unsafe smoking environment and injury. An Immediate Jeopardy (IJ) situation was identified on 8/10/2023 at 1:23 p.m. While the IJ was removed on 8/18/2023 at 12:08p.m. the facility remained out of compliance at a scope of isolated with actual harm due to the facility's need to evaluate the effectiveness of the corrective system. This failure could place residents at risk of severe injuries, require hospitalization, or death due to lack of supervision by facility staff. Findings included: Record review of CR #1's face sheet revealed a [AGE] year-old male who was admitted to the facility on [DATE]. CR #1 had diagnoses which included: Quadriplegia(paralysis of all four limbs), injury of cervical spinal cord, contracture of left and right hand(condition that causes one or more fingers to bend towards the palm of the hand), contracture of muscle(a fixed tightening of muscle, tendons or ligaments), acute respiratory failure with hypoxia (impairment of gas exchange between the lungs and the blood), flexion deformity(the inability to straighten or extend the knee), stage 4 pressure ulcer on spine(injury to skin and underlying tissue resulting from prolonged pressure on the skin) and epilepsy(disorder of the brain). Record review of CR #1's quarterly MDS assessment, dated 6/17/23, indicated the following: Section B0600- Speech clarity- (2) no speech B0700- Ability to make self-understood (3)-Rarely or never. B0800- Ability to understand others (3)-Rarely or never Section C500- Brief Interview of Mental Status was unscored. Section G0110- Activities of Daily Living (ADL's) include: bathing, toileting, grooming and hygiene) revealed the following: A. Bed Mobility - total dependence (4) required full staff performance every time during 7-day period with support (2)- (one-person physical assist), B. Transfer (4-total dependence) support (3) (two-person assist), C. Walk in room by self- 8 (never happened), toilet use -total dependence (4) support -(1-person assist), Bathing (4-total dependence)- support (1-person assist) Section G0130- Functional Status revealed CR #1 was dependent - helper did all effort. Resident did none of the effort to complete activity for eating, oral hygiene, toileting hygiene, shower/bathe, upper body dressing, lower body dressing, and putting on or taking off footwear. Section G0170- Mobility revealed CR #1 was dependent on staff (01) for roll left and right, sit to lying, lying to sitting on side of bed, chair/bed, chair transfer and sit to stand. Code 01- dependent- Helper does all of the effort. Resident did none of the effort to complete the activity. Toilet transfer, car transfer, and walk 10 feet were coded (88) for not attempted due to medical condition or safety concerns. Section H0300 - Urinary Incontinence revealed CR #1 was (3) always incontinent of bowel and bladder. Record review of CR #1's care plan, dated 6/17/23, revealed CR #1 had an ADL self-care performance deficit r/t traumatic brain injury and spinal cord injury. Interventions were transferring required total assistance with mechanical lift and two-person staff assistance and bed mobility required extensive assistance by (2) staff to turn and reposition. Record review of CR#1 facesheet, careplan dated 6/17/2023 and MDS dated [DATE], revealed that CR#1 had no diagnosis of Osteoarthritis and no care plan interventions for the disease. Record review of progress note, dated 8/1/23 at 6:37 p.m. written by LVN A, revealed CNA A reported CR #1's knee was swollen. Record review of physician orders revealed Physician A ordered a blood test and x-rays of bilateral knees for CR #1 on 8/1/23. Record review of progress note dated 8/2/23 at 12:01 p.m, RN C wrote called to follow up with local x-ray company on orders for bilateral patella X-ray and was informed that the order was in dispatch status. Record review of progress note dated 8/2/23 at 9:34 p.m., written by, revealed the results of the x-ray report showed a fractured femur, MD notified, ordered to send CR#1 to local hospital emergency room. Record review of progress note dated 8/2/23 at 10:16 p.m., written by LVN A, indicated CR#1 was transported to a local hospital via ambulance. Record review of radiology results for CR #1, dated 8/2/2023 at 2:19 PM, revealed the resident had an impacted acute or subacute fracture of the supracondylar distal femur. Conclusion: Fracture of the distal right femur. Record review of CR#1 facesheet, careplan dated 6/17/2023 and MDS dated [DATE], revealed that CR#1 had no diagnosis of Osteoarthritis and no care plan interventions for the disease. Record review of CR #1's hospital record revealed CR#1 was admitted on [DATE] at 10:48 PM. Chief complaint was at baseline nonverbal patient with possible fracture of the right femur and swollen right knee. A pre-operative evaluation was conducted and surgical procedure to repair the fracture would take place on 8/3/23. Observation of CR#1 on 8/4/23 at 2:40 p.m. at the local hospital revealed the resident was asleep. His right leg was wrapped with bandages from his thigh to just passed his knee. Interview with the hospital charge nurse on 8/4/23 at 3:07 p.m., revealed the leg injury caused CR #1 to require a surgical procedure. She said he had a broken right femur, lateral collateral ligament (LCL) repair, washout, and open reduction internal fixation (process of putting pieces of a broken bone into place using surgery). She stated it was in her professional experience as a registered nurse that the resident was not capable of falling out of bed on his own. She said he was not able to move his limbs. She said whatever happened to him took force. She said that she was unable to say if it was abuse. She said the resident had not grimaced or shown any facial expressions since she had been observing him today (8/4/23). Interview with an anonymous nurse at the local hospital on 8/4/23 at 3:32 pm, revealed her to state that it appears that someone intentionally hurt him. She said, off the record, the charge nurse might not have said that, but everyone that has cared for him at the hospital felt like someone did this to him. She said as a