**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that the resident environment remained as free of accident hazards as was possible to prevent accidents for 1 of 20 residents (Resident #5) reviewed for accidents and hazards related to coffee burns. The facility failed to follow the policy and procedure for preparing and temping coffee. On 10/02/24, Resident #5 spilt coffee on herself, which caused a second-degree burn (tissue damage to the outer layer of your skin and the second layer of your skin) to Resident #5's right upper thigh and lower abdomen. The noncompliance was identified as PNC. The Immediate Jeopardy (IJ) began on 10/02/2024 and ended on 10/02/2024. The facility had corrected the noncompliance before the survey began. This failure could place residents at an increased risk for serious burn injuries while drinking hot liquids. The findings included: Record review of the face sheet dated 10/29/24, reflected Resident #5 was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses that included Parkinson's disease (a chronic, progressive brain disorder that affects movement and other systems of the body), dementia (memory loss), muscle weakness, and lack of coordination. Record review of the quarterly MDS assessment dated [DATE], reflected Resident #5 was able to make herself understood and usually understood by others. The MDS reflected Resident #5 had a BIMS score of 1, indicating her cognition was severely impaired. The MDS reflected Resident #5 had bilateral (both) upper and lower extremity limited range of motion. The MDS reflected Resident #5 required partial/moderate assistance with eating, oral hygiene, and upper body dressing. The MDS reflected Resident #5 was dependent on staff with toileting, showering and personal hygiene. Record review of the comprehensive care plan dated 10/02/24, completed post incident, reflected Resident #5 was at risk for burns due to impaired cognition and Parkinson's. The care plan interventions included: coffee and other hot liquids should not be served if over 140 degrees, resident to use a cup with lid, resident to wear clothing/lap protector when drinking hot liquids and should be seated in upright position with table or overbed table when hot liquids are being consumed. Record review of the event nurses note dated 10/02/24 signed by the DON, reflected Resident #5 had a burn/blister, caused by coffee, tea, or other hot liquid, to her right upper thigh that occurred in the dining room. The note reflected under details of injury; Resident #5 had a superficial layer of skin peeled measuring 2.5cm x 1.3cm. The note reflected Resident #5 had cognitive impairment. The note reflected the nursing description of the event, which indicated . Resident was drinking coffee in the dining room and dropped coffee on herself. The note reflected the resident statement of event was I spilt my coffee. The note reflected new orders to cleanse are with normal saline, Silvadene cream twice a day. Record review of the hot liquid assessment dated [DATE], completed post incident, reflected Resident #5 had moderate to severe cognitive impairment and Parkinson's. The assessment reflected Resident #5 could not consume hot liquids/food without special interventions. The assessment reflected the interventions needed to decrease potential burns included: lids on cups, clothing/lap barrier, and should be seated in upright position with table or overbed table. Record review of the self-reporting protocol/ad hoc QAPI dated 10/2/24, reflected the physician was notified and treatment was initiated, hot liquids assessment and care plans were updated for residents determined at risk, in-servicing was provided to dietary and nursing staff. The ad hoc QAPI reflected monitoring was initiated by the dietary manager at least 5 days per week. Record review of the witness statement dated 10/02/24, signed by the DON, reflected I was notified by [Student NA Z] that [Resident #5] had spilt coffee on herself in the dining room. [Student NA Z] and I took her to the bathroom to get her changed and assessed her. I noticed a 2.5 cm x 1.3 cm red area. Notified NP and hospice immediately. Received new orders for Silvadene cream twice daily. I immediately went to the dining room to confiscate any coffee that had been poured for a resident. I took the coffee pot into the kitchen to allow it to cool down. At this time only residents in the dining room had been served coffee. No other residents had any spilt coffee on them at this time. Record review of a list of residents identified at risk for hot liquid spills dated 10/02/24, reflected 21 residents (Resident's #3, #5, #6, #8, #17, #21, #23, #24, #25, #26, #36, #39, #41, #44, #45, #46, #48, #49, #109, #259, and #260) were at risk. Record review of Resident's #3, #5, #6, #8, #17, #21, #23, #24, #25, #26, #36, #39, #41, #44, #45, #46, #48, #49, #109, #259, and #260 comprehensive care plan, dated 10/02/24 after the incident, reflected they were at risk for hot liquid spills and interventions were put in place. Record review of Resident's #3, #5, #6, #8, #17, #21, #23, #24, #25, #26, #36, #39, #41, #44, #45, #46, #48, #49, #109, #259, and #260 hot liquids assessments, dated 10/02/24 after the incident, were completed. Record review of the in-service training attendance roster dated 10/02/24, reflected education was provided on residents at risk for spills. There were 47 staff signatures from across all shifts and disciplines. Record review of the in-service training attendance roster dated 10/02/24, reflected 1:1 education was provided to Cook, DD, [NAME] UU, [NAME] VV, [NAME] WW, DA H, DA XX, and DM SS regarding the coffee preparation steps, which included cooling the coffee down prior to serving. Record review of the in-service training attendance roster dated 10/02/24, reflected all staff were provided education on reporting burns immediately to the abuse coordinator, DON, and charge nurse. There were 76 staff signatures from across all shifts and disciplines. Record review of the in-service training attendance roster dated 10/02/24, reflected education was provided on if residents are demanding coffee, it cannot be served if not under 140 degrees. Notify administrator and DON of resident's demand. There were 26 staff signatures from across all shifts and disciplines. Record review of the in-service training attendance roster dated 10/02/24, reflected education was provided on hot liquids and food spills. There were 76 staff signatures from across all shifts and disciplines. Record review of the in-service training attendance roster dated 10/02/24, reflected education was provided on abuse and neglect. There was 76 staff signatures from across all shifts and disciplines. During an observation and interview on 10/28/24 beginning at 11:33 AM, DA H performed a temperature check on the coffee. The coffee temperature was 136.6 degrees Fahrenheit. DA H stated she was unable to serve coffee above the temperature of 140 degrees Fahrenheit. DA H stated the kitchen had a process for preparing the coffee that had to be followed. DA H stated she was provided 1:1 in-service training on preparing the coffee and making sure the coffee was at or below 140 degrees F prior to serving. During an observation and attempted interview on 10/28/24 beginning at 4:13 PM, Resident #5 was lying in her bed. Resident #5 was unable to answer questions appropriately as evidenced by confused conversations. During an interview on 10/28/24 beginning at 5:02 PM, the DON stated the incident on 10/02/24 with Resident #5 happened early in the morning during breakfast time. The DON stated staff were still getting residents into the dining room. The DON said a student nurse was looking for Resident #5 and found her in the dining room fanning her pants, which were wet. The DON stated she was immediately notified by the student nurse and immediately took Resident #5 for an assessment. The DON stated she observed a burn on her leg which appeared to have the top layer of skin missing. The DON stated she notified Resident #5's family member and physician. The DON stated she thought the coffee had to have been too hot, so she into the dining room and removed all the coffee. The DON stated she temped the coffee at 158 degrees F, so she had the