**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure resident were free of significant medication errors for 1 of 7 (Resident #1) reviewed for pharmacy services. The facility failed to ensure Resident #1 was free of significant medication errors and received medication as prescribed by a physician on 8/29/2025. LVN A administered Resident #2's medications to Resident #1. This resulted in administration of two schedule IV-controlled substances: non prescribed medications: Temazepam 22.5 mg, Phenobarbital 129.6 mg, levothyroxine 75 mcg, Tamsulosin 0.4 mg, Levetiracetam 1250 mg, Oxcarbazepine 300 mg, Mirtazapine 7.5 mg, Risperdal 1 mg and prescribed Quetiapine (Seroquel) 800 mg which was a dose 32 times greater than prescribed for Resident #1. This medication error resulted in a change of condition, hospitalization and ICU stay for hypothermia, hypotension, and metabolic encephalopathy. The resident returned to the facility on 8/31/2025. This failure resulted in the identification of an Immediate Jeopardy (IJ) on 9/04/2025 at 6:00 p.m. The IJ template was provided to the facility on 9/04/2025 at 6:07 p.m. While the IJ was removed on 9/07/2025 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 the facility needed to monitor the implementation of the plan of removal. This failure could place residents at risk for medication errors and could result in side effects, a decline in health, hospitalization and/or death. The findings included: Record review of Resident #1's face sheet dated 9/03/2025 revealed a [AGE] year-old female admitted on [DATE] and readmitted on [DATE] with diagnoses which included: epilepsy, hypotension (low blood pressure), cardiomyopathy (disease of the heart muscle) and schizophrenia (serious mental health condition that affects how people think feel and behave). Record review of Resident #1's quarterly MDS dated [DATE] revealed a BIMS score of 3, which indicated a severe cognitive impairment with behaviors that included rejection of care less than daily. Resident #1's functional status was listed partial assistance showering/bathing and supervision for oral care and eating. Record review of Resident #1's BIMS evaluation dated 9/02/2025 revealed a score of 15 which indicated the resident was cognitively intact. Record review of Resident #1's progress notes dated 8/29/2025 at 7:50 p.m. as a late entry revealed the DON documented: Medication given to wrong Resident. She documented normal vital signs, alert and oriented with no change to mentation (Mental activity or the process of thinking). Hospice RN notified with new orders to hold all medications for the rest of the evening and for the next morning. Monitor for 72 hours for any complications or reactions. Record review of Resident #1's progress notes dated 8/29/2025 at 8:35 p.m. documented as a late entry revealed: Medication Error with blood pressure 70/40 (low), HR 72 (normal), oxygen saturation 98% on room air. A temperature was not documented. Level of consciousness: not arousable. Resident not responsive to voice or touch, called 911, hospice and DON. Record review of an incident report for Resident #1 dated 8/29/2025 written by the DON revealed: Resident was accidently given the wrong medication during med-pass. Nurse (LVN A) mistakenly administered the wrong medication, I thought I handed her the right pill cup then I turned around and saw her medication on the med cart. Immediate action taken immediately assessed Resident #1 for complications and none noted, called DON and she stated to call hospice and RP. RN from hospice stated to monitor resident. Vital signs BP 110/72 (normal), HR 74 (normal) respirations 16 (normal) oxygen saturation 98% on room air (normal) with no injuries noted post incident. The documentation indicated Resident #1 was oriented to person, place, time and situation (normal cognition). Record review of Resident #1's Hospice notes dated 8/30/2025 revealed on Friday 8/29/2025 at 7:59 p.m. LVN A reported a medication error. Hospice physician notified.hold meds except carbidopa/levodopa and monitor Q1hr (every hour). Send to ED if vital signs change or sedation occurs. 9:03 p.m. LVN A reported EMS activated, secondary to hypotension. (low blood pressure). Record review of Resident #1's physician order summary for August 2025 revealed the following medication orders:Carbidopa-Levodopa 25/100 mg give 3 tablets four times a day related to neuroleptic induced parkinsonism with a start date of 6/17/2025.Divalproex (Depakote) sodium oral tablet delayed relates 500 mg, give 2 tablets by mouth two times a day for seizures with a start date of 8/15/2025Entacapone oral tablet 200 mg, give one tablet by mouth four times a day for Parkinson's disease with a start date of 5/08/2025.Lacosamide oral tablet 50 mg, give tablet by mouth two times a day with a start date of 6/17/2025.Quetiapine fumarate oral tablet 25 mg, give 1 tablet by mouth at bedtime for depression.Hydrocodone-acetaminophen oral tablet 10/325 mg, give 0.5 tablet by mouth every 8 hours as needed for pain with a start date 8/29/2025. Record review of Resident #1's Medication Audit, dated 9/03/2025 revealed LVN A documented the following medications were administered on 8/29/2025 at 7:35 p.m. (medications ordered for Resident #1):Lacosamide 50 mg-2 tablets (used to treat seizures)Carbidopa-Levodopa 25/100 mg-3 tablets (Parkinson's)Entacapone 200 mg-1 tablet (Parkinson's)Divalproex (Depakote) 500 mg-2 tablets (seizures)Quetiapine (Seroquel) 25 mg-1 tablet (antipsychotic used to treat schizophrenia) Record review of Resident #1's Narcotic Administration Record for hydrocodone-acetaminophen 10/325 mg revealed LVN A signed out one dosage (0.5 mg) of the narcotic on 8/29/2025 at 8 p.m. Record review of Resident #1's August 2025 MAR revealed hydrocodone-acetaminophen 10/325 mg tablet, give 0.5 tablet every 8 hours as needed was not documented as administered. Record review of Resident #2's face sheet dated 9/05/2025 revealed a [AGE] year-old male admitted on [DATE] with diagnoses which included: hypothyroidism, schizophrenia, and epilepsy. Record review of Resident #2's quarterly MDS dated [DATE] revealed a BIMS score of 13 which indicated he was cognitively intact with no documented behaviors. He required was independent or required supervision for ADL care. Record Review of Resident #2's Medication Audit, dated 9/03/2025 revealed LVN A documented the following medications were administered on 8/29/2025 at 7:34 p.m. (medications intended for Resident #2, but administered to Resident #1 as medication error): 1. Levothyroxine 75 mcg-1 tablet (used to treat hypothyroidism)2. Phenobarbital 64.8 mg- 2 tablets (a barbiturate, Class IV controlled substance, used for seizures)3. Tamsulosin 0.4 mg-1 capsule (used for incontinence)4. Levetiracetam 1250 mg-2 tablet (used for seizures)5. Oxcarbazepine 300 mg-1 tablet (used for seizures and/or bi-polar disorder)6. Temazepam 22.5 mg-1 tablet (a benzodiazepine, Class IV controlled substance used for insomnia)7. Mirtazapine 7.5 mg (used for anxiety/depression)8. Risperdal 1 mg-1 tablet (schizophrenia)9. Quetiapine (Seroquel) 400 mg- 2 tablets (antipsychotics used to treat schizophrenia) Record review of a handwritten statement dated 8/29/2025, signed by LVN A revealed:7:25 p.m.-realized meds given to (Resident #1) were meds for (Resident #2).7:30 p.m.-called DON. Was instructed to call the resident's physician and RP.7:40 p.m.-hospice was called, talked to RN. Was instructed to monitor resident and wait for RN to call back with orders.7:50 p.m. RN from hospice called back with orders from hospice physician. Orders were to hold all medications, monitor for 72 hours, hold morning medications. If any adverse reactions occur call 911.8:00 p.m.-Checked on Resident #1. Resident woke up easily, talked to this nurse, went back to sleep. Vitals taken BP 110/72 (normal), HR 74 (normal), oxygen saturation 98% on room air (normal).8:35 p.m.- Checked on resident again. Resident was difficult to wake. Not responsive to voice or touch. Manual BP 70/40 (low), HR 72 (normal) oxygen 97% on room air (normal).8:50 p.m.- Called 911, notified DON, notified RN hospice9:00 p.m.-Paramedics arrived at 9:00 p.m., left at 9:10 p.m. Record review of Resident #1's hospital records dated 8/31/2025 revealed the resident was admitted to the hospital due to inadvertent administration of another patient's medication while at her nursing facility. The records reflected, This resulted in acute encephalopathy, hypothermia. She received several doses of Narcan (medication used to reverse opioid overdose) which did not seem to change the patient's clinical course significantly. The hospital MD called the nursing facility and confirmed medications (given) as follows: Quetiapine 800 mg (a dosage 32 times greater than ordered by Resident #1's physician), Levetiracetam 1250 mg, Mirtazapine 7.5 mg, Oxcarbazepine 300 mg, Phenobarbital 129.6 mg, Risperdal 1 mg, Temazepam 22.5 mg, Levothyroxine (no dose specified), and questions mark hydrocodone. Nursing facility staff stated this (hydrocodone) may not have been administered as it was a later dose for this patient. Urine drug screen noted positive for opioids, TCA's (tricyclic antidepressants) and benzos (benzodiazepines). The patient was later noted to be obtunded and hypothermic .transfer to ICU. She was very lethargic but followed commands in all extremities. She would attempt to open eyes but could not open them fully. After arriving in the ICU, the patient's mental status worsened .she was given an additional dose of Narcan with no significant response. She was noted to be hypotensive and required norepinephrine. [NAME] was put in place given her hypothermia. Assessment/Plan: accidental overdose, EEG on 8/30-moderate encephalopathy-supportive care, discussed with poison control, hypotension: likely additive effect of sedating medications, hypothermia, secondary to thermal dysregulation given multiple neuroleptic medications and acute encephalopathy. Record review of form 3613-A Provider Investigative Report dated 9/04/2025 [BH6] revealed the facility self-reported a medication error when charge nurse LVN A self-reported she gave the wrong medication to Resident #1. The report indicated the medication error occurred on 8/29/2025 at 7:10 p.m. and Resident later became lethargic and was hypotensive (low blood pressure) and was sent to the hospital for evaluation on 8/29/2025 at 9:12 p.m. The report indicated Resident #1 was given several doses or Narcan at the hospital and was monitored for hypotension and metabolic encephalopathy. The report indicated it was an isolated incident, LVN A received counseling, a written warning, and additional training. The findings were confirmed. During an observation and interview on 9/03/2025 at 1:57 p.m., Resident #1 was observed moving around her room. She was awake and alert. She was able to correctly identify the correct time and year, had knowledge of the current president, knew her location and was able to recall what she had for lunch. Resident #1 stated on Friday (8/29/2025), she could not remember what time, she was near the 200-hallway nurse's station. She stated she remembered someone giving her medicine and then a short time later they gave her some more. She stated she remember someone saying her name and then it was lights out and she did not remember anything else until she woke up in the hospital. She stated when she woke up in the hospital, the hospital staff told her, her blood pressure was dangerously low, and her temperature was very low. She stated they also told her she had received someone else's medication that was really strong, in addition to her own medication. Resident #1 stated staff was now pouring out her medication and identifying each pill. She stated she was taking the medication and had not refused any. She described the person who gave her medication as female but was unable to recall her name and could not remember if she had seen the staff since the incident. She stated she was not able to describe any of the medication given to her. She stated she did not pay much attention. She stated the same person had approached her twice with the medication and she trusted them and just took it. She stated taking medication was just part of the routine, even when it was given twice. She stated they might give her a water pill one time and then something else at a later time. Resident #1 stated since she had returned to the facility, she felt fine and was back to herself with no lingering effects. During an interview on 9/03/2025 at 5:41 p.m., LVN A stated on 8/29/2025 at 7:25 p.m. she gave Resident #1, Resident #2's medication in error. She stated she was standing with the med cart near Resident #1's doorway speaking with the resident. She stated she remembered preparing and passing meds to another resident and then preparing meds for both Resident #1 and Resident #2 at the same time on top of the medication cart [BH7] and she got the two medication cups confused. She stated she was trying to give medications to two residents at the same time, got distracted and made a mistake. She stated Resident #2 had approached her asking for his medication. LVN A stated immediately after Resident #1 had consumed the pills, she turned around, saw the other medication cup with contained two Depakote pills that belonged to Resident #1 and realized her error. LVN A stated she did not give Resident #1 her pills. She stated she had pulled Resident #1's normal evening pills, plus hydrocodone. She stated she threw all the pills in the sharps container but did not have any witnesses. She stated she was panicking and was focused on Resident #1. She stated no other staff were around. She stated she immediately called the DON who told her to call the hospice physician and notify them. She stated she called hospice and told them Resident #1 was okay and that her vitals were normal. She stated the hospice RN gave her orders from the hospice physician to monitor the resident as she saw fit anywhere from every 15 minutes to one hour, to hold the rest of her medication for that evening and if there were any adverse reactions to send her out (send to the emergency room). LVN A stated at first, she was okay but when she checked on her at 8:25 p.m., Resident #1 was lethargic. LVN A stated she tried to obtain a blood pressure and at first was unable to get one. She stated she was finally able to get a manual blood pressure reading of 70/40 (low). She stated at 8:25 p.m., Resident #1 was unresponsive. LVN A stated it looked like Resident #1 was sleeping in her bed but there was something about her eyes that did not look normal. She stated her eyes were cracked open a little and she knew they were not normal. She stated she took the rest of her vital signs which were all normal. She described her breathing as normal but breathing very deeply and a little slower. LVN A stated she performed a sternal rub, which made the resident open her eyes. She stated the resident was not communicating. LVN A stated she notified hospice and called 911. She stated she was honest on the 911 call and with EMS personnel. She told them what happened. She stated she recognized she made a mistake, and it was important for her to be honest so they would know how to appropriately treat Resident #1. LVN A stated the DON told her she was glad she had reported it immediately. She stated she was written up and was told they needed to go over what happened. She stated she received an in-service on the medication 5 rights (of administration). She stated ADON O shadowed her on her next shift watching her perform medication pass to ensure she was doing everything correctly. LVN A stated she administered Levothyroxine 25 mg, Seroquel 800 mg, Keppra 1250 mg, Risperdal 50 mg, mirtazapine 7.5 mg, phenobarbital 65 mg, temazepam 22.5 mg, Buspar 20 mg and tamsulosin 7.25 mg. She stated those are the medications she remembers giving. LVN A stated she couldn't remember for sure if she gave hydrocodone but thinks she probably did not. She stated she thinks it was part of the wasted medications because she does not remember giving it to Resident #1. LVN A stated the whole situation scared her and she had been very concerned about Resident #1's outcome and wellbeing. She stated she kept in contact with the hospital post incident until she knew she was recovering. LVN A stated she was trained to administer medications to the right person, right dose, right time, right medication with the right documentation. She stated she was trained to pull one patient's med, take it to the resident, watch them take it, throw away the cup before moving on to the next patient. She stated it did not happen like that because she made a mistake. She stated she had no excuses for it. LVN stated she was fairly new to the facility. She had completed nurse competencies upon hire in June 2025? which included a medication pass which she passed. She stated it was not an intentional act, and she was not trying to harm Resident #1. She stated she was not okay until she learned Resident #1 was okay. LVN A stated it was important to give the right medication to the right resident so they could live. During an interview on 9/04/2025 at 12:46 p.m., Resident #1's RP stated she was informed by an unknown person at an unknown time that Resident #1 was given too many medications. She stated she was given a list of the medications that should not have been given verbally. The RP stated Resident #1 ended up in the hospital in ICU, mostly because she could not stay warm and because of the medications. The RP stated when Resident #1 woke up in ICU she was her regular self which was about 12 hours later. The RP stated Resident #1 just had to sleep and let the medications work out of her system. She stated Resident #1 was back at the facility doing her normal activities and doing fine. The RP stated Resident #1 had not expressed any issues or concerns about staff. The RP stated she thought there should be better safeguards at the facility and believes there to be some sort of reprimand going on. She described Resident #1's as picking and choosing what she wanted to remember. She stated she could typically remember things that had occurred within the past two weeks but not necessarily things of the past with accuracy. During an interview on 9/04/2025 at 12:47 p.m., the hospice case manager stated the hospice RN was not available for interview. She stated the RN had documented notes in the hospice record. During an interview on 9/04/2025 at 1:23 p.m., the hospice physician stated he did receive notification from the hospice RN of the medication error. He stated the hospice RN sent him a list of medications that Resident #1 had received. He stated he gave orders to watch vitals and watch for sedation. He stated approximately 40 minutes later Resident #1 was sent to the ER. He stated it was important to avoid medication errors because it could cause side effects and the scheduled III and scheduled IV medications and other medications, such as non-prescribed medications could cause complications. He stated hydrocodone was not on his list of medications given, however probarbital, Risperdal, mirtazapine, oxcarbazepine, and levothyroxine were that he could remember. He stated the facility monitored her vital signs and sent her to out when she had a change. The hospice physician stated Resident #1's hospital stay was directly related to the medication error. During an interview on 9/04/2025 at 1:39 p.m., the DON stated LVN A absolutely did not follow the facilities policy for medication administration. She stated the facility policy indicated they were supposed to only pull one person's medication at a time. The DON stated if LVN A had done that, we would not be having a conversation. She further stated LVN A did not follow the five rights of medication administration which included the right patient, right time, right medication, right dosage and right documentation. The DON stated on 8/29/2025 at 7:31 p.m., she received a call from LVN A. She stated LVN A stated she gave Resident #2's medication to Resident #1 on accident. The DON stated she told LVN A to call hospice and the RP and she asked if Resident #1 was okay. The DON stated LVN A said yes. She stated LVN A called back and told me hospice gave orders to monitor Resident #1. The DON stated she told LVN A, Resident #1 needed monitoring for 72 hours, she told her she needed to write a statement and notify her of any changes. The DON said LVN A was freaking out, but med errors occur all the time. She stated she spoke with LVN A several times. The DON said at 9:16 p.m., LVN A notified her that Resident #1 was experiencing hypotension (low blood pressure) and was hard to rouse. The DON said she told LVN A she needed to send her house, even though she was on hospice she needed to go to the hospital. The DON said Resident #1 received Narcan and was treated in ICU for metabolic encephalopathy. She stated the facility self-reported the incident because of the serious injury. She stated she notified the Administrator, and he agreed. The DON stated she participated in the investigation. She found that LVN A had two medication cups on the top of the med cart, and she went and grabbed the wrong cut. The DON stated LVN A realized it right away and called her. The DON stated there were a million different reasons med errors occur. She stated there are lots of distractions, nurses try to multitask while doing med pass. The DON stated she told LVN A she had a lot of integrity for admitting it. The DON stated she had no concerns about the way the change of condition was handled. She stated Resident #1 was monitored and sent out pretty quickly when a change of condition was noted. The DON stated the facility did not have a SW that was working, they had just hired one who was still training. She stated she had spoken to Resident #1 in the hallway and asked how she was doing. She said Resident #1 indicated she was glad to be back. She stated she did not ask her any specific questions just a general how you are doing. She stated to her knowledge Resident #1 had not expressed a desire to speak to anyone about the incident. The DON stated the next day, ADON O in-serviced LVN A on the five rights of safe administration and watched her do med pass. The DON stated LVN A was current on her competencies and there had been no concerns with the med pass observation. The DON denied any other complaints about medication administration or complaints or grievances about LVN A. The DON stated LVN A was written up, she was provided more education. She was instructed to write out a timeline which she did. The DON stated she helped LVN A put the notes in the computer. She stated she reviewed LVN A's notes to make sure it was accurate. The DON stated to avoid reoccurrence they were providing in-service education to all staff who administer meds. She stated they had not completed the training at the time of the interview. She stated their goal was to watch a med pass with all staff who perform medications which had not been completed. She stated today (9/04/2025, after surveyor entrance on 9/03/2025), they completed a med cart review. The DON stated she had provided 1:1 counseling to LVN A and would have her sign the write up today. She stated the medication error was an isolated event. The DON stated she ensures residents are free from harm by ensuring the facility policies are being followed and ensuring staff was competent. She stated she was available to staff at all times, even at night and had an open-door policy. She stated it was important for Resident's to receive the right medications to treat chronic illness and because it was detrimental if medications were not dispensed properly. During an interview on 9/04/2025 at 5:30 p.m., the Administrator stated he became aware of the medication error by phone call from the DON. He stated he was not a clinical person, so a lot of the investigation of the incident fell on the DON, although he provided oversite. The Administrator stated he could not specify if there was serious harm, but he knows Resident #1 was being watched for something very serious. The Administrator stated the facility ensured the incident was isolated, that everyone else was fine. He stated LVN A was distraught and knew what she had done wrong. He stated he was surprised to learn Resident #1 had to be sent to the hospital. The Administrator stated he had not spoken to Resident #1 since she had returned to the hospital but did inquire to staff who reported she was not having any difficulties. He stated he did self-report the incident as required. He stated LVN A was new to the facility, they had not had any complaints from residents or families. He stated although medication errors are fairly common for nurses, he could not remember the last time the facility had a medication error. The Administrator stated he communicated with residents during rounding and ensured residents were free from harm by being involved in clinical stand-up meetings. He stated he reviews facility incidents in the evenings for the next business day. The Administrator stated safety was important. He stated LVN A made the mistake and the facility was responsible. When asked if she followed facility policy for medication administration, he stated he did not know the details of how the medication error occurred. He stated the DON, who was clinical could answer the question better. The Administrator stated the facility had not held an AD HOC QAPI meeting to discuss the incident. He stated he had a conversation with the Medical Director. The Administrator stated the Medical Director gave directions to the facility, but he was going to decline to answer on what the direction was because he was not qualified to speak on it. The Administrator stated he was confirming on the investigative report the medication error by LVN A and stated there was no intent to harm. Record review of a facility Medication Administration Policy In-Service dated 8/22/2025-8/25/2025 (prior to medication error) which covered the facility policy, following physician orders precisely, including parameters, notifying the physician promptly for any variance or concerns revealed: LVN A had signed the in-service record as completed. Record review of LVN A's Nursing Orientation and Competency Checklist dated 7/11/2025 revealed she had successfully completed a med-pass video, med pass with supervision by preceptor (a teacher or instructor) and medication pass skills check off. Record review of a facility policy, titled Medication Administration last revised 5/07/2025 revealed: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice.3. Identify resident 10. Ensure that the six rights of medication administration are followed. a. Right resident b. Right drug c. Right dosage d. Right route e. Right time f. Right documentation. 11. Review MAR to identify medication to be administered. 12. Compare medication source (bubble pack, vial, etc.) with MAR to verify resident name, medication name, form dose, route and time. 14. Remove medication from source.15. Administer medication as ordered in accordance with manufacturer specifications 19. Observe resident consumption of medication. Record review of a facility policy, titled Medication Errors last revised 05/07/2025 revealed: It is the policy of this facility to provide protection for the health, welfare, and rights of each resident by ensuring residents receive care and services safely in an environment free of significant medication errors. Definitions: Significant medication error means one which causes the resident discomfort or jeopardized his/her health and safety. Policy Explanation and Compliance Guidelines: 1. The facility shall ensure medications will be administered as follows: a. according to physician orders c. In accordance with accepted standards and principles which apply to professionals providing services 6. To prevent medication errors and ensure safe medication administration, nurses should verify the following information: a. Right medication, dose, route, and time of administration b. Right resident and right documentation. The Administrator was notified of an IJ on 09/04/2025 at 6:00 p.m. and was given a copy of the IJ Template and a Plan of Removal (POR) was requested. The Plan of Removal was accepted on 09/05/2025 at 5:39 p.m. and included the following: Correction for the Resident Affected Immediate clinical response (COMPLETED 8/29/25): Resident assessed; EMS/transfer to ED for hypotension. Drug name/strength/route/quantity/time and vitals documented in EMR and incident record. Notifications (COMPLETED 8/29/25): Attending provider, responsible party, DON/Administrator, and Hospice were notified and documented. Protection on return: Enhanced monitoring per medical director (e.g., every shift x 72 hours, focused assessments as indicated, provider follow-up, and care plan update with specific risk reduction interventions. Resident #1 spoke with Social Services Director on 9/4 and Director of Nursing and with a licensed Social Worker, with Hospice. Resident #1 offered counseling services. She refused psych services and is going to see the Chaplain through Hospice. Identification of Other Residents Potentially Affected Cart sweep & product control completed by DON/ADON: All carts involved on unit secured; any loose/pre-popped pills destroyed per facility guidelines and documented on a medication cart sweep log. Lookback review: Full set of vitals ordered q -shift for all residents residing on the 200 hall x3days beginning 9/4/25. Facility wide spot-checks completed: Unannounced inspection of all med carts/rooms for pre-popping, unlabeled cups/bags; findings logged and corrected immediately. Safe Surveys conducted by the SS Director on 9/5 for residents on 200 hall regarding comfort with staff administering medicationsSystemic Changes to Prevent Recurrence Education & competency (to be COMPLETED by 9/4/25 or prior to next scheduled shift) by DON/Designee. Mandatory in-service for all licensed nurses/medication aides on pre-popping prohibition, two identifier verification, error reporting, and cart security; return demonstration med pass competency for every nurse. Targeted coaching & corrective action: Involved nurse was removed from independent med pass and was trained, re-educated, and monitored/supervised by the ADON until she demonstrated competency in the Six Riof Medication Pass. Pharmacy partnership: Consultant Pharmacist to conduct focused storage/handling rounds monthly x 3 months. Monitoring to Ensure Ongoing Compliance (QAPI) Med pass observations will be completed by DON/Designee 3x weekly x3 weeks, weekly x 3 weeks, then monthly x 3 months at random throughout the facility or until substantial compliance is achieved. Results/Discrepancies reported to QAPI ADHOC QAPI held on 9/5/25. The surveyor verification of the Plan of Removal on 09/07/2025 was as follows: Record review of Resident #1's progress note dated 8/29/2025 at 7:25 p.m. (documented as a late entry) by LVN A stated a medication error occurred. The DON and Hospice RN were notified of the error. Vital signs were documented all within normal limits. LVN A documented at 7:35 pm she noted Resident #1 was lethargic with low blood pressure of 70/40. Hospice notified who advised to send to the hospital. Record review of a facility incident report dated 8/29/2025 at 7:25 p.m. stated Resident #1 was accidently given the wrong medication during med-pass by handing the resident the wrong medication cup. Assessment and notifications documented. -During an interview on 9/07/2025 at 11:56 a.m., stated LVN A made the original notifications to hospice, DON and the RP and were documented in Resident #1's progress notes on 8/29/2025. -Record review of Resident #1's progress notes dated 8/31/2025 revealed the resident received an assessment, monitoring for falls and instructions not to get up unassisted to prevent falls after re-admission from the hospital. (8/32/2025) Resident #1's provider was notified of her return from hospi

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident's right to be free from abuse, neglect, misappropriation of resident property and exploitation for 7 of 7 residents (Residents #65, #19, #20, #44, #54, #23, and Unknown) reviewed for abuse. The facility failed to ensure Resident #65 was not injured after entering Resident #19's room on 6/23/2025, when Resident #19 had known aggressive behaviors related to other residents entering his room. The facility failed to ensure Resident #20 was protected from abuse after entering Resident #19's room on 7/5/2025. The facility failed to ensure Resident #44 was not injured after entering Resident #19's room on 7/5/2025. An IJ was identified on 7/24/2025 related to Resident #19 (items 1-3). The IJ template was provided to the facility on 7/24/2025 at 4:24 PM. While the IJ was removed on 7/26/2025 at 10:20 PM, the facility remained out of compliance at a scope of pattern and a severity level of potential for more than minimal harm without immediacy because the facility needed to evaluate the effectiveness of corrective actions. The facility failed to protect Resident #54 from physical abuse by Resident #23 on 6/18/2025. The facility failed to protect an unknown resident from verbal abuse by Resident #23. These failures lead to physical injury, psychosocial harm, continued abuse, and decreased quality of life. Findings included: 1. Record review of Resident #19's face sheet, dated 7/22/2025, reflected a [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnoses included anxiety disorder, vascular dementia (a progressive disorder that impairs a person's reasoning, memory, and other thinking abilities), and post-traumatic stress disorder (a mental disorder resulting from experienced trauma that causes flashbacks, severe anxiety, and/or uncontrollable thoughts). Record review of Resident #19's quarterly MDS submitted 4/19/2025 reflected a BIMS score of 03, indicating severe cognitive impairment. Section E (behavior) of the MDS revealed Resident #19 exhibited no behavioral symptoms, including physical behaviors directed towards others. Record review of Resident #19's comprehensive care plan, date printed 7/22/2025, revealed the following:Focus: [Resident #19] is/has potential to be physically aggressive r/t anger, dementia, poor impulse control. 2/10/25- ambulating in hallway with peer, peer punched resident in right shoulder. immediately separated. unable to verbalize details of event. stated no no no one hit me. I'm the one who is mad. Resident involved in an altercation with another resident. [sic] date initiated 11/14/2024, revision on 3/09/2025 Interventions: Administer medications as ordered . assess and anticipate resident's needs . provide physical and verbal cues to alleviate anxiety . [Resident #19] and peer immediately separated . psych doctor to review meds . psychiatric/psychogeriatric consult as indicated . report to provider any changes in behavior related to altercation . when [Resident #19] becomes agitated or is the receiver of peer aggressions: intervene before agitation escalates . The comprehensive care plan did not contain interventions related to maintaining the personal space of Resident #19 or known triggers of aggression. Record review of Resident #65's face sheet, dated 7/25/2025 reflected resident was a male age [AGE] admitted on [DATE] and discharged (aggression with another resident-sent to Psychiatric Hospital Unit) 4/18/2025 and re-admitted on [DATE] with diagnoses that included: Alzheimer's ( a progressive neurological disease that primarily affects memory, thinking , and behavior), dementia, (loss of cognitive functioning-thinking, remembering and reasoning) HTN (hypertension), and pseudobulbar affect (changes in mood). The face sheet also indicated Resident #65 was discharged from the facility on 7/11/2025 at 15:37 to other. Record review of Resident #65's Quarterly MDS, dated [DATE] reflected the resident's BIMS score was 3, indicative of severe impairment in cognition. The resident was ambulatory with no range of motion impairment. Record review of Resident #65's Care Plan, undated, revealed, the goals and interventions included: Goal: behavior management: interventions-minimize triggers, anticipate needs, de-escalate, and medication management. Also, seek alternate placement (6/24/25). As needed [6/23/25], 1:1 monitoring during episodes of increased behaviors and aggression. Record review of Resident #65's MAR, dated June 2025 reflected, psychotropic given medications given as ordered. Record review of Resident #65's Nurse Note dated 6/24/25 at 3:32 AM, authored by LVN J read, Resident entered other resident ['] s room [R#19] when we [LVN J and CNA K] heard noise of a loud bang. Upon entering he [R#65] was still holding on to other residents' shirt [R#19] and they went to the ground landing on [there] bottom. I told them to stop and let go. They did and got up without incident. [R#65] noted to have open laceration] . to top of head. We walked him into his room. I cleaned and dressed it. Decision was made to send him to local E.D. He came back with 12 staples which will need to be removed in 5 to 7 days. Report given to me was his CT scan of head was negative. Record review of Resident #65's risk management reported dated 6/23/25 at 10:36 PM authored by LVN J reflected: vitals were normal: BP was 134/59, pulse was 90, respiration was 22, temperature was 98, and O2 was 97 %. LVN J provided first aide to Resident #65. LVN J assessed for injury; cleaned and dressed the wound. Record review of Resident #65's elopement evaluation dated 5/10/25 reflected: resident had wandering behaviors that were likely to affect the safety or well-being of self/others. Record review of Resident #65's Care Plan dated 5/09/25 for the focus of wandering behavior listed the interventions as: monitoring, provide one to one care if the resident was agitated or triggered. Also, other interventions included: redirection, and visual reminders outside the resident's room to assist with correct room location. Record review of Resident#65's ER record, dated 6/23/25 at 11:14 PM reflected: R#65 presented at ER with laceration to the left frontal scalp from an altercation with another resident (R#19). CT scan performed was negative. Treatment given to R#2 was 12 staples to the head laceration and discharged back to the facility. Discharge diagnosis was Laceration of scalp. Observation and interview on 6/25/25 at 11:17 AM, R#65 was ambulatory and walking in the secure unit halls; there were 12 stapples present on left side of scalp; old blood present color dark red to black. R#65 was alert and oriented to self. The Resident stated, I hit my head .someone push me or hit my head .someone pushed me down .do not remember when it happened .I feel safe here Yes, they watch me . The resident stated that he had pain to is head. [The resident could not describe the level of the head pain.] The resident stated he had no complaints about the secure unit or his safety. Observation revealed 1:1 monitoring by CNA AR. During interview on 6/25/25 at 12:12 PM, LVN A stated she was not a witness to the incident on 6/23/25. LVN A stated R#65 liked to pace the hallways in the secure unit; and it was the first time an altercation occurred in the past month (she had been on duty only one month). LVN A stated that residents were kept safe by monitoring and routine checks LVN A stated she attended the ANE training in the past and the message was to report immediately. LVN A stated once the situation was safe, the facility needed to call the MD and the RP. During telephone interview on 6/25/25 at 4:05 PM, LVN J stated the timeline was correct. LVN J stated that she was making assessments of both residents and providing first aide to R#65 and vitals were stable for both residents. LVN J stated that it did not come to my head to call the police. LVN J stated preventative measures were in place prior to the incident on 6/23/25 included: monitoring, checking on conflicts, and de-escalating residents. LVN J stated the additional intervention put in place on 6/24/25 was placing R#65 on 1:1 when he returned from the ER. 2. Record review of Resident #20's face sheet, dated 07/25/2025, reflected a [AGE] year-old resident with an initial admission date of 02/28/2014, and a most recent admission date of 02/02/2025, with diagnoses which included dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgement), hypertension (a condition in which the force of the blood against the artery walls is too high), and schizoaffective disorder (a mental health condition including schizophrenia and mood disorder symptoms). Record review of Resident #20's Quarterly MDS Assessment, dated 05/19/2025, reflected Resident #20 had a BIMS score of 0, indicating severe cognitive impairment. Record review of the facility's incident report revealed that on 7/5/2025 at 4:06 PM, Resident #20 entered Resident #19's room. Staff walked in and witnessed Resident #20 getting up off of the floor. Both residents stated that Resident #19 pushed Resident #20. Record review of Resident #19's progress notes revealed the following documentation written by LVN A on 7/5/2025 at 4:54 PM: [Resident #19] being protective of room found [Resident #20] in room