mother this would be very upsetting to her. She said that she felt like he was abused. Interview with the FM on 8/4/23 at 8:11 p.m., revealed that she received a call from LVN A (8/2/23) concerning CR #1's knee being swollen and later a call from LVN A that the lab results confirmed the resident had a fractured femur. She stated she inquired about what happened to CR #1. She said LVN A stated she was not sure, but the first report of a swollen knee was on 8/1/23. She said LVN A refused to say anymore. She denied talking with any other administration or nursing staff concerning the injury. She said the surgeon told her the longest and strongest bone in the bone was broken along with ligaments in his knee had to be repaired. The FM stated the surgeon said whatever happened to him required force to break his femur. She said that the admitting physician told her that it is difficult to break this bone. She said that she believes that someone at the facility intentionally hurt him, and she is very upset about him being treated in this way. Interview with LVN A on 8/4/23 at 8:40 p.m., revealed on 8/1/23, CNA A called her to the room after discovering CR #1's knee was swollen. She said she called Physician A and he asked her to send a picture of CR #1's knee. He ordered labs and an x-ray. She said the company did not come until the next day to complete the x-ray. She stated the results on (8/2/23) confirmed he had a fractured right femur. She said she sent the results to Physician A and he said to have him transported to the emergency room. Interview with the Director of Clinical Operations on 8/5/23 at 2:03 p.m., revealed the Medical Director was working on a clinical study on CR #1. She stated the lab results revealed CR #1 had osteoarthritis and his contractures made him vulnerable to losing bone density and thus could have caused his fracture. She denied investigating the injury because she said that it was not suspicious. Interview with the DON on 8/5/23 at 2:06 p.m., revealed LVN A reported CR #1 knee was swollen (8/1), and a S-Bar was put in on Wednesday (8/2/23). She said that the Director of Clinical Operation requested that the test be done stat due to his co-morbidities, but they believe his fracture was due to his osteoarthritis. She said that he was sent to the emergency room for care. She said there were no reports of CR #1 falling or trauma. She said that LVN A was informed of the swelling from CNA A. She denied an investigation because she said that they investigate when an injury is suspicious. Interview with CNA B on 8/5/23 at 2:38 p.m., she stated she was responsible for CR #1's incontinent care and she provided bed baths. She denied using a mechanical lift with CR #1. She said she had never moved him from the bed using the lift because he never got out of the bed. She said all she would do is turn and position him. She said that she saw him last on 8/2/23. She denied his knee was swollen. Interview with Physician A on 8/8/23 at 3:05 p.m., revealed he received a call and/or text from LVN A on 8/1/23 concerning CR #1's swollen knee. He stated he ordered blood work to rule out gout and rheumatoid arthritis and an x-ray of right bilateral knee. He said the resident did not have evidence of gout or rheumatoid arthritis. He said osteoarthritis would not cause a fracture. He said given CR #1's age of 25, and the fact he did not have any diagnosis that would cause a fracture of the femur, he was baffled at how something like this could have happened. He stated CR #1 had been under his care since he was admitted to the facility (1/13/22) and have not had any seizures. Interview with CNA A on 8/8/23 at 3:23 p.m., revealed she had been off three days prior to 8/1/23. She stated upon her return to work she was doing rounds and noticed CR #1 right knee was swollen. She said it was like a large grapefruit. She said she immediately called LVN A into the room to observe. She said she had not tried to transfer or change the resident. She said she checked his brief to see if the previous shift had changed him and that is when she saw his knee as she pulled back the covers. She denied witnessing him fall or any trauma. Interview with the Orthopedic Surgeon on 8/9/23 at 1:29 p.m., he stated he conducted surgery on CR #1's femur and repaired ligaments on the outside of the patella on 8/3/23. He said he did not understand how the largest and strongest bone in your body could be fractured. He said especially since he was not ambulatory and was total care. He said CR #1 had a supra condylar femur fracture which is very complex fracture. He said that it required quite a bit of force to break. He said something traumatic happened to the resident for such as break to occur. He said he has osteoarthritis himself, but it would not cause this type of fracture. Record review of the facility's abuse, neglect policy, dated 1/2019, revealed the purpose is to prohibit and prevent abuse, neglect and exploitation of resident property and to ensure reporting and investigation of alleged violations (to include injuries of unknown source, mistreatment and involuntary seclusion) in accordance with Federal and State Laws. Record review of the DON's, undated, job description responsibilities states: (1) DON assumes responsibility of facility in absence of Administrator. (2) Works in collaboration with the center; ensures education and understanding by all team members of abuse recognition, protecting and reporting responsibilities; responds swiftly to any allegation of abuse, neglect or misappropriation by protecting, investigating and making any required reporting. The interim Administrator and DON was notified of an Immediate Jeopardy (IJ) on 8/10/23 at 1:23p.m., due to the above failures, the interim Administrator was given a copy of the IJ template and a Plan of Removal (POR) was requested. The following Plan of Removal submitted by the facility was accepted on 8/13/23 at 12:43 p.m.: Immediate action taken in response to the resident's injures included the following: The resident no longer resides at the center as of 8/2/23. He has not returned to the center as of 8/13/23. When/if he returns, the IDT team will assess the resident and update the care plan. ick Compliance Actions: 8/10/23- The Senior director of Clinical Operations conducted a root cause analysis of the injury to this resident. 