dietary staff remake the coffee and follow the coffee preparation process until the temperature was at or below 140 degrees F. The DON said the coffee preparation process was in place prior to the incident and should have been followed. The DON stated she identified all other residents at risk for burns from hot liquids. The DON said she performed new hot liquid assessments and updated the plan of care for each resident identified at risk. The DON stated residents were identified as being at risk for burns from hot liquids by observations such as increased shaking, ROM difficulties, or contractures. The DON stated in-servicing was provided to the staff on residents who were at risk, which included the interventions in place to prevent burns. The DON said 1:1 in-serving was provided to dietary staff on coffee preparation process, coffee temperatures, and temperature logs. During an observation and interview on 10/29/24 beginning at 5:32 AM, DM SS prepared the coffee. DM SS brewed the coffee and then added ice until the temperature in the coffee cup was below 140 degrees F. The final temperature was at 124 degrees F. DM SS stated he did not normally prepare the coffee but was helping out this morning. During an interview on 10/29/24 beginning at 8:05 AM, CNA E stated Resident #5 did not drink coffee routinely. CNA E stated when Resident #5 requested coffee she had to have a lid on her cup, a cover on her lap, and she must be sitting upright. CNA E stated there was a list of residents at risk for spills from hot coffee and interventions in place. CNA E stated she could also find the information in the plan of care. During interviews on 10/30/24 between 9:16 AM and 11: 23 AM, Housekeeper M, Housekeeper CC, LA Y, the Housekeeping Supervisor, DA R, [NAME] DD, DM SS, Student NA O, Student NA Z, CNA N, CNA S, CNA V, MA BB, LVN A, LVN D, LVN L, LVN T, RN AA, PTA Q, COTA W, COTA X, OT P, OT U, the MDS Coordinator, the Human Resource Coordinator, Medical Records, the AD, the Maintenance Supervisor, the ADON, and the DON were able to verbalize they were provided in-service education on how to identified residents at risk for coffee burns. The staff members were able to verbalize who was at risk for burns from hot liquids and where to find out interventions needed. The staff said there were to report coffee burns immediately to the abuse coordinator, DON, and charge nurse. The staff verbalized coffee should not have been served over 140 degrees F. The staff said if Residents demanded hotter coffee, it should have been reported to the Administrator and DON. The staff verbalized coffee burns could have been considered neglect. DA R, [NAME] DD, DM SS were able to verbalize to correct steps for preparing the coffee. During an interview on 11/01/2024 beginning at 8:50 AM, DM SS stated he was not in the facility for the coffee incident with Resident #5. DM SS stated the nursing department handled the situation. DM SS stated he was provided education on the coffee preparation process. DM SS stated he expected his staff to follow the coffee preparation process. DM SS stated coffee should not have been served until the temperature was at 140 degrees F or below. DM SS said coffee temperatures were documented in the coffee temperature log. DM SS stated it was important to ensure coffee was served at the correct temperature to prevent coffee burns. During an interview on 11/01/24 beginning at 11:42 AM, the ADO stated Resident #5 had a burn from a coffee spill on 10/02/24. The ADO stated immediate action was taken to correct the noncompliance and monitoring was put into place to prevent further incidents. The ADO stated education was provided on the coffee preparation process and coffee temperatures. The ADO stated a process was in place prior to the incident and it was not followed. The ADO stated he expected the facility staff to follow the coffee preparation process and coffee should not have been served unless it was at or below 140 degrees F. The ADO stated it was important to ensure coffee was served at the appropriate temperatures to prevent burn injuries related to hot liquid spills. Record review of the hot liquid / food spills policy, undated, reflected residents are at risk of having any hot liquid/food spilled on their person causing burns .if any staff member observes a resident spill hot liquid or food on themselves or another resident, the staff member will attempt to dissipate the heat of the item spilled with at least a liquid that is at a temperature of room temperature or below, by pouring the room temperature of cooler liquid directly on the area affected . the charge nurse is to be immediately notified so that an assessment of the resident can be completed .the charge nurse will report any injury to the attending physician and responsible party and follow any further physician orders .staff will assist with changing of clothes as needed . an incident report and investigation will then be completed and determine if the resident needs further intervention and prevent future occurrences . Record review of the coffee preparation steps, undated, reflected coffee temperature will be obtained during the coffee preparation process, ice will be added until the temperature is at or below 140 degrees F. When the temperature is at or below 140 degrees F it may be served and recorded on the temperature log.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the rights of the residents to be free from abuse and neglect for 1 of 4 residents (Resident #30) reviewed for abuse. The facility failed to keep Resident #30 free from abuse and neglect, when CNA K, CNA EE, Student NA FF, and Student NA O held her down and provided incontinent care while she was screaming and yelling stop, leave me alone on 10/05/2024. An Immediate Jeopardy (IJ) was identified on 10/29/2024 11:10 AM. The IJ template was provided to the facility on [DATE] at 11:13 AM. While the IJ was removed on 10/30/2024 the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with a potential for more than minimal harm that is not immediate jeopardy because all staff had not been trained on abuse policies, behavior management policies, and restraint policies. This failure could place residents at risk for serious psychosocial harm from abuse, humiliation, intimidation, fear, shame, agitation, and decreased quality of life. The findings included: Record review of the face sheet dated 10/29/24, reflected Resident #30 was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses that included cerebral infarction (necrotic tissue in the brain), dementia (memory loss) with behavioral disturbances, essential hypertension (high blood pressure), and need for assistance with personal care. Record review of the quarterly MDS assessment dated [DATE], reflected Resident #30 was understood by others and was able to understand others. The MDS reflected Resident #30 had a BIMS score of 10, indicating her cognition was moderately impaired. The MDS reflected Resident #30 had verbal behaviors and refused care daily. The MDS reflected Resident #30 was dependent on staff with toileting, showers, and personal hygiene. The MDS reflected Resident #30 was always incontinent of bowel and bladder. Record review of the comprehensive care plan revised on 10/15/24, reflected Resident #30 was resistive to care, refused nursing/CNA care frequently such as weights, incontinent care, medications, showers, vital signs, labs, and other care. The care plan interventions included: allow the resident to make decisions about treatment regimen, to provide sense of control; if resident resists with ADLs, reassure resident, ensure safety, leave, and return 5-10 minutes later and try again; and it was her choice to be changed or not when asked/offered by CNAs/nurses. Record review of Resident #30's comprehensive monthly note dated 10/15/24 and created by the NP indicated . When seen last week, she reported an episode of abuse to me and other staff members. DON and Administrator notified. She was seen today while lying in bed. Pt initially started off calm and pleasant, then started yelling and cursing. In the midst of her yelling, she reported physical abuse again by staff and how she has pain in her [left] arm. Offered pain meds [medications] and