and had him leave. As [Resident #20] was leaving [Resident #19] pushed him down and [Resident #20] was seen crawling out of room. Nurse and Aide went to hall and [Resident #20] got up and went to his room up set and cussing. Nurse noted no injuries and client voiced no pain. Nurse explained to [Resident #19] that he does not do that and if not happy about something tell us. [sic] The progress note was marked as struck from the medical record on 7/07/2025 at 10:51 AM due to incorrect documentation. Resident #19 was interviewed on 7/22/2025 at 11:24 AM. He was unable to recall any incidents with other residents. He denied any negative interactions with other residents since admission to the facility. Resident #20 was unable to be interviewed due to cognitive decline. In an interview with LVN A on 7/23/2025 at 3:35 AM. She stated she was the primary nurse for Residents #19 and #20 at the time of the incident on 7/05/2025. She stated that the incident between Residents #19 and #20 occurred as she had documented in the progress note. She stated that she was instructed by an unknown administrator to remove the documentation from the medical record because an unknown portion of it was incorrect. She was unsure what part of the note was determined to be incorrect and by whom the instruction was given. She stated that after Resident #20 was pushed by Resident #19, Resident #20 was not injured, but that he was mad. 3. Record review of Resident #44's admission Record, dated 06/24/2025, reflected the resident was a [AGE] year-old male initially admitted to the facility on [DATE] with diagnoses which included unspecified dementia (a general term for impaired ability to remember, think, or make decisions), depression, and history of falling. Record review of Resident #44's Significant Change MDS, dated [DATE], reflected the resident had a BIMS score of 0, indicating severe cognitive impairment. Further review reflected the resident had a fall in the last month, but did not reflect that the resident had a major injury such as a bone fracture. Record review of Resident #44's Care Plan, dated 07/28/2025, reflected it did not address wandering behaviors. Focus areas related to falls were initiated on 02/09/2025 and were addressed with preventative measures, or interventions, including: rounding frequently to assess for falls unreported by resident (initiated 05/12/2025), therapy as ordered (initiated 05/12/2025), PT consult for strength/mobility (initiated 05/20/2025), follow post-fall policy (initiated 05/20/2025), call bell in reach (initiated 02/09/2025), and perform transfer assistance as needed (initiated 05/19/2025). Record review of the facility incident report dated 7/5/2025 revealed an incident occurred at approximately 9:00 PM between Residents #19 and #44. Resident #44 was found in Resident #19's room with a bleeding head wound that required 10 staples at the local emergency department. Neither resident was able to verbalize at the time of the incident what occurred to cause the injury to Resident #44. In an interview with LVN A on 7/23/2025 at 3:35 PM, she stated she was not present at the time of the incident between Residents #19 and #44. She stated she saw blood on the headboard of the bed in Resident #19's room, and she speculated that Resident #19 had pulled Resident #44 out of the bed forcibly but she did not know with certainty what actually occurred. In an interview with RN B on 7/24/2025 at 5:47 PM, she stated she was the primary nurse for Residents #19 and #44 at the time of the incident. She said she was providing care for a different resident, when a CNA alerted her that Resident #44 was in Resident #19's room and bleeding. She stated she notified 911 and provided first aid to Resident #44 and that neither resident reported aggression or an act of violence. She stated Resident #19 told her repeatedly that Resident #44 had attempted to take his [Resident #19's] shoes, but he did not state that he had assaulted Resident #44. During an interview on 6/25/25 at 3:22 PM, the DON stated methods used to keep residents safe in the secure unit included: frequent monitoring, camera's, re-direction, and de-escalation. In an interview with LVN C on 7/23/2025 at 5:16 PM, she reported Resident #19 had exhibited aggressive facial expressions and aggressive posturing at another resident on the previous evening (7/22/2025) at approximately 7:00 PM. She stated a male resident walked too closely to Resident #19, and Resident #19 responded in a manner that she felt displayed an intention of wanting to engage in a fight with the other resident. She stated she had a CNA escort Resident #19 to his room and the behavior was de-escalated. LVN C also stated Resident #19 had unpredictable aggressive episodes and that the only method of controlling his behavior was through his prescribed medication. She reported a known trigger of aggression was other residents entering his room. She stated most of the residents were aware that they were not to enter Resident #19's room but that confused residents or residents new to the facility required redirection and increased supervision to prevent them from entering Resident #19's room. In an interview with the DON on 7/24/2025 at 3:12 PM, she stated staff provided monitoring to prevent physical aggression from Resident #19. She reported Resident #19 was put on one-to-one observation on the night of 7/5/2025 until he was able to be moved to a different room on the unsecured hall. She stated the room change was due to other residents wandering into Resident #19's room on the secured unit. She stated there had been no additional incidents of aggression since Resident #19 changed rooms. In an interview with CNA G on 7/24/2025 at 1:13 PM, she stated Resident #19 could become agitated if other residents asked him too many questions or followed him too closely. She stated she had not been advised from any nursing staff of any specific things that may cause aggressive behavior from Resident #19. In an interview with the psychiatric NP, NP D, on 7/25/2025 at 10:24 AM, she stated she had not been told by facility staff of the incidents between Resident #19 and Residents #20 and #44. She stated the staff could possibly prevent future incidents of abuse by Resident #19 by performing frequent rounding. In an interview with the Admin on 7/24/2025 at 5:00 PM, he stated the facility investigations of the incidents on 6/23/2025 and 7/5/2025 were inconclusive of abuse as the incidents were not witnessed by facility staff and the residents involved had cognitive impairment. He did not feel there were any deficiencies in the care provided to any of the residents involved in the incidents. In a subsequent interview on 7/31/2025 at 7:45 PM, the Admin reiterated to the survey team that he did not feel any of the incidents involving Resident #19 qualified as abuse to other residents. He stated the survey team was harming Resident #19 by classifying the behaviors as abusive towards the other residents, and he felt the only solution to protect other residents was to discharge any resident who has behaviors. Record review of the facility policy titled Abuse, Neglect, and Exploitation, revised 6/30/2025, revealed the following: Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental aguish, which can include staff to resident abuse and certain resident to resident altercations . Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. This was determined to be an Immediate Jeopardy (IJ) on 7/24/2025 at 4:06 PM, and the Administrator was provided with the IJ Template on 07/24/2025 at 4:24 PM. The plan of removal was accepted on 07/25/2025 at 9:02 AM and reads as follows: 1. Immediate Removal of Resident #19 from General Population On 7/24/2025 at 5:30 PM, Resident #19 placed on 1:1 supervision until he is evaluated by physician and psychiatric entities. A physician was notified, and a psychiatric consultation was requested by DON/Designee to evaluate ongoing aggressive behavior. Resident #19 remains under ongoing supervision, with documentation every 15 minutes by person providing 1:1 supervision, reviewed by licensed staff until seen by physician and psychiatric services. Staff providing 1:1 has been in serviced by DON/Designee on how to approach a resident with dementia. 2. Resident Safety Measures Implemented A full head-to-toe assessment was conducted for Residents #65, #20, and #44 immediately after each incident. Physician and family notifications were completed for all three residents. Residents were monitored for signs of trauma, pain, or behavioral changes, and care plans updated accordingly. Wandering residents are being redirected more proactively, with visual cues and barriers, stop sign to deter residents from entering installed on Resident #19's door as of 7/24/2025 by 5:30 PM. 3. Care Plan Reviews and Revisions All residents with behaviors or at risk of wandering had their care plans reviewed and revised on 7/24/2025 - 7/25/2025. Resident #19's care plan now includes: Do-not-enter signage, behavior monitoring every shift in the residents TAR, and escalation protocols if aggression is observed. 4. Staffing Adjustments and Assignments Housekeeping, laundry, and dietary personnel were also notified and instructed to knock prior to entering resident 19's room and announcing themselves. 5. Staff Education and Re-Education All facility staff (licensed and unlicensed) completed in-service training by administrator/designee on: abuse prevention, identifying and managing resident-to-resident aggression, reporting protocols for abuse and injuries of unknown origin, and interventions/supervision for dementia-related behaviors. Behavior monitoring added to all residents to be recorded on the residents TAR each shift. Licensed nurses in-serviced on documenting behavior monitoring on the TAR. Education sessions were conducted on 7/24/2025 and will be ongoing prior to the start of their next shift, and upon hire Sign-in sheets and post-tests were collected and reviewed for comprehension. 6. Monitoring and Quality Assurance Daily monitoring audits for supervision of Resident #19 began on 7/24/2025 and continue under the direction of the DON/designee. The Administrator and DON perform daily safety rounds for 7 days to ensure there are no visible signs of injury or distress without documentation, then weekly for 4 weeks. All incidents and near-misses reviewed in daily morning stand-up meetings for 14 days. 8. Policy Review and Update The facility's Abuse Prevention and Investigation Policies were reviewed by the QA Committee on 7/24/2025, no changes were made ADHOC QAPI An ADHOC QAPI meeting was held with the medical director on 7/24/25 regarding the immediate jeopardy issued for abuse. The facility's POR verification was as follows: 1. Resident #19 was observed to have one to one level of supervision on 7/25/2025 at 9:47 AM, 7/25/2025 at 2:12 PM, 7/25/2025 at 3:06 PM, and 7/26/2026 at 4:33 PM. The documentation completed by the staff member providing one to one observation was reviewed on 7/25/2025 at 10:00 and observed to have been initiated 7/24/2025 at 6:00 PM with documentation of Resident #19's observed behavior occurring every 15 minutes. Record review of Resident #19's progress notes revealed Resident #19 was assessed by NP D on 7/25/2025 at 1:08 PM. In an interview on 7/26/2025 at 6:13 PM, the MD stated that she and NP D were already evaluating Resident #19 for aggressive behaviors. She stated Resident #19 was not aggressive during any of the incidents relayed to her. In an interview on 7/26/2026 at 8:33 PM, the Admin, DON, and corporate nurse stated Resident #19 would remain on one to one observation until Resident #19 was assessed by the MD. 2. A laminated sign was observed to be posted on Resident #19's door on 7/25/2025 at 9:44 AM. The sign contained a graphic of a stop sign and text that read please knock and announce yourself before entering. Record review of Resident #65, #20, and #44's documented assessments did not reveal head-to-toe assessments correlating with the dates of the incidents. Documentation of the assessments was requested from the Admin on 7/25/2025 at 5:16 PM. Record review of Resident #19, #20, and #44's comprehensive care plans on 7/26/2025 revealed updates to include monitoring for signs of trauma, pain, or behavioral changes. Record review of the facility incident reported, dated 7/5/2025, reflected Resident #44's family and the MD were contacted after the incident. The facility handwritten attestation from LVN A dated 7/5/2025 indicating Resident #20 received a head-to-toe assessment at the time of the incident. In an interview on 7/26/2025 at 12:50 PM, the DON stated a head-to-toe assessment was performed by staff any time there was a reported incident because the documentation was built into the risk management assessments. She stated the head-to-toe assessments were included in the incident reports, but a separate head to toe assessment was not completed by the primary nurses for the incidents. She stated Resident #20 was assessed by LVN A, Resident #44 was assessed by RN B, and Resident #65 was assessed by LVN J. She also stated Resident #20 did not have an associated incident report for the incident on 7/5/2025, as Resident #20 was observed crawling on the ground so the staff could not be certain what occurred. She explained that many residents at the facility crawl on the ground. In an interview with LVN A on 7/26/2025 at 3:29 PM, she stated she performed a head-to-toe assessment on Resident #20 when she discovered him crawling on the ground. In an interview on 7/26/2026 at 5:30 PM, Resident #65's RP stated she was not aware Resident #65 had been involved in an altercation with another resident on 6/23/2025. In an interview on 7/26/2025 at 6:23 PM, the DON stated Resident #65's RP was unable to be reached at the time of the incident, and the social worker had initiated a wellness check in order to make contact with the RP and obtain consent for transfer of Resident #65 to a different facility. In an interview with the MD on 7/26/2025 at 6:13 PM, she stated she was notified after all three incidents involving Resident #19 occurred. In an interview on 7/26/2025 at 7:46 PM, Resident #20's RP stated she was notified by the facility of the incident on 7/5/2025 when it occurred. In an interview on 7/26/2025 at 8:16 PM, Resident #44's RP stated she was notified by the facility of the incident on 7/5/2025 when it occurred. 3. Record review of care plans for residents the facility determined were at risk for wandering/elopement was performed on 7/25/2025 and 7/26/2025 for 19 residents. The care plans were updated to include interventions related to wandering and elopement. Record review of Resident #19's care plan, date printed 7/25/2025 at 7:00 PM, reflected the following updates: If the resident becomes physically aggressive: call 911 only if resident or others are in immediate danger and facility protocols are exhausted. (revised 7/25/2025) Interventions: behavior monitoring (initiated 7/24/2025), one-on-one supervision until seen by psychiatric services and MD (initiated 7/24/2025), place do not enter signage on resident's door (initiated 7/24/2025) Focus: [Resident #19] exhibits episodes of physical or verbal aggression that poses a risk to self, others, or property (initiated 7/25/2025) Interventions: Use de-escalation strategies: speak calmly and clearly (initiated 7/25/2025) In an interview on 7/26/2025 at 12:50 PM, the DON revealed all residents' TARS were updated to include behavior monitoring for symptoms to include itching, wandering, and aggression. Residents with known aggression had a second behavior monitoring tool added to their TAR specific to aggression. 4. Record review of the staff in-service related to knocking and announcement of entry revealed 80 staff signatures. In an interview with the Admin on 7/26/2025 at 3:00 PM, he stated the in-service related to knocking was completed for housekeeping, laundry, and dietary department staff. The following staff were interviewed to verify receipt of the in-service related to knocking: HSK AF, HSK AG, and LA AT on 7/26/2025 at 2:09 PM all confirmed they had received the in-service. They stated they were instructed to knock before entering any resident's room, including Resident #19. They were also instructed on managing dementia related behaviors and to notify nursing staff if any residents were observed with abnormal behaviors. The Dietary Manager on 7/25/2025 at 1:57 PM, confirmed the DON provided training for the entire dietary staff on resident privacy- knocking and announcing before entry (especially Resident #19's door), abuse and neglect and resident to resident aggression prevention. She stated she monitored resident's behaviors during meals and would report any concerns to the nursing staff. AS on 7/25/2025 at 2:39 PM stated she received the in-service for knocking, as well as abuse and neglect training and resident-to-resident aggression prevention. AO, AP, and AQ on 7/25/2025 at 4:45 PM confirmed training on resident-to-resident intervention, abuse and neglect, and knocking on residents' doors and announcing before entry (including Resident #19's door). 5. Record review of the in-service training documents on 7/25/2025 at 10:15 reflected an in-service for resident-to-resident aggression prevention, an associated quiz for staff members regarding resident-to-resident aggression, and the facility policy titled Abuse, Neglect, and Exploitation for staff review (5 total pages). Record review of the facility's order listing report dated 7/25/2025, reflected a report for all residents in the facility had an order that read: Monitor for the following behaviors: itching, picking at skin, restlessness, agitation, hitting, increase in complaints, biting, kicking, spitting, foul language, elopement, stealing, delusions, hallucinations, psychosis, aggression, refusal of care every day and night shift. Record review of staff in-service sheet for resident-to-resident aggression prevention and abuse/neglect, both dated 7/24/2025, reflected 90 staff member signatures. Record review of staff in-service sheet for documenting behavior symptoms, dated 7/25/2025, reflected 17 out of 17 nurses were in-serviced. Record review of staff in-service sheet for approaching residents with dementia reflected 90 signatures. In an observation of an in-services on 7/25/2025 at 5:30 PM and 5:52 PM, ten staff members were observed receiving in-service training on interventions and supervision for residents with dementia related behaviors. On 7/26/2025, 29 out of 99 staff members (23 day shift and 6 night shift, 29% total) were interviewed to confirm receipt of the above listed in-services. In an interview with the Admin on 7/26/2025 at 3:00 PM, he reported a total of 99 staff members with 78 working day shift hours and 21 working night shift hours. He stated the DON educated the staff on the in-services. In a subsequent interview with the Admin and corporate nurse on 7/26/2025 at 8:03 PM, they stated staff who had not yet received the in-service training had been notified that must receive the in-services prior to working their next shifts. 6. Record review of the unnamed document identified by the facility as the weekly behavior monitoring tool for Resident #19 indicated no concerns with Resident #19's behavior on 7/25/2025 or 7/26/2025. In an interview with the DON on 7/26/2025 at 6:30 PM, she stated the facility was monitoring Resident #19 daily and she was overseeing the one to one observation. In an interview with the Admin on 7/26/2025 at 7:03 PM, he stated he was performing daily safety rounds every day for 7 days and daily monitoring audits, as reflected in the weekly monitoring tool previously mentioned. He reported he was overseeing the DON and her oversight of the one-to-one observation. 8. Record review of the facility's ad hoc QAPI meeting summary and agenda dated 7/24/2025 reflected attendance by the Admin, DON, corporate nurse, and MD. The agenda included review of the facility's abuse policy. In an interview on 7/26/2025 at 1:06 PM, the DON and corporate nurse stated the QAPI review of the abuse policy did not lead to any changes of the policy. While the IJ was removed on 7/26/2025, the facility remained out of compliance at a scope of pattern and a severity level of potential for more than minimal harm without immediacy because the facility needed to evaluate the effectiveness of corrective actions. 