8/10 /23 -8/12/23- Lift evaluations were completed for all residents by the Director of Nursing and the Assistant Director of Nursing. 8/10/23- 100 % audit was completed by the Director of Nurses, Assistant Director of Nursing and Unit Manager of lift evaluations compared with the care plan to assure accuracy. Care plans were updated as needed. 8/10/23- The Director of Nurses identified the center has 20 bedbound residents in need of assist with bed mobility. The Care Plan coordinator reviewed the care plans for each of the 20 bed bound residents to ensure safety measures and interventions were added for those residents. 8/10/23-8/12/23 -Education related to Turning and Positioning, Use of Lifts, Abuse and Neglect (to include reporting any incidents), and Customer Service was continued by the Administrator, Director of Nursing and the Assistant Director of Nursing. Education regarding use of lifts was based on the manufacture's guidelines. No one will be allowed to work prior to completion of in service. The Turning and Repositioning and Lift competencies criteria will be based on instruction and a successful return demonstration. 8/10/23 The Lift for Care Policy was reviewed by Senior Director of Clinical Operations. 8/10/23- All lifts were assessed by the Maintenance Director and found to be in good working order. 8/10/23-An Ad Hoc QAPI meeting was held to discuss immediate jeopardy findings and the plan of correction going forward on August 10, 2023. Attendees were Administrator, Director of Nursing, Medical Director, Senior Director of Clinical Operations, and Regional [NAME] President. 8/12/23- Competencies for all CNAs and Nurses related to turning/ repositioning and use of lifts were initiated by the Director of Nurses and Assistant Director of Nurses on 8/12 and are on- going until all CNAS are deemed competent. As of 8/12, no CNA or nurse will work until deemed competent. Going forward to assure continued compliance with corrective actions, the Director of Nursing and Assistant Director of Nursing will conduct audits of resident positioning and lifts at least 3 times per week for one month, then 2 times per week for one month, and then weekly for one month. A QAPI PIP has been initiated to report the above monitoring and audit procedures. All findings from the PIP will be presented at the monthly QAA meeting. Monitoring/auditing and reporting will continue for a minimum of three months. Monitoring of the plan of removal included the following: Interview with the Maintenance Director on 8/15/23 at 3:05 p.m., he stated he received parts for the Hoyer lifts and would be repairing 4-5 Hoyer's that were broken. Observation on 8/16/23 at 3:13pm revealed 9 mechanical lifts were operable and in good repair. The lift from Hall 100 was included in the nine repaired due to a broken brake. Interviews with multiple anonymous staff between 8/15-8/16/23 revealed they were not able to state if the mechanical lift training was conducted one-on-one or in group setting, demonstration completed or just a verbal training and when/if they had abuse, neglect and exploitation training. More interviews were conducted. Interview on 8/17/23 at 12:17pm with the DON, VP of Operations (VPO), VP of Clinical Operations (VPCO), and Interim Administration revealed staff were not consistent in what recent in-services and/or demonstration they had in the past week. The DON stated she would ensure everyone had been re-educated before working a shift. This task would be completed by 8/18/23. Interviews on 8/17/23 and 8/18/23 with 2 LVN's, 1 RN and 3 CNA's, housekeeping, floor tech and maintenance on the 6a-2pm and 2p-10pm shifts were interviewed and had been trained on reporting incidents of abuse, neglect, exploitation, falls, and use of mechanical lifts and safe transfers. Staff reported that the Interim Administrator was the Abuse Coordinator, all incidents or falls should be reported immediately to nursing administration, and they had been in-serviced on using the mechanical lift properly by Therapy Director. Interviews on 8/18/23 at 8:24am, with two overnight (10p-6am) CNAs stated that they received training on the lift, repositioning and abuse reporting. Interview with the DON on 8/18/23 at 11:15am, revealed her to state that all but four employees had been trained on the re-positioning and mechanical lift competencies. She said that two were on vacation and the two were not scheduled to work the week of 8/28-9/1/23. She said that she would ensure they were trained before working on the floor. Interview with the Therapy Director on 8/18/23 at 11:55am, revealed him to state that he provided training on properly using the mechanical lift, turning and repositioning for all CNA's on 6a-2pm and 2pm-10pm shifts. He stated that the overnight charge nurse would train the CNA's and provide documentation to the DON. Interview with Interim Administrator B on 9/8/23 at 5:47p.m., revealed her to state that when she first learned about the incident, she was told that CR#1 had co-morbidities that could have caused the injury, but that the DON started an investigation. She stated that she did not think any staff had been suspended. Record review of the list of bedbound residents included 20 residents were deemed bedfast had updated care plans. Record review of in-services on 8/17-8/18/23 revealed abuse, neglect and exploitation, reporting incidents, turning and repositioning competencies and EZ way smart lift competencies were completed by all but 4 staff. Record review of an undated lift care policy revealed the total lift will be used when residents were non-ambulatory and residents could not bear weight or if they did not qualify for the sit-to stand lift. The Interim Administrator, DON and RVP were informed the Immediate Jeopardy was removed on 8/18/23 at 12:08pm. The facility remained out of compliance at a severity level of actual