scans, she refused and started yelling more . Record review of the social history assessment dated [DATE], reflected Resident #30 had a history of trauma. The assessment reflected Resident #30 had experienced a life-threatening illness, physical assault, physically threatened, sexually assaulted, and sexually threatened. The assessment reflected Resident #30 had been in and witnessed an extremely frightening situation. The assessment reflected Resident #30 reported at the age of 29 she was kidnapped from a store where she was working at. She states that two black men kidnapped, raped, and attempted to murder her. The FBI was involved, and she was found. Record review of the Abuse/Neglect policy, revised 09/09/24, reflected the resident has the right to be free from abuse . During an observation and interview on 10/28/24 at 11:19 AM, Resident #30 stated she remembered an incident where she was held down and changed against her will. Resident #30 was unable to remember the date of the incident. Resident #30 said she did not yell unless there was a reason. Resident #30 said she did not know the names of the staff members that held her down, but it was abuse. Resident #30 stated if anyone held another person down, that was abuse. Resident #30 said she had bruising on her arm and her left shoulder was hurting from the incident. Resident #30 showed surveyor her arm, which was free of bruising. Resident #30 had large, blue, veins that were visible. Resident #30 said during the incident the woman walked in and took her stuff, moved it to the side, grabbed her arm and twisted from the elbow to her wrist. Resident #30 stated she reported it to the staff but did not know their names. Resident #30 said the Administrator came in and told Resident #30 the girls were not fired; they just were not allowed to come back into her room. During an interview on 10/29/24 at 4:29 AM, CNA K stated she remembered an incident with Resident #30. CNA K stated she had only assisted with Resident #30's care on two occasions. CNA K stated on 10/05/24 she had just clocked into work when Student NA O requested assistance cleaning up Resident #30. CNA K stated herself, CNA EE, Student NA O, and Student NA FF were in Resident #30's room. CNA K stated they explained to Resident #30 she needed to be cleaned because she had bowel movement all over her. CNA K stated as soon as CNA EE moved Resident #30's fridge all hell broke loose. CNA K stated Resident #30 started screaming, cussing, hitting, and kicking staff. CNA K stated they had to clean her, so they held her down and continued cleaning her. CNA K stated Resident #30 kept yelling No, stop! CNA K stated Resident #30 told her she was hurting her when she was wiping. CNA K stated she apologized but explained she had to get her cleaned and a new brief placed on her. CNA K stated Resident #30 said she understood but kept yelling No, stop, leave me alone! CNA K stated normally when residents refused care or said no, she would stop performing care and go back at a later time. CNA K said she was told by the charge nurses that Resident #30 had to be changed twice a shift no matter what. CNA K stated she wanted to stop but felt like if she did not get Resident #30 changed, she would have gotten into trouble for disobeying. CNA K said it was important to respect Resident #30's wishes because it was her right to refuse care. CNA K stated holding someone down against their will could have been considered abuse. CNA K stated she would have done the same thing if she was changed against her will. During an interview on 10/29/24 at 4:37 AM, CNA EE stated on 10/05/24 she was asked by Student NA O to assist with changing Resident #30. CNA EE stated she had only worked at the facility for one week at the time of the incident. CNA EE said from what she remembered, there was a lot of screaming and yelling from Resident #30 when she was changed. CNA EE stated the other staff members stated it was normal for Resident #30 to yell, scream, and become combative during care so they continued. CNA EE said she held her over from the left shoulder area and on her back. CNA EE stated Resident #30 was mostly yelling and screaming and not hitting much. CNA EE said Resident #30 was pushing against the railing to try and push herself away. CNA EE said if a resident refused care, started yelling no, or became combative they should have backed away and reported it to the charge nurse. CNA EE said they did not do that in Resident #30's case. CNA EE said 4 people were in the room and it was chaos. CNA EE stated it was important to respect the resident's rights. CNA EE said continuing care for someone against their will, could have been considered abuse. During an interview on 10/29/24 at 4:38 AM, LVN LL stated Resident #30 refused to be changed most of the time. LVN LL said when Resident #30 refused care, the CNAs reported it to her, and she would have tried to talk Resident #30 into letting them help her. LVN LL said bargaining with Resident #30 worked at times, but if she adamantly refused, then she would have documented it. LVN LL stated she was recently hired, and she was working her third shift. LVN LL said if Resident #30 refused care, she expected the CNAs to stop providing care and report it to her. LVN LL said CNAs should not have continued care if the resident refused, started yelling, or became combative. LVN LL said it was important to respect the residents' rights and it could have been considered abuse to force care on someone. During an interview on 10/29/24 at 5:00 AM, the DON stated Resident #30 had reported on 10/14/24 that she was held down and changed against her will. The DON stated 4 people were identified during the investigation, which included CNA K, CNA EE, Student NA O, and Student NA FF. The DON stated the CNAs reported they went into change Resident #30, and she became combative. The DON said the CNAs reported Resident #30 was not held down but when she became combative the CNAs blocked and protected themselves from her hitting and kicking. The DON stated the facility policy was to stop providing care if a resident was refusing or becoming combative. The DON said Resident #37 reported her arm was hurting and she had bruising to her left arm. The DON stated an assessment was completed and no bruising was observed. The DON stated an x-ray was ordered but the resident refused. The DON stated staff should have left the room and came back at a later time to provide care. The DON stated Resident #30 had a right to refuse care. The DON stated no fault was identified during the investigation because the CNAs and NAs were doing their jobs. The DON stated Resident #30 had a history of refusing incontinent care for days to the point urine was running off her bed onto the floor. The DON stated they had tried different things to convince Resident #30 to allow staff to change her, but she continued to refuse care. The DON stated she told staff Resident #30 should have been changed at least once a shift. The DON stated it was important to respect the residents right to refuse care for multiple reasons, that included resident rights, injury, and traumatization. During an attempted interview on 10/31/24 at 8:53 AM to obtain additional information, Student NA FF did not answer the phone. A brief message was left with call back number. No return call upon exit of the facility. During an interview on 10/31/24 at 8:54 AM, Student NA O stated on 10/05/24 Resident #30 had asked for assistance with incontinent care. Student NA O stated it was only her second day on the job and she was not certified yet. Student NA O stated she was unable to find other staff members to assist her with changing Resident #30 during her shift. Student NA O stated the charge nurse told her she needed assistance. Student NA O did not remember the name of the charge nurse. Student NA O stated at the end of her shift when the night shift arrived, she asked CNA K, CNA EE, and Student NA FF for assistance with changing Resident #30. Student NA O stated Resident #30 was upset it had taken so long to find assistance. Student NA O said as they started changing Resident #30, and she became really upset. Student NA O said they just kept trying to encourage her. Student NA O said Resident #30 