4. Record review of Resident #23's face sheet, dated 7/22/2025, reflected a [AGE] year-old female initially admitted to the facility on [DATE]. Relevant diagnoses included disruptive mood dysregulation disorder (chronic irritability and frequent temper outbursts), bipolar disorder (mood instability), and unspecified dementia (a progress disorder that impairs thought processes, including memory and reasoning). Record review of Resident #23's quarterly MDS, submitted 4/29/2025, reflected a BIMS score of 14, indicating intact cognition. Record review of Resident #23's progress notes revealed the following documentation by LVN AU on 6/19/2025 at 9:24 AM: [LVN AU] was notified by activity director that patient was hitting another patient that was in her bed. [LVN AU] asked patient what happened she stated she was in my bed so I hit her. No injuries noted or reported at this time. Called [Resident #23's family member] with no answer and voicemail is full at this time. Record review of Resident #54's face sheet, dated 7/25/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnoses included unspecified dementia, bipolar disorder (severe mood swings), and cognitive communication deficit. Record review of Resident #54's quarterly MDS submitted 4/16/2025, reflected a BIMS score of 06, indicating moderately impaired cognition. Record review of the facility investigation report reflected the facility self-reported the incident to the SSA on 6/19/2025. The investigation documentation reported no significant injuries to either resident. The result of the facility investigation was listed as inconlusive. As a result of the investigation, Resident #23 was moved to a private room on a different hall. Resident #23 declined to participate in an attempted interview on 7/22/2025 at 1:00 PM. Resident #54 was interviewed on 7/23/2025 at 8:33 AM, and she was unable to recall the incident. The Activities Director was interviewed on 7/25/2025 at 5:57 PM. She stated she was the staff member who initially discovered Resident #23 physically assaulting Resident #54. She reported she was walking down the hallway and Resident #54 was laying in Resident #23's bed. Resident #23 was on top of Resident #54 and striking her repeatedly in the face/head using her hands and shouting get out of my bed. The Activities Director st[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for 2 of 3 residents (Residents #19 and #44) investigated for accidents. The facility failed to ensure Resident #19 received adequate supervision to prevent physical aggression towards other residents. The facility failed to ensure Resident #44's received adequate supervision to prevent falls with interventions to prevent further injury when the resident had falls at the facility on 05/12/2025, 05/19/2025, 05/23/2025, and on 07/23/2025 and unwitnessed injuries on 05/01/2025 and 07/05/2025. The falls on 05/12/2025 and 07/23/2025 both resulted in hip fractures. An Immediate Jeopardy was identified on 07/29/2025. The IJ template was provided to the facility on 7/29/2025 at 4:46 PM. While the IJ was removed on 7/31/2025, the facility remained out of compliance at a scope of pattern and a severity level of potential for more than minimal harm without immediacy because the facility needed to evaluate the effectiveness of corrective actions. This failure could lead to physical injury, psychosocial harm, and decreased quality of life. Findings included:1.Record review of Resident #19's face sheet, dated 7/22/2025, reflected a [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnoses included anxiety disorder, vascular dementia (a progressive disorder that impairs a person's reasoning, memory, and other thinking abilities), and post-traumatic stress disorder (a mental disorder resulting from experienced trauma that causes flashbacks, severe anxiety, and/or uncontrollable thoughts). Record review of Resident #19's quarterly MDS submitted 4/19/2025 reflected a BIMS score of 03, indicating severe cognitive impairment. Record review of Resident #19's comprehensive care plan, date printed 7/22/2025, revealed the following:Focus: [Resident #19] is/has potential to be physically aggressive r/t anger, dementia, poor impulse control. 2/10/25- ambulating in hallway with peer, peer punched resident in right shoulder. immediately separated. unable to verbalize details of event. stated no no no one hit me. I'm the one who is mad. Resident involved in an altercation with another resident. [sic] date initiated 11/14/2024, revision on 3/09/2025Interventions: Administer medications as ordered . assess and anticipate resident's needs . provide physical and verbal cues to alleviate anxiety . [Resident #19] and peer immediately separated . psych doctor to review meds . psychiatric/psychogeriatric consult as indicated . report to provider any changes in behavior related to altercation . when [Resident #19] becomes agitated or is the receiver of peer aggressions: intervene before agitation escalates .The comprehensive care plan did not contain interventions related to maintaining the personal space of Resident #19 or known triggers of aggression. Record review of the facility's incident reports from 1/22/2025 through 7/22/2025 revealed the following:On 6/23/2025 around 9:30 PM, Resident #65 wandered into Resident #19's room. Staff walked in and found both residents holding each other's shirts, and Resident #65 had a 7centimeter bleeding laceration to his head that required 12 stitches to repair. Resident #65 told staff he was assaulted by Resident #19.On 7/05/2025 at 4:06 PM, Resident #20 entered Resident #19's room. Staff walked in and witnessed Resident #20 getting up off of the floor. Both residents stated that Resident #19 pushed Resident #20. On 7/05/2025 at about 9:00 PM, Resident #44 went into Resident #19's room. Resident #44 obtained an unwitnessed head injury while in Resident #19's room that required 10 staples to repair. Neither Resident #19 nor #44 were able to explain to staff what occurred to cause the injury. Record review of the facility census revealed Resident #19 resided in the men's secured unit during the above listed incidents, and he was moved to an unsecured, mixed gender hall on 7/09/2025. In an interview with Resident #19 on 7/22/2025 at 11:24 AM, he was unable to recall any incidents with other residents and denied any negative interactions. In an interview with LVN A on 7/23/2025 at 3:35 PM, she stated that all staff are aware of Resident #19's territorial behavior. She recalled the two incidents on 7/5/2025 and attributed both to aggression from Resident #19 as a result of the other residents entering Resident #19's room. She was unsure what interventions were in Resident #19's care plan related to preventing aggression. LVN C was interviewed on 7/23/2025 at 5:16 PM and reported awareness of Resident #19's history of aggressive behavior. She stated she observed aggressive behavior including facial expression and posturing from Resident #19 toward another resident on the previous day (7/22/2025) but had not witnessed any other behaviors since Resident #19 had moved into the unsecured hall. LVN C stated Resident #19's aggressive behavior towards other residents was unpredictable and unable to be prevented. She stated all staff, and most residents were aware that they should not enter Resident #19's room. She was unsure what interventions were in Resident #19's care plan related to preventing aggression. In an interview with CNA F on 7/24/2025 at 10:42 AM, he stated Resident #19 was known to exhibit aggressive behaviors in the secured unit only when other residents would enter Resident #19's room. CNA F stated Resident #19's aggression was defensive in nature, and he was otherwise docile. In an interview with CNA G on 7/24/2025 at 1:13 PM, she reported awareness of Resident #19's history of aggressive behavior but denied witnessing any aggression since Resident #19 had moved rooms into the unsecured hall. She stated Resident #19 would become aggressive if he was asked too many questions or if other residents followed him. In an interview with CNA H on 7/24/2025 at 1:56 PM, she stated Resident #19 would become physically aggressive when other residents would enter his room or touch his belongings. She stated because she knew that Resident #19 would become aggressive when others entered his personal space, she would maintain supervision on the secured unit of Resident #19's door to try to prevent other residents from entering Resident #19's room. CNA H stated she was not explicitly instructed to perform this supervision, but she did it because she knew that the behavior could trigger aggression from Resident #19. In an interview with the DON on 7/24/2025 at 3:12 PM, she stated staff provided monitoring to prevent physical aggression from Resident #19. She reported Resident #19 was put on one-to-one observation on the night of 7/5/2025 until he was able to be moved to a different room on the unsecured hall. She stated the room change was due to other residents wandering into Resident #19's room on the secured unit. She stated there had been no additional incidents of aggression since Resident #19 changed rooms. In an interview with the Admin on 7/24/2025 at 5:00 PM, he stated the facility investigations of the incidents on 6/23/2025 and 7/5/2025 were inconclusive as the incidents were not witnessed by staff. He did not feel there were any deficiencies in care provided to any of the residents involved in the incidents. In an interview with RN B on 7/24/2025 at 5:47 PM, she stated she had not observed aggressive behavior from Resident #19 on any other incidents other than the evening of 7/5/2025. She stated she was in another resident's room providing care at the time of the incident on 7/5/2025, and she was alerted of Resident #44's injury by a CNA who heard shouting from Resident #19's room. She stated Resident #19 was given one to one observation on the night of 7/5/2025 due to the aggression with Resident #44 but did not require that level of observation any other time she cared for him. 2. Record review of Resident #44's admission Record, dated 06/24/2025, reflected the resident was a [AGE] year-old male initially admitted to the facility on [DATE] with diagnoses which included unspecified dementia (a general term for impaired ability to remember, think, or make decisions), depression, and history of falling. Record review of Resident #44's Significant Change MDS, dated [DATE], reflected the resident had a BIMS score of 0, indicating severe cognitive impairment. Further review reflected the resident had a fall in the last month, but did not reflect that the resident had a major injury such as a bone fracture. Record review of Resident #44's Care Plan, dated 07/28/2025, reflected no addressing of wandering behaviors. Focus areas related to falls were initiated on 02/09/2025 and were addressed with preventative measures, or interventions, including: rounding frequently to assess for falls unreported by resident (initiated 05/12/2025), therapy as ordered (initiated 05/12/2025), PT consult for strength/mobility (initiated 05/20/2025), follow post-fall policy (initiated 05/20/2025), call bell in reach (initiated 02/09/2025), and perform transfer assistance as needed (initiated 05/19/2025). Record review of Resident #44's Orthopedic Surgeon Visit, dated 07/25/2025, reflected there was a, small fracture within the greater trochanter with the assessment/plan stating, He may weight-bear as tolerated with a walker and needs to be supervised as he had a difficult standing with me at bedside today. [sic] Record review of Resident #44's Order Summary Report, dated 07/26/2025, reflected Per [Orthopedic Surgeon] WBAT with a walker and staff assistance as well as information related to Resident #44's follow-up appointment with the orthopedic surgeon. Observation on 07/28/2025 at 11:30 AM, Resident #44 was observed on the hallway of the locked unit standing and walking away from his wheelchair. In a subsequent observation on 7/29/2025 at 9:07 AM, Resident #44 was observed resting in bed in his room. There was no walker present in the room. Interview with the Clinical Nurse Specialist from the orthopedic surgeon's office on 7/29/2025 at 8:17 AM revealed the resident was assessed by the surgeon on 7/25/2025. The surgeon diagnosed the resident with a new fracture to an area separate from the original fracture that occurred in May 2025. The surgeon recommended Resident #44 to be weight bearing as tolerated, use a walker when ambulating with staff supervision, and limit abduction of the left leg as much as possible. Interview on 7/29/2025 at 8:51 AM with PT Director, she stated the new directives for Resident #44 from the physician included weight bearing as tolerated using a walker. She also stated that the therapy department educated the staff verbally and left a walker in Resident #44's room for use. She was unsure if the care plan had been updated, and she stated the process for communicating changes to the nursing staff from the therapy department was to have conversations with the CNAs and nurses. Interviews with CNA F and LVN A on 7/29/2024 at 9:00 AM revealed Resident #44 was not able to use the call light as he did not understand how it functioned and continuously pressed the call button. In an interview with MDS Nurse on 7/29/2025 at 9:40 AM, she stated the post fall policy included all interventions performed by nursing after a fall, including assessments, notification, and documentation per the company policy. Interview with CNA F on 7/29/2025 at 8:58 AM, stated the nurse instructed him to encourage Resident #44 to limit ambulation. CNA F stated Resident #44 used a wheelchair and not a walker. He was not aware of limitations or precautions related to positioning. Interview with LVN A on 7/29/2025 at 9:01 AM, she reported Resident #44 did not have a walker in his room and had been using a wheelchair. She stated he was weight bearing as tolerated and using the wheelchair frequently. She was not aware of recommendations for Resident #44 to limit leg positions or to use walker when ambulating. Interview with ADON R on 07/29/2025 at 10:30 AM, she stated there were no interventions after Resident #44's ortho appointment and he could ambulate and bear weight as tolerated using his walker and with supervision. Interview with ADON Q on 07/29/2025 at 10:40 AM, she stated she told staff Resident #44 was allowed to be weight bearing as tolerated with staff assistance and he had to have a walker. She stated other nursing staff were informed when communicating in report. Interview with DON on 07/29/2025 at 10:40 AM, revealed care plan meetings were held quarterly or when family requested care plan meetings and that it was important to have everyone involved in the care plan meetings. The DON did not state why the care plan was not updated or revised after each fall. Record review of facility policy titled, Comprehensive Care Plans, dated 6/30/2025, reflected, Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions initially and when changes are made. Record review of the facility policy titled Abuse, Neglect, and Exploitation, revised 6/30/2025, revealed the following: The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, and misappropriation of resident properly, and exploitation that achieves: .B. Identifying, correcting and intervening in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is more like to occur with the deployment of trained and qualified, registered, licensed, and certified staff on each shift in sufficient numbers to meet the needs of the residents, and assure that the staff assigned have knowledge of the individual residents' care needs and behavioral symptoms . D. The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect; . This was determined to be an Immediate Jeopardy (IJ) and the Administrator was provided with the IJ Template on 07/29/2025 at 4:46 PM. A Plan of Removal was requested at this time. The plan of removal was accepted on 07/31/2025 at 6:57 PM and reads as follows: Deficiency:The facility failed to develop and implement a comprehensive, person-centered care plan for Resident #44 that addressed his medical, nursing, and psychosocial needs, including fall risk, cognitive impairment, and post-orthopedic care. The resident had multiple unwitnessed falls, including with injuries. 1. Corrective Actions Taken for Resident #44: Resident #44's care plan was reviewed by IDT and revised by MDS to include fall prevention strategies, post-fall and orthopedic care instructions. The family was notified of new care plan interventions. 2. Identification of Other Residents at Risk: Residents with falls, wandering and behaviors in the last 14 days were audited and care plans were reviewed/updated accordingly. 3. Systemic Changes to Prevent Recurrence: IDT was in-serviced on 7/30/2025 regarding updating care plans and fall prevention protocols. Licensed Nurses were in serviced by DON/Designee beginning on 7/30/25 ongoing until 100% of working licensed nurses are in-serviced on where to look for care plan changes and new interventions. CNAs were in-serviced by DON/Designee beginning on 7/30/25 ongoing until 100% of working CNAs on where to look for care plan changes and interventions. The DON/Designee will review new orders and recommendations each business day and ensure care plans are updated for all residents with falls, wandering or behaviors. The Director of Nursing/Designee will review all new falls for care plan documentation, therapy recommendations, assistive devices, and staff communication on each new business day. The DON/Designee will validate communication through clinical rounds and review of written 24 nursing shift report during clinical standup meetings. Licensed nursing staff will be in-serviced beginning on 7/30/25 ongoing until 100% of working licensed nurses are in-serviced to communicate changes in behavior on the written 24-hour shift change report. The administrator will attend clinical stand up weekly to ensure communication is taking place. Monitoring and Quality Assurance: Findings will be reviewed by the Quality Assurance Process Improvement Committee for three months. Ad HOC QAPI Meeting Held:7/30/25 The facility's POR Verification was as follows:1. Record review of Resident #44 Care Plan on 7/31/2025 at 8:05 AM, reflected new interventions to include, May use wheelchair if Resident #44 prefers., Resident #44 is at risk for wandering and elopement. Discourage Resident #44from entering other residents' rooms. and Per Ortho WBAT with walker and staff/PT/OT assistance. Resident may use WC per preference Interview on 07/31/2025 at 10:20 AM, the DON stated that Resident #44's Care Plan was reviewed and revised with the IDT team to include fall prevention strategies, post-fall and orthopedic care instructions. The DON also stated Resident #44's Kardex was updated to reflect their POC. The DON stated the MDS Nurse updated Resident #44's Care Plan. Interview on 7/31/2025 at 4:07 PM, the Administrator stated he was present for the IDT care plan meeting. The Administrator stated the IDT team is the administrator, the medical director, the director of nursing. Observation on 7/31/2025 at 5:35 PM revealed Resident #44 self-propelling in wheelchair in the hallway. Further observation revealed a walker in Resident #44's room. Resident #44 was observed being redirected away from other resident rooms. Record review of Resident #44 Progress Note dated 07/29/2025 at 6:19 PM reflected, Care conference with IDT and Resident RP via phone to discuss plan of care and new fall and wandering related interventions. IDT informed RP of interventions in place. RP agrees with interventions and requests that staff provides a busy board for Resident to keep him busy. RP states that Resident has always paced, even prior to dementia and RP would not like staff to restrict him from doing that. However, she would like staff to redirect Resident out of other Residents rooms and unsafe environments. IDT informed RP of medication list per her request. Resident RP states that she would like staff to be sure and offer Resident fluids due to a history of dehydration prior to admission to this facility. Resident RP states that she would like staff to notify her immediately when a fall occurs. Rp will call if any other issues arise and staff will notify RP with any changes or concerns. Interview on 07/31/2025 at 9:01 AM, Resident #44's RP stated she was involved in the resident's new care plan. Interview on 07/31/2025 at 3:53 PM, the DON stated that Resident #44's RP was notified of the new interventions added to Resident #44's Care Plan. 2. Record review of facility Incident By Incident Type log reflected there were 12 falls between 07/17/2025 and 07/31/2025. Further review reflects that of these 12 falls, 6 were unwitnessed, and 6 were witnessed. Record review