harm that is not IJ and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. A second supervision issues was discovered on 8/11/2023 at 12:40pm Findings Included: 1. The facility failed to ensure Resident #4 did not have smoking materials on his person and in his room. 2. The facility failed to ensure Resident #5 did not have smoking materials in her room. 3. The facility failed to ensure Resident #7 was supervised and wore a smoking apron while smoking. These deficient practices could place residents at risk for an unsafe smoking environment and injury. Findings Included: Record review of the facility list of smokers revealed there were 23 smokers who resided at the facility. Resident #4 Record review of Resident #4's face sheet revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #4 had diagnoses which included spinal stenosis (spinal narrowing often caused by age-related wear and tear) , abnormality of gait(an usual walking pattern), polyarthritis(when at least five joints are affected by arthritis), presence of left artificial knee joint. Record review of Resident #4's care plan, dated 4/12/2022 and revised on 8/19/2023, revealed Resident #4 was at risk for smoking related injuries related to attempts to obtain lighters or matches and a history of smoking incidents. Intervention: Resident is not to have cigarettes or smoking material on person. Record review of nursing progress note, dated 8/12/23, revealed the DON must be notified if Resident # 4 is non-compliant with the facility's smoke policy. Observation from the items from Administrator, DON and ADON room sweep on 8/11/23 at 2:17 p.m., revealed the administration team found the following: Resident #4 had a Ziplock bag of cigarette filters, 2 packs of buglers (loose tobacco used for rolling into a cigarette) and 6 lighters found in his room. Interview with Resident #4 on 8/11/23 at 3:04 p.m., revealed he always kept his cigarette filters and materials with him. He stated as a resident he should be able to keep his smoking material. He said he smoked at least 5-6 times per day. He stated that the former Administrator was going to discharge him. But they could not discharge him without him having someplace to live. He said he guessed that they could not find anywhere else for him to go. Resident #5 Record review revealed Resident #5's face sheet revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #5 had diagnoses which included: Lack of coordination, Abnormality of gait and mobility (change to normal walking pattern), cognitive communication deficit, schizoaffective disorder (a combination of symptoms of schizophrenia and mood disorder), infection and inflammatory reaction due to internal prosthetic devices, implants or grafts. Record review of progress note dated 8/12/23, for Resident #5 revealed the DON was to be informed if she should be incompliant with the facility's smoking policy. Observation on 8/11/23 at 12:40 PM, revealed Resident #5 was smoking a cigarette. No staff was outside at the time. Observation of items from the sweep on 8/11/23 at 2:17 p.m., revealed 2 packs of cigarettes and a lighter was found in Resident #5's room. Interview with Resident #5 on 8/11/23 at 3:07 p.m., revealed her to state that she did not have anything to say. Record review of Resident #7's face sheet revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #7 had diagnoses which included: Chronic systolic (congestive heart failure), Chronic kidney disease, Diabetes Mellitus uncontrolled, Schizophrenia, Hypertension, Dysphagia, Abnormality of gait and mobility, muscle wasting in right and left shoulders. Record review of Resident #7's smoking assessment dated [DATE] revealed in section D. Summary of evaluation 1. Based on the above evaluation the resident will require supervision with smoking the answer was (1) Yes. Goal: Will have no smoking related injury. Interventions: place patient in position to assure visualization of ashtray, provide smoking apron while smoking, review smoking policy and storage of smoking materials per center policy. Record review of Resident #7's care plan, dated 6/22/23, revealed the resident was at risk for smoking related injury related to his inability to manage ashes and non-compliant with smoking policies, refuses to wear apron and smoking outside of schedule. Interventions: 6/22/23- Provide smoking apron while smoking. 8/15/23-Resident requires supervision while smoking. 8/21/23-refused to wear smoke apron during smoke break. Observation on 8/11/23 at 12:40 p.m., revealed Resident #7 was smoking in the smoking area unsupervised and without a smoking apron. Interview with the ADON on 8/11/23 at 12:47 p.m., revealed her to state that the residents should not have been smoking unsupervised, and it was not their smoke times. She was at the nursing station at the time. But she stated that she did not see them going out there. She said different staff are scheduled to supervise the residents at each smoke time. Interview with CNA E on 8/11/23 at 1:45 p.m., revealed the residents were aware of the smoke times, they should not have been out there. He said they were also sharing cigarettes because Resident #4 left the facility and got his cigarettes and shared them with other residents. Interview with Resident #6 on 8/11/23 at 1:49 p.m., he stated although he was sitting out in the smoking area he was not smoking earlier when the State Surveyor was getting the names of the residents that were unsupervised. He stated they all knew the smoke times and the facility threatened the residents with 30-day notices but did not kick them out because they did not have anywhere else to go or they did not want to leave. He said they continued to do whatever they wanted to do and smoked anytime they pleased. Interview with the DON on 8/11/23 at 2:00 p.m., revealed she was aware there was an issue with compliance of the smoke policy. She said since day one of her employment she learned it was a problem in the facility (July 2023). She said they had given discharge notices and yet the residents still smoked when they should not be smoking. She said she would provide