hit CNA K in the face a couple of times. Student NA O stated they rolled Resident #30 so they could change her brief and Resident #30 kicked her in the chest. Student NA O said she grabbed Resident #30's legs and loosely put them beside her body to block her hitting and kicking. Student NA O stated she used her body to keep Resident #30 from hitting and kicking. Student NA O said CNA EE was shielding Resident #30's hands from hitting other staff by holding her hands. Student NA O stated they were holding her hands for protection. Student NA O said Resident #30 was yelling and cussing at them. Student NA O stated Resident #30 said they did not know what the fuck they were doing, and it only took one person to change her. Student NA O said Resident #30 was mad because of all the staff members in the room. Student NA O said she talked to Resident #30 after the incident and Resident #30 explained she only liked one person in the room with her. Student NA O said changing Resident #30 against her will could have been considered abuse or a restraint. This was determined to be an Immediate Jeopardy (IJ) on 10/29/24 at 11:10 AM. The ADO was notified. The ADO was provided the IJ template on 10/29/24 at 11:13 AM. The following plan of removal submitted by the facility was accepted on 10/29/24 at 5:11 PM and included the following: Interventions 1. Resident #30 was assessed for emotional distress by the DON on 10/29/24. A trauma informed care assessment was completed on 10/29/24 by the DON. No additional emotional distress was noted. On 10/29/2024, DON completed a skin assessment and pain assessment with no negative findings. 2. The DON, and ADON were in-serviced 1:1 by the Regional Compliance Nurse on following topics below. The administrator is on paid time off. The administrator will be in-serviced prior to returning to work by the Area Director of Operations. Completed with DON and ADON on 10/29/24. a. Abuse and Neglect to include not to hold a resident down while providing care at any time. If a resident is yelling stop, the staff members will stop and notify the charge nurse, DON, or Administrator for assistance and further direction. b. Behavioral management policy- Explain care to be provided prior to providing the care. If the resident refuses care or becomes combative with care, stop attempting to perform the care being resisted, ensure the resident's safety allow the resident to calm down. Attempt the care at a later time or with different staff. Continued combativeness with care should be reported to the Charge nurse, Administrator and/or DON immediately. c. Restraint Policy- holding a resident against their will to provide care is considered a restraint. 3. The 4 staff members were in-serviced 1:1 by the DON and ADON on 10/29/24 on the following topics below. i. Addendum - On 10/29/2204 ADO, DON, and ADON attempted to communicate with the 4 staff members via text and phone call. 2 of the 4 staff members verbally self-termed, 1 staff member was a no call no show for their shift on 10/29/2024 and is being termed and the 4th staff member is PRN and has not responded to text messages or phone calls. Images of the in-services have been texted to her and if she is to return to work she will be in serviced by DON or ADON prior to the start of her shift. a. Abuse and Neglect to include not to hold a resident down while providing care at any time. If a resident is yelling stop, the staff members will stop and notify the charge nurse, DON, or Administrator for assistance and further direction. b. Behavioral management policy- Explain care to be provided prior to providing the care. If the resident refuses care or becomes combative with care, stop attempting to perform the care being resisted, ensure the resident's safety allow the resident to calm down. Attempt the care at a later time or with different staff. Continued combativeness with care should be reported to the Charge nurse, Administrator and/or DON immediately. c. Restraint Policy- holding a resident against their will to provide care is considered a restraint. 4. The medical director was informed of the immediate jeopardy citation on 10/29/24 by DON. 5. An ADHOC QAPI meeting was held on 10/29/24 to include the interdisciplinary team and medical director to discuss the immediate jeopardy citation and plan of removal. In-services: All staff will be in-serviced on 10/29/2024 for the following topics below by the ADO and Regional Compliance Nurse, DON, and ADON. All staff not present will not be allowed to assume their duties until in-serviced. All PRN staff will be in-serviced prior to their next assignments. All new hires will be in-service on their date of hire, during facility orientation. All agency staff will be in-serviced prior to the start of their assignment. a. Abuse and Neglect to include not to hold a resident down while providing care at any time. If a resident is yelling stop, the staff members will stop and notify the charge nurse, DON, or Administrator for assistance and further direction. b. Behavioral management policy- Explain care to be provided prior to providing the care. If the resident refuses care or becomes combative with care, stop attempting to perform the care being resisted, ensure the resident's safety allow the resident to calm down. Attempt the care at a later time or with different staff. Continued combativeness with care should be reported to the Charge nurse, Administrator and/or DON immediately. c. Restraint Policy- holding a resident against their will to provide care is considered a restraint. On 10/30/24 the survey team confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: 1. Record review of Resident #30's electronic medical record, reflected a new trauma informed care assessment dated [DATE] was completed. The assessment reflected Resident #30 had a history of trauma, was sexually assaulted, had been in a situation that was extremely frightening, had witnessed an extremely frightening situation, and did not feel comfortable explaining any of the situations. 2. Record review of Resident #30's skin assessment dated [DATE], reflected no injuries or skin concerns. 3. Record review of Resident #30's pain assessment dated [DATE], reflected no pain concerns. 4. Record review of the ADHOC QA meeting document dated 10/29/24, reflected the immediate jeopardy concerns were discussed with the plan of removal and monitoring. The Medical Director attended verbally and a copy of the plan was provided. 5. Record review of the in-service training attendance roster dated 10/29/24, reflected education was provided on behavior management to the DON and the ADON. 6. Record review of the in-service training attendance roster dated 10/29/24, reflected education was provided on restraints policy to the DON and the ADON. 7. Record review of the in-service training attendance roster dated 10/29/24, reflected education was provided on abuse and neglect polices to the DON and the ADON. 8. Record review of the in-service attendance roster dated 10/29/24, reflected education was provided to all staff across all shifts and disciplines on the restraint policy. There were 47 staff signatures. 9. Record review of the in-service attendance roster dated 10/29/24, reflected education was provided on the restraint policy via telephone to twelve staff members across all shifts and disciplines. 10. Record review of the in-service attendance roster dated 10/29/24, reflected education was provided on abuse and neglect policies. There were 47 staff signatures from across all shifts and disciplines. 11. Record review of the in-service attendance roster dated 10/29/24, reflected education was provided on abuse and neglect policies via telephone to 11 staff members from across all shifts and disciplines. 12. Record review of the in-service attendance roster dated 10/29/24, reflected education was provided on the behavior management policy. There were 47 staff signatures from across all shifts and disciplines. 13. Record review of the in-service attendance roster dated 10/29/24, reflected education was provided on the behavior management policy via telephone to 12 staff members from across all shifts and disciplines. 