of 58% (7 of 12) of Residents with falls, wandering and behaviors in the last 14 days reflected that their care plans were reviewed and updated accordingly. Record review reflects all care plan updates were implemented between 7/22/2025 and 7/31/2025. Further review reflected 58% of Residents with falls, wandering and behaviors in the last 14 days had updates to their Kardex to accurately reflect their Care Plan. Record review reflected an audit form, created by the facility; to track and trend falls for the last 14 days. Interview on 7/31/2025 at 10:20 AM, the DON and ADON R stated care plan updates were completed on all residents with falls in the last 14 days. The DON stated they had updated all Kardex's. 3. Interview on 07/31/2025 at 3:51 PM, the DON stated the IDT team was in-serviced on updating care plans in a timely fashion, the expectations for each staff member to appropriately complete the Kardex, in-servicing of staff, and care plans. Interview on 7/31/2025 at 4:07 PM, the Administrator stated that the in-service was completed by the Regional Corporate Nurse and discussed updating care plans. Interview on 7/31/2025 at 4:19 PM, the Regional Corporate Nurse stated the Administrator was in the IDT team meeting regarding care plans. Record review of Fall Prevention In-Service Training reflected that 100% of the IDT team was in-serviced on 07/29/2025 on, protocols for identifying residents at risk, implementing appropriate interventions, and complying with post-fall procedures to ensure resident safety and regulatory compliance. Further review reflects the IDT team was in-serviced on 07/29/2025 on, To educate all Interdisciplinary Team (IDT) members on their role in the timely review, revision, and communication of resident care plan updates, ensuring compliance with F656 and delivery of person-centered care. Interview on 07/31/2025 at 10:37 AM, LVN N stated she typically works 6 AM - 6 PM, and was in-serviced on finding changes in the care plan in the Kardex and care profile and was able to describe situations which warranted inclusion in the 24-hour report. Interview on 07/31/2025 at 1:29 PM, LVN V stated she typically works 6 PM - 6 AM, and was in-serviced on care plan changes and interventions, LVN V stated she felt comfortable looking for changes made to care plans. Interview on 7/31/2025 at 1:33 PM, LVN W stated she typically works 6 AM - 6 PM and was trained on care plan changes and interventions. LVN W stated she felt comfortable with communicating care plan changes with other nursing staff. Interview on 7/31/2025 at 2:09 PM, RN X stated she typically works 6 PM - 6 AM and was in-serviced on care plan changes and interventions. RN X was able to demonstrate how to view any changes or updates in care plans or Kardex. Interview on 7/31/2025 at 3:00 PM, MDS Nurse stated she typically works at the facility 2 of 5 days a week between 8 AM and 5 PM, and was familiar with care plan changes, as she typically implements the care plan changes. Interview on 7/31/2025 3:50 PM, the DON stated there are less than 5 staff who still need to be in-serviced, and they will be in-serviced prior to beginning their next shift on the floor taking care of residents. The DON stated the staff who have not been in-serviced are because they are not currently working and have not responded to phone call attempts to complete in-servicing. Interviews were completed on 07/31/2025 between 10:30 AM and 5:15 PM with 1 of 4 Medication Aide's, 7 of 25 CNA's, 4 of 13 LVN's, and 1 of 2 RNs to verify completion of in-servicing for a total of 11 of 49 staff members. Staff members interviewed were staff who worked all shifts. Record review of in-service titled, Viewing the Kardex in PointClickCare (PCC), reflected, how to properly access and interpret the Kardex in PCC to ensure resident care aligns with current care plans. Record review of in-service sign-in reflected that 18 of 20 Licensed Nurses were in-serviced by the DON on the in-service titled, Viewing the Kardex in Point Click Care (PCC) Interview on 07/31/2025 at 10:43 AM, MA Y stated that she typically works 6 AM - 6 PM, and received in-servicing on care plan changes, looking in the point of care, and looking in the kardex. Interview on 07/31/2025 at 10:44 AM, CNA G stated they typically work the 6 AM - 6 PM shift and received in-servicing on care plan changes and interventions, looking at the Kardex, and looking at the care plan itself. Interview on 07/31/2025 at 12:45 PM, CNA S stated they typically work 6 PM - 6 AM and received in-servicing on care plan changes and interventions, to include the Kardex. Interview on 7/31/2025 at 1:05 PM, CNA T stated they typically work 6 AM - 6 PM and was in-serviced on care plan changes and interventions to include accessing the Kardex for resident's care plan interventions. Interview on 7/31/2025 at 1:13 PM, CNA U stated they typically work 6 AM - 6 PM and received in-servicing on care plan changes and interventions and knew how and where to review the residents POC. Interview on 7/31/2025 at 3:31 PM, CNA Z stated they typically work 6 AM - 6 PM and received training on care plan changes, interventions, and reviewing the Kardex. Interview on 7/31/2025 at 3:33 PM, CNA AA stated they typically work 6 AM - 6 PM, and received training on reviewing the Kardex and implementing care plan changes. Interview on 7/31/2025 at 3:37 PM, CNA AB stated they typically work 6 PM - 6 AM and had recently received training on the Kardex, resident behaviors, and new interventions. Interview on 7/31/2025 3:50 PM, the DON stated there are less than 5 staff who still need to be in-serviced, and they will be in-serviced prior to beginning their next shift on the floor taking care of residents. The DON stated the staff who have not been in-serviced are because they are not currently working and have not responded to phone call attempts to complete in-servicing. Record review of in-service titled, Viewing the Kardex in PointClickCare (PCC), reflected, how to properly access and interpret the Kardex in PCC to ensure resident care aligns with current care plans. Record review of in-service sign-in reflected that 24 of 29 CNA's were in-serviced by the DON on the in-service titled, Viewing the Kardex in Point Click Care (PCC) Interview on 07/31/2025 at 3:41 PM, the DON stated the ADON would be the designee if she was not available, and she will be checking 24-hour reports each day to review for behaviors or changes that need to be placed on the care plan and place. The DON stated she had reviewed all new orders and would continue to do so each business day and would check any orders occurring over the weekend that were not emergent on Monday morning. Record review reflected, Daily Sign-Off Calendar for the DON/Designee to review new orders and recommendations each business day and ensuring that all care plans are updated. Further review reflected the DON had signed off on new orders and recommendations on 7/30/2025 and 7/31/2025. Interview on 07/31/2025 at 3:43 PM, the DON stated the ADON would be the designee if she was not available. The DON stated that typically staff will call her when a resident falls, and she will review the 24-hour report and risk management on Monday and update as needed. Record review reflected, Daily Sign-Off Calendar for the DON/Designee to review all new falls for care plan documentation, therapy recommendations, assistive devices, and staff communication. Further review reflected the DON had signed off on new orders and recommendations on 7/30/2025 and 7/31/2025. Interview on 07/31/2025 at 3:45 PM, the DON stated that clinical standup meetings typically happen in the morning Monday through Friday. The nurse for the unit will discuss the 24-hour report with the DON and discuss any changes, as well as rounding throughout the day at the facility. Record review reflected, 24-Hour Report dated 07/31/2025, reflected the DON reviewed and signed off on the written 24-hour nursing shift report. Interview on 07/31/2025 at 10:37 AM, LVN N stated she typically works 6 AM - 6 PM, and was in-serviced on finding changes in the care plan in the Kardex and care profile and was able to describe situations which warranted inclusion in the 24-hour report. Interview on 07/31/2025 at 1:29 PM, LVN V stated she typically works 6 PM - 6 AM, and was in-serviced on changes in resident care plans, behaviors, and communicating those behaviors on the 24-hour report. Interview on 7/31/2025 at 1:33 PM, LVN W stated she typically works 6 AM - 6 PM and was trained on documenting changes in behaviors in the 24-hour shift change report. Interview on 7/31/2025 at 2:09 PM, RN X stated she typically works 6 PM - 6 AM and was in-serviced on communicating any changes on the nurses' 24-hour report and it was something she was comfortable doing. Interview on 7/31/2025 at 3:00 PM, MDS Nurse stated she typically works at the facility 2 of 5 days a week between 8 AM and 5 PM and received education on communicating via the 24-hour report. Record review of facility in-service titled, In-service Training: Communicating Behavior Changes on 24-Hour Shift Report reflected, All licensed nurses are responsible for reporting observed behavioral changes during their shift and documenting these changes on the facility's written 24-hour shift change report. Record review of facility in-service sign-in sheet for the in-service, Communicating Behavior Changes on 24-Hour Shift Report reflected that 18 of 20 licensed nursing staff were in-serviced on communicating changes in behavior on the 24-hour shift change report. Interview on 7/31/2025 at 4:07 PM, the Administrator stated he always attends stand up meetings. Interview on 7/31/2025 at 6:13 PM, the DON stated the Administrator had attended the stand-up meetings. Interview on 07/31/2025 3:48 PM, the DON stated she was part of the QAPI Committee and will review monthly any complications they may have to identify trends and identify a process to better take care of residents. The DON stated they go through falls, admissions, and any other concerns. Interview on 7/31/2025 at 4:07 PM, the Administrator stated he is in the QAPI Committee, and they look for trends. Interview on 7/31/2025 at 4:17 PM, the Regional Corporate Nurse stated they would monitor any incidents and accidents during the three-month period and discuss any behaviors. Interview on 7/31/2025 at 3:47 PM, the DON stated she was in the Ad HOC QAPI meeting on 7/29/2025. Additional members included the Administrator, Director of Rehabilitation, and the Corporate Nurse, as well as an ADON. Interview on 7/31/2025 at 4:07 PM, the Administrator stated he was in the Ad HOC QAPI meeting on 7/29/2025. Record review of Ad HOC QAPI meeting summary provided by the facility, dated 07/29/2025, reflected that the administrator, DOR, Corporate Nurse, ADON were in the Ad HOC QAPI meeting. On 07/31/2025 at 6:57 PM, the Administrator was informed the IJ was removed, however the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with a potential for more than minimum harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide comfortable and safe temperature levels maintained within a range of 71 to 81 degrees Fahrenheit for 7 of 7 residents (Resident #s 1, 2, 3, 5 on Hall 100 Male Secured Unit) and (Resident #s 4, 6, 7 - Hall 200) reviewed for environment. The facility presented with 2 non-functioning Heating Ventilation and Air Conditioning [HVAC] systems, which resulted in cold resident room interior temperatures (low 50s - 60s Fahrenheit) for residents living in 100 Hall (Male Secured Unit) and 200 Hall. Facility leadership was aware the HVAC systems were not adequately functioning since October 2023. An Immediate Jeopardy (IJ) situation was identified on 01/17/24. While the IJ was removed on 01/22/24, the facility remained out of compliance at a scope of pattern with the potential for more than minimal harm that was not immediate due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed residents at risk for harm by a diminished quality of life, specifically, sleep deprivation and cold-related injuries (hypothermia). The findings were: Observation on 01/17/24 at 2:15 PM, when entering the facility, revealed it was noticeably cold and residents/staff were still wearing winter clothing (jackets/gloves/scarfs/ski caps) while in the building. Record review of website: Past Weather in [city] Texas, USA - Yesterday or Further Back (timeanddate.com) of the air temperatures for [city], Texas revealed the following air temperatures and corresponding dates for the city this facility was located: Date: Low High 1/12/2024 29 F 59 F 1/13/2024 24 F 61 F 1/14/2024 16 F 28 F 1/15/2024 14 F 30 F 1/16/2024 15 F 34 F 1/17/2024 13 F 52 F Interview on 01/16/2024 at 2:34 PM, the administrator stated the facility's heating units for 100 Hall (Male Secured Unit) and 200 Hall were not functioning and pending replacement. The administrator stated 2 portable heating units had been placed at both ends of the 100 Hall (Male Secured Unit) and one large space heater was placed at the end of 200 Hall until the facility's permanent heating units could be replaced. The administrator also said portable heaters were purchased and offered to residents who wanted one in their room in response to staff and residents complaining of cold temperatures within the building on the night of 1/13/2024. Observation on 01/16/2024 at 3:06 PM of 100 Hall (Secured Men's) revealed 2 temporary heating units (THU) located at both ends of the hall. Further observation revealed the THU at the beginning of 100 Hall was running at a setting of 80 F and indicated room temperature (Hallway) of 69 F. Observation of the THU at the end of 100 Hall revealed the THU was not running. Observation and interview on 01/16/2024 at 3:09 PM, Resident #1 was observed walking 100 Hall (Male Secured Unit) and lead this investigator his room. Resident #1 indicated his room was cold and would get colder at night. Resident #1 proceeded to show this investigator 4 blankets on his bed he was utilizing in an attempt to stay warm. The room temperature in this location felt uncomfortably cold while wearing a jacket. Observation and interview on 01/16/2024 at 3:14 PM, Resident #2 (100 Hall - Male Secured Unit) was observed lying in his bed. Resident #2 was observed wearing gloves and when asked why, Resident #2 responded, because I like them! When asked if the resident was cold at night, he responded, Yes! When asked how the resident was doing in an attempt to stay warm, he responded, The blankets. The room temperature in this location felt uncomfortably cold while wearing a jacket. Observation and interview on 01/16/2024 at 3:16 PM, Resident #3 (100 Hall - Male Secured Unit) was observed sitting in the secured dining area in his wheelchair. During the interview, Resident #3 said that this week had been, really cold. The room temperature in this location felt uncomfortably cold while wearing a jacket. Observation on 01/16/2024 at 3:38 PM revealed a space heater at the end of Hall 200.The space heater was on and glowing. The room temperature in this hall felt uncomfortably cold while wearing a jacket. Observation and interview on 01/16/2024 at 3:40 PM, Resident #4 (200 Hall) was asked about the temperature of her room and indicated she had been, Very cold, and said she had been using multiple blankets in an attempt to stay warm. The room temperature in this location felt uncomfortably cold while wearing a jacket. Observation and interview on 01/17/2024 at 7:38 AM, facility staff were observed wearing winter-clothing in the building which consisted of extra layers and ski hats. At this time, an unknown staff shouted, It's cold in there, 50 degrees. Observation and interview on 01/17/2024 at 7:44 AM, Resident #1 was observed lying in his bed with a blanket over his head. A reading of the room's temperature revealed a temperature of 56 F. During an interview at this time, Resident #1 was asked if he was cold and responded, Yes The resident stated he did not sleep well because his room was cold. Observation and interview on 01/17/2024 at 7:57 AM with LVN B, this investigator pointed a thermal thermometer laser at the wall closest to Resident #1's bed which revealed a temperature reading of 56 F. LVN B confirmed the temperature in Resident #1's room was 56 F and responded, Oh wow, that's cold. Observation and interview on 01/17/2024 at 7:44 AM, Resident #5 was observed lying in bed with a navy blue blanket over his head (photo taken). A reading of the room's temperature revealed a temperature of 51 F. During an interview at this time, Resident #5 was asked how he was doing and responded, Cold. When asked if the Resident #5 felt tired, he responded, Yeah, I can't sleep. Observation and interview on 01/17/2024 at 7:58 AM with LVN B, this investigator pointed a thermal thermometer laser at the wall closest to Resident #5's bed which revealed a temperature reading of 51 F. During an interview at this time, LVN B was asked what the temperature should be to be considered comfortable to which she responded, Around 70 F. Observation and interview on 01/17/2024 at 8:07 AM with Staff C, this investigator pointed a thermal thermometer laser at the wall closest to Resident #4's bed which revealed a temperature reading of 51 F. Staff C confirmed the temperature for Resident #4's room was 51 F. During an interview at this time, Staff C said Resident #4 had requested to be moved to a new location due to feeling cold in her room. Staff C mentioned another resident, Resident #7 - Hall 200, had also requested to be moved because she was cold in her room. Interview and observation on 01/17/2024 at 9:50 PM, the Maintenance Supervisor and this investigator compared thermal temperature guns and confirmed their readings matched within +/-.3 degrees F. The Maintenance Supervisor's thermal temperature gun was orange and black (IR1 Infrared Thermometer), The Maintenance Director was asked what the room temperatures should be and responded, Around 75 F in the winter and around 70 F in the summer. Interview and observation on 01/17/2024 at 10:00 AM, the Maintenance Supervisor measured Resident #1's room (100 Hall - Male Secured Unit) with his infrared temperature gun by pointing the laser at the wall closest to the Resident #1's which revealed a temperature of 61 F. During an interview at this time, the Maintenance Supervisor said, It feels chili in here, I would need more blankets and double socks. Interview and observation on 01/17/2024 at 10:04 AM, the Maintenance Supervisor measured Resident #5's room (100 Hall - Male Secured Unit) with his infrared temperature gun by pointing the laser at the wall closest to the Resident #5's which revealed a temperature of 61 F. Resident #5 was observed still lying in bed with blankets over his head. A space heater was observed in this resident's room and was emitting heat but the room still felt cold. During an interview at this time, Resident #5 was asked if he was still cold to which he responded, Ya. At this time, the Maintenance Director said, Even with a space heater the room still feels cold. I don't see why the main heating unit (for 100 Hall) wasn't fixed before the cold weather. Interview on 01/17/2024 at 10:15 AM, the administrator stated she had moved all but 1 resident on 200 Hall from the second half of 200 Hall to other locations including the first half of 200 Hall. The Administrator also stated she had closed the smoke barrier doors located in the middle of 200 Hall in an effort to prevent cold air coming down the first half of the 200 hall. Additionally, the Administrator said all residents on the 100 Hall (Male Secured Unit) were moved to the 100 Hall (Female Secured Unit) and indicated that section of 100 Hall had a HVAC. Interview and observation on 01/17/2024 at 10:29 AM, the Maintenance Supervisor measured Resident #7's room (200 Hall) with his infrared temperature gun by pointing the laser at the wall closest to the Resident #1's which revealed a temperature of 57.7 F. Resident #6 was observed lying in her bed under layers of blankets. During an interview at this time, Resident #6 was asked how she was doing to which she responded, I'm cold. The Maintenance Director then said, Ya, it's cold, I wouldn't want to be in there. The Maintenance Director then confirmed Resident #7's room was on the first half of 200 Hall that was supposed to be the side residents were moved to because it was warmer than the second half of 200 Hall. The Maintenance Supervisor agreed it felt much colder in the resident's room than in the hall. Interview on 01/17/2024 at 4:45 pm with the Chief Operations Officer (COO) and the administrator revealed the facility discovered in October 2023 the HVAC for 100 Hall Male Secured Unit and 200 Hall were not adequately functioning. The administrator indicated the facility had been in the process of replacing the units since then but there had been delays. The administrator further stated she anticipated the heating units for 200 Hall and 100 Hall (Male Secured Unit) would be replaced by 01/19/2024. Record review of facility policy, Quality of Life - Homelike Environment, (Revised May 2017), stated, Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible . 2. The facility and staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: .h. Comfortable and safe temperatures (71 F - 81 F) . Record review of website, https://www.nia.nih.gov/health/safety/cold-weather-safety-older-adults , dated, 01/03/2024 , stated: Older adults have a higher chance of being affected by cold weather. Changes that come with aging can make it harder for older adults to be aware of their body becoming too cold, which can turn into a dangerous health issue quickly. Hazards of cold weather include falls on wintry surfaces; injury caused by freezing (frostbite); and hypothermia, a medical emergency that occurs when your body temperature gets too low. Being informed and taking certain actions can help lessen risks during the colder months . Staying warm indoors. About 20% of injuries related to exposure to cold occur in the home. Here are some tips to help keep warm: Even mildly cool homes with temperatures from 60 to 65°F can lead to hypothermia in older adults. This was determined to be an Immediate Jeopardy on 01/17/24 at 5:50 PM. The administrator and COO were notified. The administrator was provided the Immediate Jeopardy template on 01/17/24 at 6:00 PM . The following Plan of Removal submitted by the facility was accepted on 01/19/24 at 2:00 PM: Plan for REMOVAL The facility failed to provide a safe, clean, comfortable, and homelike environment, to include maintenance services necessary to maintain comfortable and safe temperature levels, for 1 of 1 facility reviewed for a safe, clean, comfortable, and homelike environment. F584 1- On 1/17/2024 Residents on 100 unit (men's secure unit) were moved to warm secure unit. Residents on 200 hallway cold areas were moved to warm side of the unit by IDT. Units that are not holding temperature of 71 degrees Fahrenheit were temporarily closed by Maintenance Director. 2- On 1/17/2024 Maintenance Director ordered and paid for heating units repairs which are scheduled for 1/22/204 to be installed due to a delay in the crane delivery. Per the contractor all work on the HVAC units will be repaired on the same day as arrival. 3- On 1/17/2024 Social Worker/Designee notified RPs of the room changes. 4- On 1/17/2024 Director of Nursing/Designee assessed residents for s/s of hypothermia or sleep deprivation due to feeling cold - no negative findings noted. The Medical Director updated on findings by Administrator on 1/17/2024. 5- On 1/17/2024 COO (Chief Operating Officer) completed 1:1 in-service with Administrator and Maintenance Director on emergency readiness, inclement weather preparedness, and s/s of hypothermia. 6- On 1/17/2024 Director of Nursing/Designee initiated in-services with staff of identifying s/s of hypothermia, timely notification of Administrator/Supervisor when noting patients room/residents' areas feel cold or residents/staff/visitors complaints of feeling cold, residents' sleep deprivation, and cold-related injuries (hypothermia) due to cold temperatures in the facility. Staff will not be allowed to work until they receive training, including agency staff and PRN. Anyone who is not able to receive training will not be allowed to work until the in servicing is completed. 7- Ad-Hoc QAPI meeting was held on 1/17/2024, with the Medical Director, NHA (Nursing Home Administrator), DON, and Maintenance Director to review the alleged deficiencies, policy and procedure, and the plan for removal of immediacy. The policies pertaining to Emergency readiness were reviewed on 1/17/2024 by the NHA (Nursing Home Administrator), DON, and Medical Director. 8- Starting on 1/17/2024, IDT (Interdisciplinary team), including Administrator, Activity Director, DON, Social Worker, admission manager, MDS, and Maintenance Director will meet with residents daily to identify if any residents have sleep deprivation and s/s of hypothermia due to cold temperatures Monday through Friday, and Manager on Duty on Saturday, Sunday, until heating units are repaired. Any issues or concerns will be brought up to the Administrator immediately and IDT team members for any follow-up needed. Residents' room temps will be taken daily to ensure compliance by Maintenance Director or designee until HVAC units are installed. If any room temperatures are below 71 degrees; the Administrator will be contacted and the resident will be offered another room that is above 71 degrees. Temperatures of the rooms will be taken 2xs a day and temps recorded in the temperature spreadsheet in maintenance book until HVAC units are installed. Residents' temperature will be taken daily to ensure no signs or symptoms of hypothermia. 9-The Administrator/designee will monitor compliance by completing an audit of five (5) residents per week for four (4) weeks until heating units are repaired. This was initiated on 1/17/2024. Any identified concern will be addressed immediately and if trends and patterns are identified, the facility will conduct an Ad-Hoc QAPI meeting to discuss if additional interventions are needed to ensure compliance. 10- The COO will provide oversight of Administrator to ensure that the items on the plan of removal are reviewed and completed.[sic] The facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy by: -Observations on 01/19/2024 of 200 Hall, between 3:15 PM and 3:17 PM revealed room temperatures between 71.4 F to 74.4 F. Further observation reviewed smoke barrier doors were closed in the middle of 200 Hall to prevent the escape of warm air. Observations on 01/19/2024 of 100 Hall, between 3:18 PM and 3:19 PM revealed room temperatures between 71.4 F to 74.4 F. Observations on 01/19/2024 at 3:20 PM revealed 100 Hall (Male Secured Unit) had been completely vacated by all residents. Interview on 01/19/2024 at 4:08 PM, the Maintenance Director stated 3 HVAC three units had been ordered and paid for and had heard they would be installed on Monday 01/22/2024. Record review at this time supported the information provided specific to this interview. Observation on 01/22/2024 at 2:00 PM, HVAC staff were observed over 200 Hall working on the HVAC Unit on the roof. Interview on 01/22/2024 at 2:05 PM, the administrator stated the new HVAC unit was being in-stalled over 200 Hall and said HVAC installers were in the process of custom fitting the plenum and anticipated both units would be completely installed by cob. Record review of the facility's Electronic Resident Database under section, Progress Notes. Revealed documentation inputted by the facility's social worker indicating RP and/or attempted RP notifications for residents that had been moved to a different room. Interview and record review on 01/19/2024 at 3:42 PM, the DON stated she assessed all residents impacted by the cold weather to ensure they did not have s/s of hypothermia. Record review of facility documentation supported this statement. Interview on 01/19/2024 at 3:53 PM, the administrator stated the emergency preparedness in-service covered inclement weather and other items specific to disasters. This included checking the generator, making sure an evacuation plan was in place, extra blankets were available, and a phone roster for staff in-case of an emergency. Regarding hypothermia, the administrator said this can be determined by body temperature, vital signs, and alert/oriented status. Interview on 01/19/2024 at 4:00 PM, the Maintenance Director stated he would look for drowsiness, confusion, shivering, memory loss et specific to hypothermia. Regarding emergency preparedness, the Maintenance Director said he was instructed to make sure there were adequate blankets, an addendum to have heaters, check room temps periodically throughout the day. He said he was also in-serviced regarding inclement weather, specifically ensuring thermostats were set properly, windows were to be shut, the generator was adequately working, et. He further stated the generator was tested on [DATE] and added a solution to prevent gelling of the gasoline. Interview with the administrator on 01/22/2024 at 5:44 PM, the administrator said that if conditions were extreme, heaters would be used as needed. The Administrator stated they would be placed in the hallways within the line of sight of nurses/aides). The administrator said this was indicated in her emergency preparedness manual. Record review of sign in sheets on 01/22/2024 provided by the administrator revealed information that supported this interview. Interview on 01/19/2024, the Corporate Nurse stated staff that have been in-serviced by person or via telephone were documented on a list and said that staff who have not yet received the in servicing will not be able to work. Record review of a 3 page document titled, Employee Roster, generated on 01/17/2024, revealed a list of all facility staff. Further review of this document revealed signatures next to staff who had completed the trainings. This list also showed attempts to contact 6 staff but had been unsuccessful. Observations and interviews on 01/18/2024 thru 01/22/2024 of resident rooms where residents were temporarily transferred 100 Hall (Women's Secured Unit) and the first half of 200 Hall (before smoke barrier doors) measured above 71 degrees F and it was noticeably a comfortable temperature in those resident rooms. Interviews with a sample of staff (CNAs, LVNs, RNs, DON - from all 3 facility shifts), the Maintenance Director, and administrative staff 01/19/2024 thru 01/22/2024 revealed staff had been in-serviced specific to the Plan of Removal and knew to immediately notify the administrator if they noticed an unusual occurrence, which included if the heat went out in the building. Staff were also able to explain their familiarity with signs and symptoms of hypothermia and indicated they would provide blankets, warm liquids, and ensure all doors and windows were closed to keep the heat inside. Record review of sign in sheets on 01/22/2024 provided by the administrator revealed information that supported this interview. Interview on 01/19/2024 at 4:06 PM, the Maintenance Director stated he had been checking room temps 4 times daily to ensure compliance and said the nurses were also checking room temps in the evening utilizing his thermal temperature gun (the same thermal temperature gun utilized during previous temperature observations with this investigator). Record review facility documentation revealed monitoring was occurring in accordance to this plan. Interview on 01/18/2024 at 4:42 PM, the administrator said she would be monitoring 5 residents a week for 4 weeks and would be monitoring residents daily to ensure there were not signs or symptoms of hypothermia or other potential adverse reactions related to cold weather or new interventions. She said they would be utilizing a resident roster daily to document this information. Record review of documentation on 01/22/2024 provided by the administrator revealed information that supported this interview. Interview on 01/18/2024 at 4:29 PM, the COO stated she would be frequenting the facility once per month to provide oversite to the Administrator to ensure items on the plan of removal are reviewed and completed. The administrator was informed the Immediate Jeopardy was removed on 01/22/2024. The facility remained out of compliance at a severity of potential for more than minimal harm that was not immediate jeopardy and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews the facility failed to ensure that the resident environment remained as free of accident hazards as was possible and that each resident received adequate supervision and assistance devices to prevent accidents for 3 of 3 (Residents #6, 7, and 8) residents reviewed for accidents. 1. Resident #6 had one unauthorized, unchaperoned elopement event on 07/21/2023. 2. Resident #7 had one unauthorized, unchaperoned elopement event on 07/30/2023. 3. Resident #8 had one unauthorized, unchaperoned elopement event on 10/26/2023. The non-compliance was identified as past non-compliance IJ. The non-compliance began on 10/26/2023 and ended on 10/30/2023. The facility had corrected the noncompliance before survey began. This failure could place residents at risk for harm, injury, or death due to elopement. The findings included: 1. Record review of Resident #6's Face Sheet, dated 12/06/2023 revealed Resident #6 was a [AGE] year-old female, initially admitted to the facility on [DATE] with diagnoses of Alzheimer's disease (a progressive disease that affects memory and other important mental functions), paranoid schizophrenia (a chronic mental illness characterized by delusions, hallucinations, and disordered thinking), insomnia (trouble falling and/or staying asleep), wandering (traveling aimlessly from place to place), and age-related osteoporosis (brittle and fragile bones). Record review of Resident #6's BIMS Observation Detail List Report, date completed 07/21/223 at 07:35 a.m. revealed Resident #6 had a BIMS score of 11.0 indicating moderate cognitive impairment. Record review of Resident #6's MDS assessment date 09/03/2023 revealed a BIMS score of 9 indicating moderate cognitive impairment and Wandering Presence & Frequency noted under Behavior documented as 0. Behavior not exhibited. Record review of Resident #6's comprehensive person-centered care plan, reflected Resident #6 had a problem, initiated 07/18/2023 and edited 07/25/2023, of Potential/ high risk for injury R/T identified elopement risk factors and or exit seeking behavior AEB: Resident pushed emergency exit button and then attempts to exit the facility. She was successful in her attempt one time. Approaches included Resident educated on signing out prior to leaving the facility for any reason., Assess/ record/ report to MD risk factors for potential elopement such as: wandering, repeated requests to leave facility, attempts to leave facility., and Consider placement on secure unit if wandering, elopement attempts continue. Record review of Resident #6 elopement Risk Assessment date completed 06/30/2023 at 08:38 p.m. revealed total score of 20 a score of 5 or greater suggests the resident is at risk for elopement. Care Plan Interventions noted as: Consider placement in secured unit. Assessment revealed Resident #6's physician, Resident #6, and Resident #6's RP were notified of the results of the assessment on 06/30/2023. Record review of Resident #6's Safety Events-Elopement report date completed 07/21/2023 at 07:42 a.m. revealed Resident #6 found by [a nearby church]. Resident #6 was noted as no sustained injuries. Resident #6 was noted as having had elopement attempts in the past that were unsuccessful, repeatedly opened doors/setting off alarms on secured doors and having had verbalized statements about leaving. Resident #6 noted for change in mental status or new onset with anxiety and hallucinations. Resident noted for having Alzheimer's disease, psychiatric diagnosis of schizophrenia, and paranoid schizophrenia. Measures noted as taken was one on one with interventions noted as effective. Record review of Resident #6's progress note, dated 07/21/2023 at 07:51 a.m. revealed nursing note describing elopement with resident noted to have been returned to the facility, having denied injury and pain, and now on one to one per administrator's instruction. Record review of nursing note dated 07/21/2023 at 09:40 a.m. revealed full skin assessment provided to Resident #6 at 06:00 a.m. with no skin issues identified and reported complaint of muscle pains due to walking so far. Record review of nursing note dated 07/21/2023 at 02:08 p.m. revealed Resident evaluated by the IDT team regarding 100 secure unit and resident not appropriate at this time. Resident alert and able to voice needs and reports she was going to the Medicaid office down the street. Record review of nursing note 07/22/2023 at 06:01 a.m. revealed Resident has been cooperative with staff. No exit seeking behaviors noted. Has been monitored every 15 minutes and remained in line of site with staff. Record review of nursing note 07/24/2023 at 01:38 p.m. revealed Resident #6 diagnosed with dysuria (painful urination) and a urinalysis and culture with sensitivities was ordered. Record review of nursing note 07/26/2023 at 04:03 p.m. revealed DON spoke with Resident #6's physician regarding recent elopement attempt, with physician stating no action to be taken and no new orders given. Record review of Resident #6's Elopement Risk Assessment date completed 07/25/2023 at 06:46 a.m. revealed total score of 20 with note if score is 5 or greater, the resident is at risk for elopement. Care Plan Interventions noted as: involve psychosocial and/or activity program, redirect resident, and Consider placement in a secured unit. Assessment revealed Resident #6's physician, Resident #6, and Resident #6's RP were notified of the results of the assessment on 07/21/2023. Record review of facility Provider Investigation Report signed 07/26/2023 revealed the facility ADMIN reported an incident involving Resident #6 to HHSC on 07/21/2023. The report revealed an unsecured door was identified on 07/21/2023 at approximately 05:30 a.m. when a CNA was returning into the facility following taking trash out from the shift. The investigation summary stated the facility investigation revealed per Resident #6 and staff interviews, Resident #6 discovered the emergency release button on the exit door next to the administrator's office and exited the building using the emergency button while staff were busy doing other tasks. The facility received a phone call from a good Samaritan who reported observing the resident walking in the near area. The staff were noted as having responded immediately and returned Resident #6 to the facility at approximately 06:00 a.m. The event was noted as spanning 15 to 20 minutes from the door having been found unsecured to Resident #6 having been returned to the facility. A head-to-toe assessment was noted as having been completed with no treatment or transfer required. Provider actions taken included: alarm covers noted to have been placed over the emergency button, Resident #6 and her RP educated on appropriate sign-out procedures, an IDT meeting was held with Resident #6's RP to determine plan of care and if any changes needed to be made, and staff in-services on abuse, emergency exit button, and elopement initiated. Record review of a Frequent Monitoring Flowsheet for Resident #6 dated 07/21/2023 - 07/22/2023 with 06:00 a.m. on 07/21/2023 to 06:00 a.m. on 07/22/2023 noted as completed. Record review of facility in-service training report signed 07/23/2023, topic noted as Care of Behavioral/ dementia/ Alzheimer's/ cognitively impaired and Elopement revealed 42 signatures. Record review of facility in-service training report signed 07/23/2023, topic noted as Emergency exit button- if this is activated- immediately do a head count and secure doors at once. Locations of said buttons- what to do to re-engage- pull & turn button revealed 48 signatures. Observation of Resident #6 on 07/21/2023 at 02:08 p.m. revealed resident sitting in wheelchair in room next to bed. Resident observed with two nursing staff attending to her with her providing limited responses to staff during interaction. Record review of MapQuest accessed 12/27/2023 revealed facility distance to location noted of where Resident #6 was found on 07/21/2023 was 0.3 miles away. Record review of www.timeanddate.com/weater for Kerrville, Texas on 07/21/2023 from 04:51 a.m. to 06:51 a.m. was 78-80-degree Fahrenheit, clear to sunny with 0 to 7 mph wind and visibility noted as 10 miles. 