those discharge notices. Interview with the Interim Administrator on 8/11/23 at 2:00 p.m., revealed they would conduct a sweep of the rooms to search for cigarettes and lighters and report their findings. Interview with the RVP on 8/11/23 at 2:00 pm, revealed administration would meet resident council, all smokers and give them discharge notices if necessary for them to adhere to the smoking policy. During an interview with Resident #7 on 8/12/23 at 1:03 p.m., he stated he wanted to know when the State Surveyor would be leaving the facility. He stated he used to smoke when he wanted. He stated he had to sign himself out to smoke outside of the facility smoke times. He said he did not wear an apron because he did not want to. Record review of the facility's, undated, smoke policy revealed: In order to protect all residents at the facility the following smoking policy must be strictly enforced by Team Members and adhered to by all residents and families and visitors. 1. Resident must smoke in designated area at posted times. Smoke times are: 8:30- 9:00am (Activity supervise) 11:00am- 11:30am (Nursing supervise) 1:30pm-2pm (Nursing supervise) 3:30pm-4:00pm (Activities supervise) 6:45pm-7:15pm (Station 1) 2. Residents may not have cigarettes, cigars, matches, lighters, light fluid, in their possession or in their rooms at any time. 6. Smoking privileges will be suspended entirely if a resident becomes harmful to self and others. Non-compliance with the facility smoking policy will lead to discharge. Record review of the facility's Safe Smoking policy, effective date: November 1, 2016, revealed .(4) Staff members will monitor or obtain fire igniting materials (matches/lighters) for the benefit of smokers at the nurses' station or other designated locations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews the facility failed to be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. The facility failed to ensure that residents were free from accidents and injuries for 1 (CR#1) of 8 reviewed for accident and injuries. The facility failed to follow their policy and procedure for investigating injuries of unknown origin after both Interim Administrator A and the DON became aware that CR#1 sustained an impacted acute or subacute fracture of the supracondylar distal femur. The facility failed to thoroughly investigate CR#1 injury of unknown origin which was suspicious due him being a total care resident with an impacted fracture of the distal metaphysis of the right femur and a diagnosis of Quadriplegia. The facility failed to implement interventions to ensure CR#1 was safe after learning that his knee was swollen and was totally dependent on staff for care. The facility failed to report the results of all investigations to officials in accordance with state law, including to State agency within 5 working days of the incident. An Immediate Jeopardy (IJ) situation was identified on 9/9/23 at 10:19 a.m. While the IJ was removed on 9/13/2023, the facility remained out of compliance at a scope of isolated with no actual harm due to the facility's need to evaluate the effectiveness of the corrective system. Findings Included: Record review of CR #1's face sheet revealed a [AGE] year-old male who was admitted to the facility on [DATE]. CR #1 had diagnoses which included: Quadriplegia(paralysis of all four limbs), injury of cervical spinal cord, contracture of left and right hand(condition that causes one or more fingers to bend towards the palm of the hand), contracture of muscle(a fixed tightening of muscle, tendons or ligaments), acute respiratory failure with hypoxia (impairment of gas exchange between the lungs and the blood), flexion deformity(the inability to straighten or extend the knee), stage 4 pressure ulcer on spine(injury to skin and underlying tissue resulting from prolonged pressure on the skin) and epilepsy(disorder of the brain). Record review of care plan, dated 6/17/23, revealed CR #1 had an ADL self-care performance deficit r/t traumatic brain injury and spinal cord injury. Interventions were transferring required total assistance with mechanical lift and two-person staff assistance and bed mobility required extensive assistance by (2) staff to turn and reposition. Record review of progress note #1, dated 8/1/23 at 6:37 p.m., LVN A wrote: CNA A reported CR #1's knee was swollen assessed and contacted physician. Record review of progress note dated 8/2/23 at 12:01p.m., RN A wrote: Called to follow up with local x-ray company on orders for bilateral patella X-ray and was informed that the order was in dispatch status. Record review of radiology results for CR #1, dated 8/2/23 at 2:19 p.m., revealed the resident had an impacted acute or subacute fracture of the supracondylar distal femur. Conclusion: Fracture of the distal right femur. Record review of progress note dated 8/2/23 at 9:34 p.m., LVN A wrote: The results of the x-ray report showed a fracture femur, MD notified, ordered to send CR#1 to local hospital emergency room. Record review of CR #1's hospital record revealed CR#1 was admitted on [DATE] at 10:48 PM. Chief complaint was at baseline nonverbal patient with possible fracture of the right femur and swollen right knee. A pre-operative evaluation was conducted and surgical procedure to take place on 8/3/23. Observation of CR#1 on 8/4/23 at 2:40 p.m. at the local hospital revealed the resident was asleep. His right leg was wrapped with bandages from his thigh to just passed his knee. Interview with the hospital charge nurse on 8/4/23 at 3:07 p.m., revealed the leg injury caused CR #1 to require a surgical procedure. She said he had a broken right femur, lateral collateral ligament (LCL) repair, washout, and open reduction internal fixation (process of putting pieces of a broken bone into place using surgery). She stated it was in her professional experience as a registered nurse that the resident was not capable of falling out of bed on his own. She said he was not able to move his limbs. She said whatever happened to him took force. She said that she was unable to say if it was abuse. She said the resident had not