14. During a telephone interview on 10/30/24 at 9:48 AM, the Medical Director stated he was notified of the immediate jeopardy situation and attended a QAPI meeting via phone over the immediate jeopardy and subsequent plan of removal on 10/29/24. 15. During interviews on 10/30/24 between 9:16 AM and 11: 23 AM, Housekeeper M, Housekeeper CC, LA Y, the Housekeeping Supervisor, DA R, [NAME] DD, DM SS, Student NA O, Student NA Z, CNA N, CNA S, CNA V, MA BB, LVN A, LVN D, LVN L, LVN T, RN AA, PTA Q, COTA W, COTA X, OT P, OT U, the MDS Coordinator, the Human Resource Coordinator, Medical Records, the AD, the Maintenance Supervisor, the ADON, and the DON were able to verbalize they were provided in-service education on behavior management policy, restraint policy, and abuse neglect policies. The staff members were able to explain if residents were refusing care or became combative during care, they should stop providing care, ensure the resident was safe, and notify the charge nurse. The staff stated they could attempt care at a later time with a different staff member. The staff members stated holding a resident down against their will to provide care was considered a restraint. The staff members stated it could have also been considered abuse. The staff members were able to verbalize the different types of abuse, when to report abuse, and who the abuse coordinator was. 16. Record review of the personnel action form reflected CNA K was self-terminated effective 10/30/24. 17. Record review of the personnel action form reflected CNA EE was self-terminated effective 10/20/24. The ADO was informed the IJ was removed on 10/20/24 at 11:54 AM. The facility remained out of compliance at a scope of isolated and a severity level of no actual harm with a potential for more than minimal harm that is not immediate jeopardy 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 observations, interviews, and record review, the facility failed to ensure that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for 3 of 4 residents' (Resident's #2, #4, and #30) reviewed for trauma-informed care. 1. The facility failed to ensure Resident #30 was not held down and provided incontinent care while she was screaming and yelling stop, leave me alone on [DATE] by CNA K, CNA EE, Student NA FF, and Student NA O. 2. The facility failed to ensure Resident #30's history of being kidnapped, raped, and almost murdered was included on the care plan. 3. The facility failed to ensure Resident #30's potential triggers for re-traumatization were assessed and documented in the care plan. 4. The facility failed to ensure Resident #4's history of trauma and diagnosis of PTSD was reflected on her trauma screening. 5. The facility failed to ensure Resident #4's history of trauma and diagnosis of PTSD was included on the care plan, with her potential triggers for re-traumatization identified. 6. The facility failed to ensure Resident #2's trauma screening reflected her diagnosis of PTSD. An Immediate Jeopardy (IJ) was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 11:13 AM. While the IJ was removed on [DATE] the facility remained out of compliance at a scope of patterned and a severity level of no actual harm with a potential for more than minimal harm that is not immediate jeopardy because all staff had not been trained on abuse policies, behavior management policies, and restraint policies. These failures could put residents at an increased risk for severe psychological distress due to re-traumatization. The findings included: 1. Record review of the face sheet dated [DATE], reflected Resident #30 was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses that included cerebral infarction (necrotic tissue in the brain), dementia (memory loss) with behavioral disturbances, essential hypertension (high blood pressure), and need for assistance with personal care. Record review of the quarterly MDS assessment dated [DATE], reflected Resident #30 was understood by others and was able to understand others. The MDS reflected Resident #30 had a BIMS score of 10, indicating her cognition was moderately impaired. The MDS reflected Resident #30 had verbal behaviors and refused care daily. The MDS reflected Resident #30 was dependent on staff with toileting, showers, and personal hygiene. The MDS reflected Resident #30 was always incontinent of bowel and bladder. Record review of the comprehensive care plan revised on [DATE], reflected Resident #30 was resistive to care, refused nursing/CNA care frequently such as weights, incontinent care, medications, showers, vital signs, labs, and other care. The care plan interventions included: allow the resident to make decisions about treatment regimen, to provide sense of control; if resident resists with ADLs, reassure resident, ensure safety, leave, and return 5-10 minutes later and try again; and it was her choice to be changed or not when asked/offered by CNAs/nurses. The comprehensive care plan did not address Resident #30's history of trauma to include potential triggers for re-traumatization. Record review of the social history assessment dated [DATE], reflected Resident #30 had a history of trauma. The assessment reflected Resident #30 had experienced a life-threatening illness, physical assault, physically threatened, sexually assaulted, and sexually threatened. The assessment reflected Resident #30 had been in and witnessed an extremely frightening situation. The assessment reflected Resident #30 reported at the age of 29 she was kidnapped from a store where she was working at. She states that two black men kidnapped, raped, and attempted to murder her. The FBI was involved, and she was found. Record review of Resident #30's comprehensive monthly note dated [DATE] and created by the NP indicated . When seen last week, she reported an episode of abuse to me and other staff members. DON and Administrator notified. She was seen today while lying in bed. Pt initially started off calm and pleasant, then started yelling and cursing. In the midst of her yelling, she reported physical abuse again by staff and how she has pain in her [left] arm. Offered pain meds [medications] and scans, she refused and started yelling more . Record review of Resident #30's progress note dated [DATE], reflected . Pt [patient] gets anxious and combative with nursing care. She has a history of being sexually assaulted by several males. She denies symptoms of PTSD (a mental and behavioral disorder that develops from experiencing a traumatic event). I cannot rule out post-traumatic stress disorder at this time . During an interview on [DATE] at 11:19 AM, Resident #30 stated she remembered an incident where she was held down and changed against her will. Resident #30 said she did not yell unless there was a reason. Resident #30 said she did not know the names of the staff members that held her down, but it was abuse. Resident #30 stated if anyone held you down, that was abuse. Resident #30 said she had bruising on her arm and her left shoulder was hurting. Resident #30 said the woman walked in and took her stuff, moved it to the side, grabbed her arm and twisted from the elbow to her wrist. Resident #30 stated the girls were not fired; they just were not allowed to come back into her room. Resident #30 stated she was kidnapped by two men, sexually assaulted, and almost murdered. Resident #30 said the two men came into the store and asked for some liquor. Resident #30 stated they followed her into the back and grabbed her. Resident #30 stated they placed a gun to her head and made her take off her clothing. Resident #30 stated she was raped for hours. Resident #30 said her brain shut off, but she remembered being by some water. Resident #30 said after they were done, they tried to make her get out of the car. Resident #30 said a short time later the FBI rescued her. Resident #30 said she knew if she got out of the car she would have been killed. Resident #30 said for the longest time she was unable to talk about the incident because her brain was trying to protect itself. During an interview on [DATE] at 4:29 AM, CNA K stated she remembered an incident with Resident #30. CNA K stated she had only assisted with Resident #30's care on two occasions. CNA K stated on [DATE] she had just clocked into work when Student NA O requested assistance cleaning up