2. Record review of Resident #7's Face Sheet, dated 12/06/2023 revealed Resident #7 was a [AGE] year-old male, admitted to the facility on [DATE] and discharged on 08/07/2023. Resident #7 diagnoses included atrial fibrillation (a quivering, irregular heartbeat), age-related physical debility (weakness), restlessness and agitation, and Parkinson's disease (a disorder of the nervous system that affects movement, often including tremors). Record review of Resident #7's BIMS Observation Detail List Report, date completed 08/02/2023 at 01:06 p.m. revealed a BIMS score of 13.0 indicating cognitively intact. Record review of Resident #7's MDS, assessment date 06/16/2023 revealed Wandering Presence & Frequency noted under Behavior documented as 0. Behavior not exhibited. Record review of Resident #7's comprehensive person-centered care plan reflected Resident #7 had a problem, initiated 07/17/2023 and edited 07/31/2023, of Potential/ high risk for injury R/T identified elopement risk factors and or exit seeking behavior AEB: Impaired cognition/ and or daily decision making, length of say < (less than) one year, elopement history, and exit seeking/ elopement history/ episodes. Approaches included Continuous one on one care by staff due to elopement risk and Sent to [medical center] 07/29/2023 for Altered mental status .discussed placement wishes with resident. Record review of Resident #7's Elopement Risk Assessment, date completed 08/02/2023 at 01:24 p.m. revealed a total score of 17, with document note if the score is 5 or greater, the resident is at risk of elopement. Care Plan Interventions included: Routine monitoring of resident, Involve Psychosocial and/or Activity Program, Redirect resident, and Consider placement in a secured unit. Resident #7's physician noted as receiving notification of the assessment on 07/30/2023 at 12:45 p.m. Record review of Resident #7's progress note dated 07/29/2023 at 11:02 a.m. revealed nursing note of CNA report that Resident #7 became physically aggressive and attempted to leave out the front door resulting in call to transfer Resident #7 to local medical center for physical aggression and wanting to leave in confused mental status. Record review of nursing note dated .07/29/2023 at 02:39 p.m. revealed local medical center completed labs, revealing no abnormality, was ready to discharge Resident #7 back to the facility, and DON recommended to schedule a telephone psychosocial visit for Resident #7. Record review of nursing note dated 07/29/2023 at 06:45 p.m. revealed Resident #7 had returned to the facility. Record review of nursing note dated 07/29/2023 at 08:15 p.m. revealed Resident #7 was observed in the parking lot outside the facility but was noted as heading back inside on his own at the time of observation. Record review of nursing note dated 07/30/2023 at 09:31 a.m. revealed staff had kept resident insight since he first got up that morning and had no signs of distress. Record review of nursing note dated 07/30/2023 at 10:52 a.m. by DON revealed Resident #7's physician did not make any changes to Resident #7's plan of care at that time. Record review of nursing note dated 07/30/2023 at 12:10 p.m. revealed staff had maintained a direct line of sight on Resident #7 that morning, he had progressively become more verbally aggressive to staff and others, he would not listen to reasoning, and could be overheard talking at the nursing station when the nurse (writing of the note) and the CNA left the nursing station. Record review of nursing note dated 07/30/2023 at 12:18 p.m. revealed facility received call from local fire department reporting that Resident #7 was at the fire department in his wheelchair and asking for them to help him get away from the people who were trying to murder him at that place. Record review of nursing note dated 07/30/2023 at 12:45 p.m. revealed Resident #7 was at the fire station, observed to be in a delusional state, refusing to return to the facility, and taken by emergency services to the local hospital at 12:40 p.m. Record review of administrator note dated 07/30/2023 at 12:56 p.m. revealed the ADMIN had a telephone conversation with Resident #7 on 07/29/2023 regarding being found in the parking lot on 07/29/2023 evening. Resident #7 stated he got outside through the front door after a visitor exited because he wanted some fresh air and reported that he knew he would be coming back when he went out. The note revealed the ADMIN discussed the sign-out policy and procedure with Resident #7 who stated he would follow the procedure. Record review of nursing note dated 07/30/2023 at 04:57 p.m. revealed the facility received a call from the local hospital that Resident #7 refused to return to the facility. Record review of nursing note dated 07/30/2023 at 05:53 p.m. revealed Resident #7 was returning to the facility due to medical order. Record review of nursing note dated 07/30/2023 at 09:34 p.m. revealed Resident #7 returned to the facility. Record review of nursing note dated 07/31/2023 at 05:20 p.m. revealed Resident #7 on constant one on one with staff member since return from hospital the prior night. Note revealed an alternate placement option had been found for Resident #7 to transfer to and the option had been communicated to Resident #7. No distress was noted. Record review of nursing note dated 08/01/2023 at 09:06 a.m. revealed Resident #7 remained on one to one and had attempted to go to the exit door twice during the night but was redirectable. Record review of psych note encounter dated 08/01/2023 at 10:05 a.m. revealed Resident #7 reported depression from being in the facility and occasional increased anxiety. Ordered Sertraline 25 mg daily for depression. Record review of Elopement Risk assessment dated as completed on 08/02/2023 at 01:08 p.m. revealed score of 17, with document note indicating if score is 5 or greater, the resident is at right of elopement. Care Plan Interventions noted as: routine monitoring of resident, involve psychosocial and/or activity program, redirect resident, and consider placement in a secured unit. Notification noted as physician on 07/29/2023 at 06:45 p.m. and phone disconnected for family/responsible party. Record review of nursing note dated 08/03/2023 at 03:11 p.m. revealed Resident #7 remained on one-to-one care, was wandering through the facility, and denied pain or distress. Discharge planning noted for medication continuation and setting up home care. Record review of facility Provider Investigation Report signed 08/07/2023 revealed the facility ADMIN reported an incident involving Resident #7 to HHSC on 07/31/2023. The report revealed the incident occurred on 07/30/2023 at 12:18 p.m. The report revealed Resident #7 left the facility without notifying staff and was discovered approximately two blocks from the facility. Upon discovery at 12:30 p.m., a LVN attempted to perform a nursing assessment on Resident #7. He refused and was then sent to the hospital ER for evaluation. Facility investigation revealed Resident #7 stated that he applied intense pressure to the exit door next to the administrator's office, while ensuring he was unobserved, and went out the door to the fire department. The report revealed Resident #7 was observed by staff in the facility 8 minutes prior to having been discovered at the fire department. Upon discovery, Resident #7 stated he left without notifying staff by stating I just wanted to and refused to return to the facility. Upon return from the hospital for evaluation, Resident #7 was placed on one on one observation and an alternate placement was secured for his transfer on 08/07/2023. Provider actions noted included security of all doors were evaluated and a wireless door sensor alarm was placed on the door Resident #7 eloped from with in-servicing of staff initiated. Record review of facility in-service training report dated 07/31/2023, topic noted as Elopement revealed 45 signatures. Record review of facility in-service training report dated 07/31/2023, topic noted as Behavioral Aggression in the Cognitively Impaired revealed 48 signatures. Record review of facility in-service training report dated 08/04/2023, topic noted as Exit Door by Administrator office is now alarmed. If alarm is heard, report to exit at once., revealed 39 signatures. Record review of MapQuest accessed 12/27/2023 revealed facility distance to location noted of where Resident #6 was found on 07/30/2023 was 0.1 miles away. Record review of www.timeanddate.com/weater for Kerrville, Texas on 07/30/2023 from 11:51 a.m. to 12:51 p.m. was 94-95-degrees Fahrenheit, sunny with 0 to 6 mph wind and visibility noted as 10 miles. 3. Record review of Resident #8's Face Sheet, dated 12/06/2023 revealed a [AGE] year-old male admitted to the facility initially on 05/09/2023 with diagnoses of personal history of transient ischemic attack (a brief, stroke-like attack that resolves itself), cerebral infarction (a disruption in the brain's blood flow) without residual deficits (conditions left behind), muscle wasting and atrophy (shrinking of muscle or nerve tissue), and dementia (a general term for impaired ability to remember, think, or make decisions). Record review of Resident #8's MDS assessment date 09/05/2023 revealed a BIMS score of 8 indicating moderate cognitive impairment and Wandering Prescence & Frequency noted under Behavior documented as 0. Behavior not exhibited. Record review of Resident #8's comprehensive person-centered care plan reflected Resident #8 had a problem, initiated 10/26/2023 and edited 10/27/2023, of Potential/ high risk for injury R/T identified elopement risk factors and or exit seeking behavior AEB: impaired cognition/ and or daily decision making; length of stay < (less than) one year; elopement history; independent locomotion; decreased safety awareness; exit-seeking/elopement history/ episodes. Approaches included Resident moved to 111B in the locked unit for safety, Assess/ record/ report to MD risk factors for potential elopement such as: wandering, repeated requests to leave facility, attempts to leave facility., Supervise closely and make regular compliance rounds whenever resident is in room. Resident is a 1:1, and The facility works .to assist with guardianship for residents d/t financial and medical decision-making needs .D/T no safe discharge location. Unable to get consent for memory care unit as resident refuses. Record review of Resident #8's Elopement Risk Assessment, completed date 05/10/2023 at 11:02 a.m. revealed a total score of 15, with document note if the score is 5 or greater, the resident is at risk of elopement. Care Plan Interventions included: routine monitoring of resident, redirect resident, and consider placement in a secured unit. Resident #8's physician, Resident #8, and family/ RP noted as having received notification of the assessment on 10/25/2023. Record review of Resident #8's Elopement Risk Assessment, completed date 10/27/2023 at 11:53 a.m. revealed a total score of 15, with document note if the score is 5 or greater, the resident is at risk of elopement. Care Plan Interventions included: routine monitoring of resident. Resident #8's physician, Resident #8, and family member noted as having received notification of the assessment on 05/10/2023 at 11:00 a.m. Record review of Resident #8's nursing note, dated 10/26/2023 revealed at 11:25 p.m. Resident #8 was identified as missing. The staff had found Resident #8's wheelchair next to an exit door with a book propping the door open. The police, administrator, and DON were notified. The police arrived at the facility at 12:01 a.m. and following a discussion with the nurse and administrator, left to search for Resident #8. A CNA located Resident #8's cell phone number, called him, and Resident #8 answered the phone and stated he was in the creek behind the facility and with a friend. Resident #8 was observed coming out of the creek with a police office. He stated, I was trying to make the great escape and got stuck in the creek. Resident #8 was noted as being covered in mud and soaked with water. Resident #8 noted to having an abrasion to his right elbow, left hand/knuckles, the left hand was purple, and both knees were red. Resident #8 noted to be put on a one on one and stated, I'm going to continue to escape, next time it'll be during the day. Record review of Resident #8 nursing note dated 10/26/2023 at 12:50 a.m. revealed resident assessed for injury, multiple abrasions and redness noted. Record review of Resident #8 nursing note dated 10/26/2023 at 02:58 p.m. revealed x ray revealed torn scapholunate ligament tear (partial tear or stretch) in left wrist. Record review of Resident #8 nursing note dated 10/26/2023 at 04:40 p.m. revealed Resident #8's physician present to examine resident. Resident #8's left wrist still has range of motion and was to wear a soft support wrap or ACE wrap. Resident #8 reported area is tender during range of motion but that in general he has no pain. Record review of Resident #8 nursing note dated 10/26/2023 at 04:54 p.m. revealed Resident #8 remained on one-on-one care due to elopement. Resident #8 denied distress but stated I will do it again when I get the chance. Record review of Resident #8 nursing note dated 10/27/2023 at 12:53 p.m. revealed Resident #8 was moved to the locked unit for his safety. He was noted as no longer on one to one due to being in the secure unit. Resident stated Do you think this room will keep me here? Good luck, I'll get out of here too. Record review of facility Provider Investigation Report signed 11/01/2023 revealed the facility ADMIN reported an incident involving Resident #8 to HHSC on 10/26/2023. The report revealed the incident occurred on 10/25/2023 at 11:43 p.m. Report revealed on 10/25/2023 around 10:00 p.m. an exit door was noted as propped open, nursing staff initiated a roster check for all residents, and discovered Resident #8 was not found in the facility. Report revealed the police department was notified and was able to locate the resident and return him to the facility. Resident #8 was assessed by the LVN on duty and EMS with noted abrasions to his right elbow, left hand/knuckles, and both knees. Bruising was noted on Resident #8's left hand, which resulted in the physician ordering an x-ray and a torn ligament in the left hand was identified. Resident was noted as being placed on a one to one due to his elopement risk and ordered to the secure unit for safety. Record review revealed facility document Elopement Drill Record dated 10/26/2023 which revealed Resident #8 was noted as missing at 11:25 p.m. on 10/25/2023, he was last seen at 09:45 p.m. on 10/25/2023, and located in 2 hours. Report revealed the weather conditions as raining and muddy. Actions taken included: searched rooms, searched outside, called contacts, Administrator, DON, ADON. Called police. Corrective Action taken revealed resident on one on one initiated. Report signed by 9 staff: the two facility ADONs (both LVNs), a LVN, three CNAs, the Maintenance Director, the Activity Assistant, and a nurse aide. Record review of facility in-service training report dated 10/26/2023, topic noted as Elopement revealed 40 signatures. Record review of facility in-service training report dated 10/26/2023, topic noted as Door Propping revealed 43 signatures. Record review of MapQuest accessed 12/27/2023 revealed facility distance to location noted of where Resident #8 was found on 10/25/2023 was approximately 150 feet away. Record review of www.timeanddate.com/weater for Kerrville, Texas on 10/25/2023 from 08:51 p.m. to 12:20 a.m. was 69-78-degrees Fahrenheit, overcast to light rain with fog, with 6 to 15 mph wind and visibility noted as 1 to 10 miles. Observation on 12/06/2023 from 03:35 p.m. to 03:45 p.m. revealed the facility to be parallel to a main city street with two driving entrances from the main street to the facility parking lot. The facility's main entry/exit door of facility was located off the right of the facility with the primary parking lot and a private street. Across the private street was a walled off construction site for new homes/complex. The primary parking lot at the facility entrance was noted to be full of approx. 20 cars. Toward the right and back of the facility was a private property with home and a river. The private property was located between the facility and the river. Along the outside of the facility on all sides is a small facility road with 3 secured doors to the back (toward the river/private property) and with enclosed patio toward the back. To the left of the facility is a creak. At the main road, the creak had around a 1.5-foot decline in elevation over around 3 feet. The creek quickly drops in depth, around 20 feet distance from the main road, the creek had a steep drop-off from level ground to around 16 feet drop and around 5 feet across. The main street was observed to be moderately busy with 2-way, 1 road each direction. An estimated 20 cars passed at the time of observation in under 5 minutes. No sidewalks or easy to walk grass within a minimum 1 block for each way and for each side of the road from the facility. The fire station was observed to be 0.3 miles from facility, took around 10 minutes to walk with a brief stop to observe the creek. The main street curved slightly during walk to the fire station resulting in the fire station and traffic on the road not being visible for greater than 1 block. The fire station was located on the main street, across the street without any sidewalks for travel if in wheelchair until arrival. No stop signs, lights, or traffic signs upon the main street when walking this direction. During an observation and interview with Resident #8 on 12/08/2023 at 02:35 p.m., Resident #8 was observed to be standing and walking around his room without assistance but with a wheelchair observed parked next to his bed. Resident #8 stated he did not fall into a creek. Resident #8 stated that he used to be a carpenter and while he was touring his prior hall, he noticed that one of the exit door handles was installed backwards, with the lock on the wrong side of the door/building. He stated that he tried the door and found it to be unlocked. He stated he exited the building because he was just wanting to explore his surroundings and didn't know he was breaking the law. Resident #8 stated he couldn't really see because it was dark and had started to rain, causing his glasses to fog up. Resident #8 stated his walking cane became stuck in the mud after he walked across the parking lot and he tried to call 911 but he didn't know how to operate his new cell phone. Resident #8 stated he finally contacted a family member, who called 911 for him and by the time the police arrived he was back in the parking lot. Resident #8 stated that they moved him to his current hall (secure unit) for my safety. Resident #8 stated that he wasn't trying to go anywhere, just explore his environment. Interview with the Mnt A on 12/08/2023 at 03:08 p.m. revealed the facility entry/exit doors were secured and require a code for entry and exit. The Mnt A stated the entry/exit doors have an emergency exit button located near ceiling and would automatically release if the facility was on generator power or the fire alarm was activated. The Mnt A stated the only door that does not have a code for entry/exit is the door in the lobby, next to the administrator's office. The Mnt A stated the lobby door is not considered an entry/exit door and due to a past recommendation had an alarm installed on it in case a resident forces it open. The Mnt A stated the alarm was installed on the lobby door following a resident elopement. The Mnt A stated the facility entry/exit doors daily by either himself or the maintenance director. Interview with the Mnt Dir on 12/14/2023 at 04:14 p.m. revealed the facility entry/exit doors are checked every morning and afternoon by himself or the maintenance assistant, who will act as his back-up. The Mnt Dir revealed an alarm was placed on the door next to the administrator's office (lobby door) after an elopement in July but then upgraded after the last elopement due to the administrator's request that the alarm be louder. The Mnt Dir stated that after the last upgrade, the alarm on the lobby door can be heard throughout the facility. Interview with the Admin on 12/18/2023 at 04:37 p.m. revealed she was unaware of changes had been made or interventions put in place following Resident #6 and resident #7's elopements, stating this was prior to her hire at the facility. Regarding Resident #8, she said the resident was placed in the secure unit per physician orders due to elopement tendencies. Record review of facility policy Wandering, Unsafe Resident, noted as revised August 2014 revealed The facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk for elopement. Policy Interpretation and Implementation included: 1. The staff will identify residents who are at risk for harm because of unsafe wandering (including elopement). 2. The staff will assess at-risk individuals for potentially correctable risk facture related to unsafe wandering. 