grimaced or shown any facial expressions since she had been observing him today (8/4/23). Interview with an anonymous nurse at the local hospital on 8/4/23 at 3:32 p.m., revealed her to state that it appears that someone intentionally hurt him. She said, off the record, the charge nurse might not have said that, but everyone that has cared for him at the hospital felt like someone did this to him. She said as a mother this would be very upsetting to her. She said that she felt like he was abused. Interview with the FM on 8/4/23 at 8:11 p.m., revealed that she received a call from LVN A (8/2/23) concerning CR #1's knee being swollen and later a call from LVN A that the lab results confirmed the resident had a fractured femur. She stated she inquired about what happened to CR #1. She said LVN A stated she was not sure, but the first report of a swollen knee was on 8/1/23. She said LVN A refused to say anymore. She denied talking with any other administration or nursing staff concerning the injury. She said the surgeon told her the longest and strongest bone in the bone was broken along with ligaments in his knee had to be repaired. The FM stated the surgeon said whatever happened to him required force to break his femur. She said that the admitting physician told her that it is difficult to break this bone. She said that she believes that someone at the facility intentionally hurt him, and she is very upset about him being treated in this way. Interview with the Interim Administrator A on 8/5/23 at 12:11 p.m., revealed he was a traveling Administrator and his 1st day of work at the facility was on 8/3/23. He said that he was just made aware of the incident on 8/3/23. He stated he did not call in an incident to State Agency. He said that the Administrator is responsible for investigating and reporting incidents of unknown origin. However, the DON and ADON can investigate and call in an incident as well. He said that incidents not investigated or reported to State agency can leave residents vulnerable to abuse, neglect or exploitation. Interview with the Director of Clinical Operations on 8/5/23 at 2:03 p.m., revealed the lab results revealed CR #1 had osteoarthritis and his contractures made him vulnerable to losing bone density and this could have caused his fracture. She denied investigating the incident of unknown origin because she said that it was not considered suspicious. She denied reporting the incident of unknown origin to the State Agency. Interview with the DON on 8/5/23 at 2:06 p.m., revealed LVN A reported CR #1's knee was swollen (8/1/23), and a S-Bar was put in on Wednesday (8/2/23) once the results came back and informed them of his fracture. She said the Director of Clinical Operation requested the test be done stat due to his co-morbidities, but they believed his fracture was due to his osteoarthritis. She said he was sent to the emergency room for care. She said there were no reports of CR #1 falling or trauma. She denied an investigation because she said they investigated when an injury was suspicious. She stated she had not called the State Agency because she was not sure if the former Administrator had called it in. She said the Administrator was not the only person who could call in an incident of unknown origin. She said, I guess any nurse could have called the incident in to State agency. Interview with Physician A on 8/8/23 at 3:05 p.m., revealed he received a call and/or text from LVN A on 8/1/23 concerning CR #1's swollen knee. He stated he ordered blood work to rule out gout and rheumatoid arthritis and an x-ray of right bilateral knee. He said the resident did not have evidence of gout or rheumatoid arthritis. He said osteoarthritis would not cause a fracture. He said given CR #1's age of 25, and the fact he did not have any diagnosis that would cause a fracture of the femur, he was baffled at how something like this could have happened. He stated CR #1 had been under his care since he was admitted to the facility (1/13/22) and have not had any seizures. Interview with CNA A on 8/8/23 at 3:23 p.m., revealed she had been off three days prior to 8/1/23. She stated upon her return to work she was doing rounds and noticed CR #1 right knee was swollen. She said it was like a large grapefruit. She said she immediately called LVN A into the room to observe. She said she had not tried to transfer or change the resident. She said she checked his brief to see if the previous shift had changed him and that is when she saw his knee as she pulled back the covers. She denied witnessing him fall or any trauma. Interview with the Orthopedic Surgeon on 8/9/23 at 1:29 p.m., he stated he conducted surgery on CR #1's femur and repaired ligaments on the outside of the patella on 8/3/23. He said he did not understand how the largest and strongest bone in your body could be fractured. He said especially since he was not ambulatory and was total care. He said CR #1 had a supra condylar femur fracture which is very complex fracture. He said that it required quite a bit of force to break. He said something traumatic happened to the resident for such as break to occur. He said he has osteoarthritis himself, but it would not cause this type of fracture. Interview with DON on 9/8/23 at 5:50 p.m., she stated that she did conduct an interview she stated that she started the investigation process by getting statements from staff. She did not call in CR#1 injury of unknown origin to State agency because she said that it was not suspicious. She stated that she should have called it in to the State because now she understands how it was could have been considered suspicious. She stated that no staff had been suspended pending an investigation. She said that she had no evidence to accuse anyone. She stated that she does understand that she was supposed to protect CR#1 while investigating. Interview with LVN A on 9/10/23 at 12:29 p.m., revealed her to state that she worked on 8/1 (day CNA reported CR#1 swollen knee), 8/2/23 (day results confirmed fracture) and worked Hall 100 (where CR#1 resided) on both days. She admitted that she had not