Resident #30. CNA K stated herself, CNA EE, Student NA O, and Student NA FF were in Resident #30's room. CNA K stated they explained to Resident #30 she needed to be cleaned because she had bowel movement all over her. CNA K stated as soon as CNA EE moved Resident #30's fridge all hell broke loose. CNA K stated Resident #30 started screaming, cussing, hitting, and kicking staff. CNA K stated they had to clean her, so they held her down and continued cleaning her. CNA K stated Resident #30 kept yelling no, stop. CNA K stated Resident #30 told her she was hurting her when she was wiping. CNA K stated she apologized but explained she had to get her cleaned and a new brief placed on her. CNA K stated Resident #30 said she understood but kept yelling no, stop, leave me alone. CNA K stated normally when residents refused care or said no, she would stop performing care and come back at a later time. CNA K said she was told by the charge nurses that Resident #30 had to be changed twice a shift no matter what. CNA K stated she wanted to stop but felt like if she did not get Resident #30 changed, she would have gotten into trouble for disobeying. CNA K stated she was aware of Resident #30's history of trauma. CNA K stated Resident #30 told her the story of being kidnapped, raped, and almost murdered. CNA K stated changing someone against their will could have triggered re-traumatization, but she was told by the DON Resident #30 had to be changed. CNA K stated she would have done the same thing if she was changed against her will. During an interview on [DATE] at 4:37 AM, CNA EE stated on [DATE] she was asked by Student NA O to assist with changing Resident #30. CNA EE stated she had only worked at the facility for one week at the time of the incident. CNA EE said from what she remembered, there was a lot of screaming and yelling from Resident #30 when she was changed. CNA EE stated the other staff members stated it was normal for Resident #30 to yell, scream, and become combative during care so they continued. CNA EE said she held her over from the left shoulder area and on her back. CNA EE stated Resident #30 was mostly yelling and screaming and not hitting much. CNA EE said Resident #30 was pushing against the railing to try and push herself away. CNA EE said if a resident refused care, started yelling no, or became combative they should have backed away and reported it to the charge nurse. CNA EE said they did not do that in Resident #30's case. CNA EE said 4 people were in the room and it was chaos. CNA EE stated she was unsure if Resident #30 had a history of trauma. Resident #30 said it was important to know if a resident had a history of trauma, but she was unsure where to find out if a resident had a history of trauma. CNA EE said she usually asked the nurse. CNA EE said continuing care for someone against their will, could have traumatized the resident. During an interview on [DATE] at 4:38 AM, LVN LL stated Resident #30 refused to be changed most of the time. LVN LL said when Resident #30 refused care, the CNAs reported it to her, and she would have tried to talk Resident #30 into letting them help her. LVN LL said bargaining with Resident #30 works at times, but if she adamantly refused, then she would have documented it. LVN LL stated she was recently hired, and she was working her third shift. LVN LL said if Resident #30 refused care, she expected the CNAs to stop providing care and report it to her. LVN LL said CNAs should not have continued care if the resident refused, started yelling, or became combative. LVN LL said she was not aware if Resident #30 had a history of trauma. LVN LL said she found out if residents had a history of trauma by looking in the chart or asking staff. LVN LL said if Resident #30 had a history of trauma and was changed against her will, it could have caused re-traumatization. During an interview on [DATE] at 5:00 AM, the DON stated Resident #30 had reported that she was held down and changed against her will. The DON stated 4 people were identified during the investigation, CNA K, CNA EE, Student NA O, and Student NA FF. The DON stated the CNAs reported they went into change Resident #30, and she became combative. The DON said the CNAs reported Resident #30 was not held down but when she became combative the CNAs blocked and protected themselves from her hitting and kicking. The DON said Resident #30 reported the Administrator she was assaulted in her 30's. The DON stated she was unaware of Resident #30's history of trauma until the incident occurred. The DON said Resident #30 being held down and changed against her will could have triggered her and caused re-traumatization. The DON stated the facility policy was to stop providing care if a resident was refusing or becoming combative. The DON stated staff should have left the room and came back at a later time to provide care. The DON stated no fault was identified during the investigation because the CNAs and NAs were doing their jobs. The DON stated Resident #30 went days refusing incontinent care to the point urine was running off her bed onto the floor. The DON stated they had tried different things to convince Resident #30 to allow staff to change her, but she continued to refuse care. The DON stated she told staff Resident #30 should have been changed at least once a shift. The DON stated it was important to respect the residents right to refuse care for multiple reasons, that included resident rights, injury, and traumatization. During an interview on [DATE] at 8:10 AM, the psychiatric NP stated he was familiar with Resident #30. The psychiatric NP stated Resident #30 was on his services. The psychiatric NP said the staff reported Resident #30 was irritable and refused care. The psychiatric NP said when he visited with Resident #30, she was pleasant and in a good mood. The psychiatric NP stated Resident #30 reported no issues. The psychiatric NP stated Resident #30 did not want help or medications. The psychiatric NP stated Resident #30 reported a history of trauma, that included sexual assault on her initial evaluation but denied any PTSD symptoms. The psychiatric NP stated Resident #30 had depressive symptoms that included irritable mood and lack of motivation to care for herself. The psychiatric NP stated he had tried several antidepressant medications in the past and Resident #30 recently started sertraline (antidepressant). The psychiatric NP said Resident #30 recently reported an incident were staff held her down to change her. The psychiatric NP said that incident had the potential to cause PTSD symptoms related to her history of trauma. The psychiatric NP said that she was assessed for trauma and trauma triggers on initial evaluation but since Resident #30 denied symptoms of PTSD, they did not assess further. The psychiatric NP stated counseling and medications were the only interventions attempted at this time. 2. Record review of the face sheet dated [DATE], reflected Resident #4 was a [AGE] year-old female who originally admitted to the facility on [DATE] with diagnoses that included cerebral palsy (group of neurological disorders that affect a person's ability to move, balance, and maintain posture), intellectual disabilities (below average intelligence and set of life skills present before age [AGE]), essential hypertension (high blood pressure), and post-traumatic stress disorder (disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event). Record review of the quarterly MDS assessment dated [DATE], reflected Resident #4 was able to make herself understood and usually understood others. The MDS reflected Resident #4's had a BIMS score of 13, indicating her cognition was intact. The MDS reflected Resident #4 had no behaviors or refusal of care. The MDS reflected Resident #4 had an active diagnosis of PTSD. Record review of Resident #4's comprehensive care plan, last reviewed on [DATE], reflected no care plan in place for her diagnosis of PTSD or history of trauma. The care plan did not address potential triggers for re-traumatization. Record review of the social history dated [DATE], reflected Resident #4 had no diagnosis of PTSD or history of trauma. Record review of the most recent psychiatric note dated [DATE], reflected Resident #4's diagnosis of PTSD was not addressed. During an interview on [DATE] at 10:15 AM, Resident #4 said she had trauma related to being born with drugs in her system. Resident #4 said her family member molested her and poured drugs and alcohol down her. Resident #4 stated she was made to take care of her younger family members at the age of 10. Resident #4 said the facility staff were aware of her history of trauma. 3. Record review of Resident #2's face sheet dated [DATE], indicated a [AGE] year old female who admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included Cerebral palsy (also known as CP, a group of neurological disorders that affect a person's ability to move, balance, and maintain posture), diabetes mellitus type 2 (also known as diabetes, a chronic disease that occurs when the body has high blood sugar levels), Post-traumatic stress disorder (also known as PTSD, a mental health condition that can develop after someone experiences or witnesses a traumatic event),Depression (a mental health condition that can affect anyone, causing a persistent low mood and loss of interest in activities), and Anxiety( a feeling of fear, dread, and uneasiness that can be a normal reaction to stress). Record review of Resident #2's annual MDS assessment dated [DATE], indicated Resident #2 was usually able to make herself understood and understood others. The MDS assessment indicated Resident #2 had a BIMS score of 06, indicating her cognition was severely impaired. The MDS assessment indicated Resident #2 had received insulin 7 days out of the 7-day look back period. The MDS assessment indicated Resident #2 had received a hypoglycemic medication within the last 7 days of the look back period. Record review of Resident #2's comprehensive care plan dated [DATE] indicated Resident #2 had PTSD or other similar diagnoses related to memories from her childhood. The interventions were for staff to identify situation/event/images that trigger recollections of the traumatic event and limit the resident's exposure to these as much as possible, If the resident has escalated, if possible do not touch the resident unless absolutely necessary for resident's or others safety. Monitor for escalating anxiety, depression or suicidal thought and report immediately to the nurse. Record review of Resident #2's physician order dated [DATE] revealed an order for [name] Psychiatric Services. Record review of Resident #2's social history dated [DATE] completed by the social worker did not indicate any history of PTSD. During an interview on [DATE] at 9:14 AM, Resident #2 said she had PTSD related to being verbally and mentally abused by her family member from the age of nine months old until she was [AGE] years old when her family member died. Resident #2 said she told one of the social workers at the facility when she was admitted , and she had also told some of the other staff about having PTSD. During an interview on [DATE] at 4:45 PM, the Social Worker said he screened residents for a history of trauma on admission when he completed the social history. The Social Worker said if a resident had trauma or PTSD the DON asked him to complete a trauma assessment as needed. The Social Worker said he was responsible for checking the residents for trauma. The Social Worker said he also assessed for the triggers, and sometimes he put them in the notes because there was no column on the social history to add the triggers. The Social Worker said PTSD/trauma and the triggers were placed in the care plan by the MDS Coordinator. The Social Worker said it was important to assess for trauma and the triggers to understand the residents' behaviors. The Social Worker said Resident #2 had not reported her mother abusing her to him. The Social Worker was aware Resident #4 and Resident #30 had a history of trauma. During an attempted interview on [DATE] at 8:53 AM to obtain additional information, Student NA FF did not answer the phone. A brief message was left with call back number. No return call upon exit of the facility. During an interview on [DATE] at 8:54 AM, Student NA O stated on [DATE] Resident #30 had asked for assistance with incontinent care. Student NA O stated it was only her second day on the job and she was not certified yet. Student NA O stated she was unable to find other staff members to assist her with changing Resident #30 during her shift. Student NA O stated the charge nurse told her she needed assistance. Student NA O stated at the end of her shift when the night shift arrived, she asked CNA K, CNA EE, and Student NA FF for assistance with changing Resident #30. Student NA O stated Resident #30 was upset it had taken so long to find assistance. Student NA O said as they started changing Resident #30, she became really upset. Student NA O said they just kept trying to encourage her. Student NA O said Resident #30 hit CNA K in the face a couple of times. Student NA O stated the rolled Resident #30 so they could change her brief and Resident #30 kicked her in the chest. Student NA O said she grabbed Resident #30's legs and loosely put them beside her body to block her hitting and kicking. Student NA O stated she used her body to keep Resident #30 from hitting and kicking. Student NA O said CNA EE was shielding Resident #30's hands from hitting other staff. Student NA O stated they were holding her hands for protection. Student NA O said Resident #30 was yelling and cussing at them. Student NA O stated Resident #30 said they did not know what the fuck they were doing, and it only took one person to change her. Student NA O said Resident #30 was mad because of all the staff members in the room. Student NA O said she talked to Resident #30 after the incident and Resident #30 explained she only liked one person in the room with her. Student NA O said Resident #30 had a history of trauma. Student NA O said changing Resident #30 against her will could have caused her to re-live her traumatic event. During an interview on [DATE] at 4:37 PM, the MDS nurse said she did the comprehensive care plans. She said the social worker usually does the trauma care plans and they reviewed them during the care plan meetings. She said she did not realize Resident #2 and Resident #4's care plan was not specific to their trauma. During an interview on [DATE] at 11:45 AM, the ADON said she was aware Resident#2 had trauma but did not know in full detail what the trauma was until this week ([DATE] until [DATE]) when she asked her what happened. She said she was not aware of who was supposed to do the care plan for trauma but said it needed to be on the care plan. She said it was important for the staff to know how to meet her needs. Record review of the Trauma Informed Care policy, dated 10/2022, reflected the intent of this requirement is to ensure that facilities deliver care and services which, in addition to meeting professional standards, are delivered using approaches which are culturally- competent and account for experiences and preferences, and address the needs of trauma survivors by minimizing triggers and/or re-traumatization .facilities should use a multi-pronged approach to identifying a resident's history of trauma as well as his or her cultural preferences .include asking resident about triggers that may be stressors or may prompt recall of a previous traumatic event .facilities must identify triggers which may re-traumatize residents with a history of trauma The facility should collaborate with resident trauma survivors to develop and implement individualized interventions .trigger specific interventions should be identified . This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 11:10 AM. The ADO was notified. The ADO was provided the IJ template on [DATE] at 11:13 AM. The following plan of removal submitted by the facility was accepted on [DATE] at 5:11 PM and included the following: Interventions 1.Resident numbers #2, #4, and #30 were assessed for emotional distress by the DON on [DATE]. A trauma informed care assessment was completed for each resident on [DATE] by the DON. No additional emotional distress was noted for each resident. DON updated care plans for resident #2, #4 and #30 on [DATE]. DON documented trauma informed care interventions with identified triggers and assistance with avoidance on Care Plan and Kardex as of [DATE]. Residents #2, #4, and #30 are all receiving psych services. Residents #2, #4, and #30 were involved in setting interventions to reduce re-traumatization. 