been sent home or suspended. She was not aware of an investigation, but she said documented the progress note as they are required to do. Subsequent interview with DON on 9/11/23 at 2:10 p.m., revealed her to state that her investigation revealed that no one saw anything. She said no one was suspended because she did not find that anyone intentionally hurt CR#1. When asked how did she protect CR#1 during her investigation, she responded, He was already gone, we sent him to the ER after getting the results. She was asked if the same staff (LVN A, CNA A and CNA P had access to CR#1 and she responded, she was not sure without looking at the schedule. But, she should have suspended the CNA that worked overnight 10p-6a on 7/31/23, CNA P (worked 6-2pm shift on 8/1 and 8/2) , CNA A (reported the swollen knee 2-10pm shift on 8/2). She was unable to say why she did not protect CR#1 as their policy requires. Interview with Interim Administrator B on 9/11/23 at 2:16 p.m., revealed her to state that she was not working here at the time, but she began an investigation of her own. She stated that because of his osteoarthritis no one suspected abuse. She said that she can understand how this incident could be viewed as suspicious though and thus called for a thorough investigation and reporting. She said she would report the incident to State agency immediately. Record review of the schedule dated 8/1/23 and 8/2/23, revealed that LVN A was scheduled as the nurse for Hall 100, CNA B worked 6a-2pm shift on Hall 100, CNA A was scheduled to work Hall 100 (2pm-10pm shift). Record review of punch detail report dated 8/1/23- 8/4/23 provided by HR revealed that LVN A, CNA A and CNA B all worked on 8/1/23, 8/2/23 and 8/3/23 and had access to CR#1 for over 24 hours. Record review of the DON's, undated, job description responsibilities states: (1) DON assumes responsibility of facility in absence of Administrator. (2) Works in collaboration with the center; ensures education and understanding by all team members of abuse recognition, protecting and reporting responsibilities; responds swiftly to any allegation of abuse, neglect or misappropriation by protecting, investigating and making any required reporting. Record review of the facility's abuse, neglect policy, dated 1/2019, revealed the purpose is to prohibit and prevent abuse, neglect and exploitation of resident property and to ensure reporting and investigation of alleged violations (to include injuries of unknown source, mistreatment and involuntary seclusion) in accordance with Federal and State Laws. Definitions: Injuries of Unknown origin source: When both criteria are met: the source of the injury was not observed, or the source could not be explained by the resident and the injury is suspicious because of the extent of the injury or the location of the injury (i.e. the injury is located in an area not generally vulnerable to trauma). Protection: First and foremost, the resident/patient will be immediately assessed and removed from any potential harm. The results of all investigations must be reported to the Administrator, designee to the appropriate state agency, as required by state law, within five (5) working days of alleged violation. Record review of TULIP on 8/9/23 and 9/9/23 revealed no incident report was found concerning CR #1's injury of unknown origin. Record review of TULIP on 9/14/23 revealed a provider's report dated 9/12/23 with findings of inconclusive for the allegation of injury of unknown origin. The Interim Administrator B was notified of an Immediate Jeopardy (IJ) on 9/9/2023 at 10:19p.m., due to the above failures, the Interim Administrator B was given a copy of the IJ template and a Plan of Removal (POR) was requested. The following Plan of Removal submitted by the facility was accepted on 9/13/23 at 1:56pm Facilities Plan to ensure compliance quickly by the following actions: The center initiated an investigation immediately upon the knowledge of the incident on 8/2/2023, concerning the fracture of the right knee for resident. After the IJ was given on 9/9/23 the interim Administrator reviewed the findings and agreed that the etiology of the fracture was inconclusive. Based on interviews with staff, residents, observation of other residents, medical record review and medical record review by the Medical Director, there was lack of evidence to support abuse and neglect. Based on the investigation, and the review, the facility is unable to substantiate abuse and neglect. Immediate action to ensure residents were not in jeopardy and threat of harm: The previous full-time administrator who was in charge of the building at the time of the incident separated employment with the center on the day following the incident. Since then, the center secured a new administrator. This administrator will assume the assignment as the center leader on 9/18/23. Until she arrives, the center will be directed by an interim administrator. On 9/8/23, the Administrator and the DNS immediately took the following actions to address the citation to prevent any additional residents from experiencing an adverse outcome. On 9/8/23, the DNS and her designee conducted medical record reviews of all residents to identify which residents were interview able verses those that could not be interviewed. BIMS scores were collected to determine those residents that could be interviewed verses those that were considered non interview able. On 9/8/23, the DNS and her designees completed physical assessments of all residents with a BIMS score of less than 11 to determine if there was evidence or abuse or injury of unknown origin. Assessments of these resident revealed no such evidence of abuse or injury of unknown origin. Documentation of these assessments was captured on an assessment tool and placed in the survey binder. This action was completed on 9/8/23. On 9/8/23, the DNS and her designees interviewed each resident with a BIMS of 11 or higher to assure they had not been abused or experienced an injury of unknown origin. Interview of these residents was captured on an interview tool and placed in the survey