2. The DON, and ADON were in-serviced 1:1 by the Regional Compliance Nurse on following topics below. The administrator is on paid time off. The administrator will be in-serviced prior to returning to work by the Area Director of Operations. Completed with the DON and ADON [DATE]. a. Trauma Informed Care Policy- all residents with a history of trauma or a diagnosis of PTSD will be assessed for potential triggers and have their plan of care modified accordingly. b. Abuse and Neglect to include not to hold a resident down while providing care at any time. If a resident is yelling stop, the staff members will stop and notify the charge nurse, DON, or Administrator for assistance and further direction. c. Behavioral management policy- Explain care to be provided prior to providing the care. If the resident refuses care or becomes combative with care, stop attempting to perform the care being resisted, ensure the resident's safety allow the resident to calm down. Attempt the care at a later time or with different staff. Continued combativeness with care should be reported to the Charge nurse, Administrator and/or DON immediately. d. Restraint Policy- holding a resident against their will to provide care is considered a restraint. 3. The 4 staff members were in-serviced 1:1 by the DON and ADON on [DATE] on the following topics below. i. Addendum - On [DATE] ADO, DON, and ADON attempted to communicate with the 4 staff members via text and phone call. 2 of the 4 staff members verbally self-termed, 1 staff member was a no call no show for their shift on [DATE] and is being termed and the 4th staff member is PRN and has not responded to text messages or phone calls. Images of the in-services have been texted to her and if she is to return to work, she will be in-serviced by DON or ADON prior to the start of her shift. a. Abuse and Neglect to include not to hold a resident down while providing care at any time. If a resident is yelling stop, the staff members will stop and notify the charge nurse, DON, or Administrator for assistance and further direction. b. Behavioral management policy- Explain care to be provided prior to providing the care. If the resident refuses care or becomes combative with care, stop attempting to perform the care being resisted, ensure the resident's safety allow the resident to calm down. Attempt the care later or with different staff. Continued combativeness with care should be reported to the Charge nurse, Administrator and/or DON immediately. c. Restraint Policy- holding a resident against their will to provide care is considered a restraint. 4. The medical director was informed of the immediate jeopardy citation on [DATE] by DON. 5. An ADHOC QAPI meeting was held on [DATE] to include the interdisciplinary team and medical director to discuss the immediate jeopardy citation and plan of removal. In-services: All staff will be in-serviced on [DATE] regarding the following topics below by the ADO and Regional Compliance Nurse, DON, and ADON. All staff not present will not be allowed to assume their duties until in-serviced. All PRN staff will be in-serviced prior to their next assignments. All new hires will be in-service on their date of hire, during facility orientation. All agency staff will be in-serviced prior to the start of their assignment. a. Abuse and Neglect to include not to hold a resident down while providing care at any time. If a resident is yelling stop, the staff members will stop and notify the charge nurse, DON, or Administrator for assistance and further direction. b. Behavioral management policy- Explain care to be provided prior to providing the care. If the resident refuses care or becomes combative with care, stop attempting to perform the care being resisted, ensure the resident's safety allow the resident to calm down. Attempt the care at a later time or with different staff. Continued combativeness with care should be reported to the Charge nurse, Administrator and/or DON immediately. c. Restraint Policy- holding a resident against their will to provide care is considered a restraint. All clinical staff will be in-serviced on [DATE] regarding the following topic below by the ADO and Regional Compliance Nurse, DON, and ADON. All staff not present will not be allowed to assume their duties until in-serviced. All PRN staff will be in-serviced prior to their next assignments. All new hires will be in-service on their date of hire, during facility orientation. All agency staff will be in-serviced prior to the start of their assignment. a. Trauma Informed Care - Definition of and locating triggers/interventions on Care Plan or Kardex. On [DATE] the survey team confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: 1. Record review of Resident #2, Resident #4, and Resident #30's electronic medial record, reflected a new trauma informed care assessment dated [DATE] was completed. 2. Record review of Resident #2, Resident #4, and Resident #30's comprehensive care plan, reflected an updated plan of care to include potential triggers for re-traumatization was dated [DATE]. 3. Record review of Resident #2, Resident #4, and Resident #30's Kardex, reflected the history of trauma and interventions in place to prevent re-traumatization. 4. Record review of Resident #2, Resident #4, and Resident #30's progress notes, reflected they were being seen by psychiatric services. 5. Record review of the ADHOC QA meeting document dated [DATE], reflected the immediate jeopardy concerns were discussed with the plan of removal and monitoring. The Medical Director attended verbally and copy of the plan was provided. 6. Record review of the in-service training attendance roster dated [DATE], reflected education was provided on trauma informed care to the DON, the ADON, and the Social Worker. 7. Record review of the in-service training attendance roster dated [DATE], reflected education was provided on behavior management to the DON and the ADON. 8. Record review of the in-service training attendance roster dated [DATE], reflected education was provided on restraints policy to the DON and the ADON. 9. Record review of the in-service training attendance roster dated [DATE], reflected education was provided on abuse and neglect polices to the DON and the ADON. 10. Record review of the in-service attendance roster dated [DATE], reflected education was provided to all staff on the restraint policy. There were 47 staff signatures. 11. Record review of the in-service attendance roster dated [DATE], reflected education was provided on the restraint policy via telephone to twelve staff members. 12. Record review of the in-service attendance roster dated [DATE], reflected education was provided to clinical staff on trauma informed care. There were 27 staff signatures. 13. Record review of the in-service attendance roster dated [DATE], reflected education was provided to clinical staff on trauma informed care via telephone to 5 staff members. 14. Record review of the in-service attendance roster dated [DATE], reflected education was provided on abuse and neglect policies. There were 47 staff signatures. 15. Record review of the in-service attendance roster dated [DATE], reflected education was provided on abuse and neglect policies via telephone to 11 staff members. 16. Record review of the in-service attendance roster dated [DATE], reflected education was provided on the behavior management policy. There were 47 staff signatures. 17. Record review of the in-service attendance roster dated [DATE], reflected education was provided on the behavior management policy via telephone to 12 staff members. 18. During a telephone interview on [DATE] at 9:48 AM, the Medical Director stated he was notified of the immediate jeopardy situation and attended a QAPI meeting via phone over the immediate jeopardy and subsequent plan of removal on [DATE]. 19. During interviews on [DATE] between 9:16 AM and 11: 23 AM, Housekeeper M, Housekeeper CC, LA Y, the Housekeeping Supervisor, DA R, [NAME] DD, DM SS, Student NA O, Student NA Z, CNA N,