binder. Neither evidence of abuse nor injury of unknown origin was identified through interviews or body audits. This action was completed on 9/8/23. If evidence of abuse or injury of unknown origin had been identified, the Administrator would have suspended any accused staff and reported the incidents to the state and law enforcement in accordance with the State law and licensing agency requirements. A detailed investigation would have been conducted and the results submitted within 5 days of the negative findings. On 9/8/23, the Regional [NAME] President and the Senior Director of Clinical Operations provided training for the interim administrator and the Director of Nurses regarding abuse identification, protection, conducting a thorough investigation and reporting requirements. This action was completed on 9/8/23. Following the Adm and DNS training on 9/8/23, training on the center's abuse and neglect policy was initiated by DNS and her designee to include identification of abuse, protections of residents, investigation and reporting requirements. The DNS completed training on the morning of 9/9/23 for all staff that were working on the evening and night shifts. This training will continue until all staff are training. Employees will not be allowed to work until they have received this training. Facilities Plan to ensure compliance quickly by the following actions: All federal and State protocols will be followed going forward to include investigating and reporting abuse and injury of unknown origin allegations. The ADM is designated as the Abuse Coordinator. On 9/8/23, the Regional [NAME] President and the Senior Director of Clinical Operations provided training for the interim administrator and the Director of Nurses regarding abuse identification, protection, conducting a thorough investigation and reporting requirements. This action was completed on 9/8/23. On 9/8/23, Residents with BIMS scores of 11 or higher were interviewed by the DNS and her designees to identify in they felt safe and if they had experienced abuse while living at the center. No concerns were identified. These interviews were completed on 9/8/23. On 9/8/23, the Abuse policy was reviewed by the Regional [NAME] President and the Senior Director of Clinical Operations. This review was completed on 9/8/23. No updates were necessary. On 9/8/23, Interim Administrator implemented an abuse investigation checklist to ensure investigations will be initiated and completed thoroughly. On 9/8/23, the DNS and her designee educated all staff on abuse prevention and reporting. This education was completed on 9/8/23. Going forward, any staff that were not present on 9/8/23 will not be allowed to work until they have been trained. On 9/9/23, the Activities Director will hold a Resident Council meeting in which the residents will be educated on the facility's abuse policies. This council meeting will conclude on 9/9/23. The Administrator or designee will continue to interview residents with a BIMS score of 11 or greater monthly to ensure they have not experienced abuse. 5 residents per week will be interviewed for 3 months starting the week of 9/11/23. The Director of Nursing or designee will conduct physical assessments on 5 residents per week with BIMS score of less than 11 to determine if there is evidence of abuse or injury of unknown origin for 3 months starting the week of 9/11/23. The findings of these interviews will be presented in QAPI as a PIP project. On 9/9/23, the Regional Director of Maintenance will conduct an environmental safety concern assessment of the center. This assessment will be completed by the center's maintenance director or the administrator on a weekly basis for 3 months beginning the week of 9/11/23. The findings of these assessments will be presented in QAPI as a PIP project. Competency of staff related to the Abuse/Neglect training will be captured by a competency test after each training. These competencies will continue until all are trained and deemed competent. Monitoring of the plan of removal included the following: Record review of in-services revealed that abuse, neglect, expliotation, including injuries of unknown origin, turning and repostioning, lift and transfers, customer service, reporting incidents and abuse coordinator acknowledgements were conducted. Interview with the Interim Administrator B on 9/10/23 at 11:24 a.m., revealed her to state that BIM scores were pulled from MDS and she compared with the census to ensure every resident was either deemed interviewable (BIM score above 11) or required a body audit if BIM score was under 11. She provided a list of the residents that were interviewed and those that they conducted body audits on. Interview with Activity Director on 9/10/23 at 12:02 p.m., revealed her to state that she conducted a resident council meeting with the residents, and none of the residents had any concerns about abuse, neglect or misappropriations. She said that she had a training and in-service on abuse and neglect, professionalism, transfers, smoking policy. Interview with two housekeepers on 9/10/23 at 12:07p.m., revealed them to state that they had an in-service on abuse, neglect, reporting if they see someone mistreating the residents to report it to the Administrator or DON. Interview with Maintenance and Regional Maintenance on 9/10/23 at 12:12 p.m., revealed them to state that on a daily basis they are checking the building for safety hazards such as: fire extinguishers, doors, outlets, Hoyer lifts and checking for any safety issues in the facility. Interviews with five CNA's on all three shifts, LVN A, two housekeepers, one floor tech, one MA, two charge nurses and maintenance and they all stated that they had been in-serviced on abuse, neglect and exploitation, reporting abuse and told if they had witnessed abuse they would report it to the Administrator. The Interim Administrator B was informed the Immediate Jeopardy was removed on 9/13/23 at 1:56 p.m. The facility remained out of compliance at a severity level of actual harm that is not IJ and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.