3. The resident's care plan will indicate the resident is at risk for elopement or other safety issues. Interventions to try to maintain safety, such as a detailed monitoring plan will be included. Record review of facility policy Elopements, noted as revised December 2007 revealed Staff shall investigate and report all cases of missing residents. The non-compliance was identified as past non-compliance IJ. The non-compliance began on 10/26/2023 and ended on 10/30/2023. The facility had corrected the non-compliance before the survey began. The facility implemented interventions to prevent further elopement risks such as discharging residents, upgrading the volume on one of the doors, and educating staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure all residents were free from abuse for 2 of 6 residents (Residents #1 and #5) reviewed for abuse in that: The facility staff failed to implement adequate interventions to ensure Resident #1 did not enter other resident rooms, which caused him to be abused by Resident #2 and Resident #3. Eventually, Resident #1 was pushed by Resident #3 and Resident #1 broke his right hip and his left index finger. Resident #1 was no longer independent after breaking his hip. The facility failed to implement adequate interventions to ensure Resident #5 felt safe at the facility after he was pushed by resident #3. This failure resulted in identification of an Immediate Jeopardy (IJ) on 3/17/23. While the IJ was removed on 3/19/23, the facility remained out of compliance level of actual harm with a scope identified as isolated until interventions were put in place to ensure residents were free from abuse. This failure could place residents at risk for abuse from other residents. The findings were: Record review of Resident #1's face sheet, dated 3/15/23, revealed Resident #1 was originally admitted to the facility on [DATE] with diagnoses of unspecified dementia [a general term for impaired ability to remember, think, or make decisions], unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, pain, unspecified, and hypocalcemia (History of) [low levels of calcium in the blood.] Record review of Resident #1's Quarterly MDS, dated [DATE], revealed Resident #1 did not have a BIMS score because Resident #1 was rarely/never understood. Record review of Resident #1's care plan, obtained 3/15/23, revealed the following: - Problem last updated 11/2/22: Behavior problem related to: Dementia AEB [As Evidenced By:] Roams into others rooms. This problem area had the following goal: Will have behavior identified so that staff may intervene quickly with listed interventions, daily, through next review date. One of the interventions was last updated on 11/2/22 read: Intervene as needed to protect the rights and safety of others. Approach and speak in a calm manner. Divert attention. Remove from situation and take to another location as needed. - Problem last updated 1/18/23: Resident resides in secure unit and is at risk for injury from wandering in an unsafe environment R/T [related to] impaired safety awareness. Resident is at risk for injury from others while residing in secure unit D/T [due to] altered cognition. This problem area had the following goal: Dignity will be maintained and resident will wander about unit without occurrence of any injury over the next quarter. One of the interventions last updated on 1/18/23 was: Keep environment free from possible hazards. This problem area also had the following goal dated 1/18/23: Activities director to monitor/discuss activity preference. This problem area also had the following goal dated 1/18/23: Allow resident to choose activities inside and outside that don't pose a safety risk. Record review of activities documentation from 2/1/23 to 3/14/23 revealed Resident #1 had outside activity, which was outside (walk), as early as 2/2/23. Other activities that took place outside of the locked unit, like bingo were seen documented as early as 2/6/23 and a coffee social on 2/15/23. Record review of Resident #2's face sheet, dated 3/15/23, revealed Resident #2 was originally admitted to the facility on [DATE] with diagnosis of dementia in other diseases classified elsewhere, unspecified severity, with other behavioral disturbance, depression, unspecified, Type 2 diabetes mellitus without complications, and unspecified dementia with behavioral disturbance. Further record review of this document revealed Resident #2 was discharged on 3/10/23. Record review of Resident #2's Discharge MDS, dated [DATE], revealed Resident #2 had a BIMS score of 3, signifying severe cognitive impairment. Record review of Resident #2's care plan, obtained 3/15/23, revealed the following: - Problem last updated 11/17/22: [Resident #2] is territorial of room/personal belongings r/t: Dementia with Behaviors. This problem area had the following goal: Will have behavior identified so that staff may intervene quickly with listed interventions, daily, through next review date. This problem area had the following intervention dated 11/3/22: Intervene as needed to protect the rights and safety of others. Approach and speak in a calm manner. Divert attention. Remove from situation and take to another location as needed. - Problem area last updated 1/4/23: Behavior problem related to: Dementia with behaviors AEB: Physical and Verbal aggression towards others. This problem area had the following goal: Will have behavior identified so that staff may intervene quickly with listed interventions, daily, through next review date. This problem area had the following interventions dated 1/4/23: Intervene as needed to protect the rights and safety of others. Approach and speak in a calm manner. Divert attention. Remove from situation and take to another location as needed. Record review Resident #3's face sheet, dated 3/15/23, revealed Resident #3 was admitted to the facility on [DATE] with diagnosis of other lack of coordination, unspecified dementia, unspecified severity, with other behavioral disturbance, anxiety disorder, unspecified, unspecified psychosis not due to a substance of known physiological condition, and persistent mood [affective] disorder [a persistent and usually fluctuating disorders of mood which can last for many years that involve considerable distress and disability], unspecified. Record review of Resident #3's 5-day MDS, dated [DATE], revealed Resident #3 had a BIMS score of 9, signifying moderate cognitive impairment. Record review of Resident #3's care plan, obtained 3/15/23, revealed the following: - Problem dated 3/10/23: Behavior problem related to: Dementia AEB: Physical Aggression/Verbal aggression. This problem area had the following goal: Will have behavior identified so that staff may intervene quickly with listed interventions, daily through next review date. This problem area had the following interventions dated 3/10/23: intervene as needed to protect the rights and safety of others. Approach and speak in a calm manner. Divert attention. Remove from situation and take to another location as needed. Record review of Resident #5's face sheet, dated 3/15/23, revealed Resident #5 was admitted to the facility on [DATE] with diagnoses of Alzheimer's Disease [a progressive disease that affects memory and other important mental functions], unspecified, other abnormalities of gait and mobility, other lack of coordination, weakness, other malaise, and muscle wasting and atrophy not elsewhere classified, unspecified site. Record review of Resident #1's incident report, dated 2/15/23 and written by LVN E, revealed the following: Brief Description of Incident: hit by another resident [Resident #2] in the head Description of injury: laceration [cut] over left eye . At 2:25 pm this nurse heard loud voices coming from . another resident's room, this resident [Resident #1] came out of the room, this nurse asked the other resident [Resident #2] what was the problem, the other resident [Resident #2] stated that he [Resident #2] hit this [sic] because he repeatedly told him [Resident #1] to get out of his [Resident #2's] room but he [Resident #1] refused. [sic] Record review of Resident #2's nursing progress note, dated 2/15/23 and written by LVN E, revealed the following: this nurse heard loud voices coming from this resident's [Resident #2's] room, another resident [Resident #1] . came out of the room, this nurse asked the resident [Resident #2] what was the problem, resident [Resident #2] stated he hit the other [Resident #1] because he [Resident #2] repeatedly told him [Resident #1] to get out of his [Resident #2's] room but he refused. Record review of Resident #1's incident report, dated 3/9/23 and written by LVN F, revealed the following: Patient went into another patient room when the Aggressor Punched other patient in the nose . Nurse was notified by CNA Patient was seen walking up and down hall with Excessive bleeding coming down from nose and another patient verbalized to her he came into his room and 'he got what he deserved.' Record review of Resident #2's nursing progress note, dated 3/9/23 and written by LVN F, revealed the following: Nurse was notified by CNA Patient admitted to hitting another patient in the nose verbalized He got what he deserved because he walked into his room. Record review of Resident #2's electronic health record revealed no 30-day discharge notice dated prior to his discharge on [DATE]. Record review of Resident #5's nursing progress note, dated 3/11/23 at 10:31 a.m. and written by LVN F, revealed the following: Patient requested to [NAME] [sic] to nurse out in 'secret' He feels unsafe around another resident and would like for him to leave him alone. Nurse spoken [sic] to other resident and separated the two nurse will continue to monitor patients. Record review of Resident #5's nursing progress note, dated 3/11/23 and written at 10:31 a.m. by LVN F, revealed Rm changed to 116B. Record review of Resident #3's nursing progress note, dated 3/11/23 at 10:42 a.m. and written by LVN F, revealed the following: Patient seen trying to shove roommate into his room. When asked patient to please leave other patient alone he does not want to be in the room he shouted, 'I didn't touch him, I don't have blood on my hands.' Nurse talked to patient about keeping his hands to himself and patient understood. Record review of Resident #3's nursing progress note, dated 3/11/23 at 4:06 p.m. and written by LVN F, revealed the following: Patient arguing and yelling at other patients in the hall, Nurse instructed patient to sit at nurse station for 1:1 Observation. For behavior problems. Record review of Resident #1's incident report, dated 3/12/23 and written by LVN C, revealed the following: Brief description of incident: wandered to another resident room, pushed to the floor by another resident [Resident #3] . 3/12/23 at 9:29 a.m This hour resident [Resident #1] sent out to ER to evaluate/tx [treat.] Pushed to floor by another resident [Resident #3.] Record review of Resident #3's nursing progress note, dated 3/12/23 and written by LVN C, revealed the following: This am [a.m., meaning morning,] Resident voiced 'I didn't do it. I have no blood on my hands' A commotion could be heard during resident smoke hour. This resident shouted, 'get outta my room'! Then a slapping noise. This writer check the hall another resident [Resident #1] on the floor. That resident [Resident #1] is unable to communicate the incident related to DX. Record review of Resident #1's hospital physician progress note, dated 3/13/23, revealed the following: Presents after was wondering about other patients room, was pushed, fall, subsequent inability to stand up, brought to the ED [Emergency Department] which showed nondisplaced fracture of right femoral neck [right broken hip] as well as fracture of [left] proximal second digit [broken index finger.] He is scheduled to have surgical correction his afternoon. Record review of Resident #1's hospital X-ray results, dated 3/13/23, revealed total right hip arthroplasty [hip replacement] without hardware complication. Record review of Resident #1's Physical Therapy Evaluation & Plan of Treatment, dated 3/15/23, revealed Resident #1 had the following short-term goals: -Patient able to perform sit <>[to] stand 3x [3 times] mod A [Moderate Assistance] to improve safety with transfers . PLOF [Prior Level of Function] (prior to onset) Independent. Baseline (3/15/23) dependent. -Patient able to stand with BUE [Bilateral Upper Extremities, meaning both arms] 1 minute min A [minimal assistance] to improve safety with transfers . PLOF (prior to onset) independent for most of the day. Baseline (3/15/23) unable limited by pain. Further record review of this same Physical Therapy Evaluation & Plan of Treatment, dated 3/15/23, revealed Resident #1 had the following long-term goals: -Patient able to perform supine [lying on bed face-up] <> [to] sit supervision to decrease caregiver assistance . PLOF (prior to onset) independent. Baseline (3/15/23) dependent. -Patient able to transfer bed <> [to] W/C [wheelchair] supervision to decrease caregiver assistance and risk for falls . PLOF (prior to onset) independent. Baseline (3/15/23) unable. Admit on stretcher to facility. Limited by pain. -Patient able to ambulate [walk] with FWW [four wheel walker] 150' [150 feet] with supervision to decrease risk for falls . PLOF (prior to onset) independent no device. Baseline (3/15/23) unable. Record review of Resident #1's Occupational Therapy Evaluation & Plan of Treatment, dated 3/15/23, revealed Resident #1 had the following short-term goals: -Patient will increase activity tolerance for functional activities of choice to 20 min in order to w/o [without] signs/symptoms of physical exertion increased participation with ADL tasks . PLOF Prior to onset) 20 min. Baseline (3/15/23) 30-60 seconds. -Patient will safely perform self feeding tasks with Set-up (A) with use of for initiation/termination of tasks in order to facilitate self esteem through increased independence with tasks . PLOF (prior to onset) S/U [set up.] Baseline (3/15/23) Min (A) [Minimal Assistance] -Patient will complete toilet/commode transfers with Modified Independence for clothing management with recognition of safety hazards . PLOF (prior to onset) MI [Modified Independence.] Baseline: Max (A) [Max Assistance]. Further record review of this same Occupational Therapy Evaluation & Plan of Treatment, dated 3/15/23, revealed Resident #1 had the following long-term goals: -Patient will complete hygiene and grooming tasks while standing at sink with Modified Independence for initiate/termination of tasks with recognition of safety hazards in order to facilitate ability to live in environment with least amount of supervision and assistance . PLOF (prior to onset) Modified Independence. Baseline (3/15/23) Max (A). -Patient will safely perform toileting tasks using grab bars with Modified Independence for clothing management with recognition of safety hazards . PLOF (prior to onset) MI. Baseline (3/15/23) Max (A). -Patient will safely and efficiently perform LB [Lower Body] Dressing with Modified Independence with use of for initiation/termination of tasks in order to be able to return to prior level of living . PLOF (prior to onset) MI. Baseline (3/15/23) Max (A) Record review of Daily Schedule, dated 3/12/23, revealed the facility had 1 LVN, 1 CMA, and 1 CNA on 3/12/23. A second CNA was seen noted for the locked unit, but the second CNA's name scratched out and moved to another unit. Record review of the facility's current staff roster, provided on 3/15/23, revealed the facility had 17 CNAs, 11 Nurse Aides, 4 CMAs, 9 LVNs, and 1 RN. Including the non-clinical staff, the facility had 65 total employees. Record review of the facility's uploaded files from TULIP for Intake #411419 (which was the incident involving Resident #1 and Resident #2 on 3/9/23), revealed the following in-services conducted on the following dates: -On 3/9/23, the facility educated 14 staff members on Falls and Unmanageable Residents. -On 3/9/23, the facility also educated 22 staff members on Prevention of Abuse and Neglect. However, of the 22 staff members, 2 staff members signed their names twice for a total of 20 staff members. Of these now 20 staff members, 14 were the same staff members educated on Falls and Unmanageable residents. Only 6 new staff members received this education. -On 3/13/23, the facility also educated 13 staff members on Abuse Reporting. -On 3/13/23, the facility also educated 13 staff members on Managing Fall Risk. The 13 staff members on this in-service were the same 13 staff members who were educated on Abuse Reporting. During an observation and interview on 3/15/23 at 1:11 p.m., Resident #1 was seen in bed, awake, alert, and fully-dressed. CO H was at Resident #1's bedside and CO H stated Resident #1 may not be able to answer questions due to his diagnosis of dementia. An interview was attempted with Resident #1. When asked if he had any issues with other residents, Resident #1 answered, yes, but he did not elaborate on his answer when this surveyor prompted Resident #1 to elaborate. CO H stated Resident #1 was attacked 3 times last week and stated Resident #1's last attack was on Sunday, 3/12/23. CO H stated she received a call from CO J and they both went to a local emergency department. CO H stated, the story they told [CO J] is that the nurse was out on the patio and she heard someone yell 'get out of here.' She [the nurse] went to investigate and [Resident #1] was on the floor. And that's when the hip was broken . They [the facility] promised me they were going to keep [Resident #1 and Resident #2] separate and keep [Resident #1] safe. During an interview on 3/15/23 at 3:11 p.m., NA G stated if [Resident #3] sees anyone walking by, he'll try to pick a fight. Usually Resident #5 is afraid of Resident #3. In a follow-up interview on 3/15/23 at 3:20 p.m., NA G stated she had heard [Resident #2] had struck [Resident #1.] NA G stated Resident #2 was no longer in the facility. During an interview on 3/17/23 at 9:21 a.m., Resident #5 stated he did not feel safe in the facility. Resident #5 stated the other residents make him feel unsafe and have hurt him before. Resident #5 did not provide the names of the other residents who had hurt him. During an interview on 3/17/23 at 9:22 a.m., LVN C stated she ensured the safety of residents in the facility's locked unit by frequently monitoring the residents. LVN C stated she currently had 2 CNAs, but she was supposed to have a 3rd CNA that was supposed to come in later. When asked how they ensured Resident #1's safety, LVN C stated frequent re-direction all the time . to the best of our ability educate the residents that it's not intentional on his part to invade their space. LVN C stated [Resident #2] could go for a good amount of time [without being aggressive] and then slowly start to show the signs and then explode. When asked how they managed Resident #2's aggressive behavior, LVN C stated they spoke with [Resident #2] firmly. LVN C stated after Resident #2 struck Resident #1 they had temporarily moved Resident #1 to the women's side until lunch the next day, 3/10/23, after Resident #2 was discharged . LVN C stated only new interventions she was aware of for [Resident #1] was to consider alternative placement but it was difficult to find alternative placement for Resident #1 due to his wandering. Continuing the interview on 3/17/23 at 9:22 a.m., LVN C stated Resident #3's aggressive behavior was new for Resident #3. LVN C stated she believed Resident #3 may be mimicking Resident #2's aggressive behavior. LVN C stated, [Resident #3] somehow got attached to him and he was always calling out for [Resident #2.] And I found that extremely odd because [Resident #3] was becoming dependent on [Resident #2.] [Resident #3] felt safe around him. LVN C stated prior to 3/12/23, Resident #3 was approaching other residents with the intent to push them over, but when [Resident #3] was aware he was being watched by the facility staff, he would leave the other residents alone. LVN C confirmed she was working on 3/12/23, the day Resident #3 pushed Resident #1. LVN C stated, We were short [a staff member] that day. I remember because I had to take them out to smoke because usually a CNA would do it. So to keep the [other residents] calm I went and initiated the smoke [smoke break.] So I let them [the residents] out and then it happened. LVN C stated after Resident #3 pushed over Resident #1 and caused Resident #1 to break his hip they made sure [Resident #3] stayed away from the others. During an interview on 3/17/23 at 10:48 a.m., LVN I stated he was currently the primary nurse for Resident #1. LVN I stated Resident #1 was currently on physical therapy and occupational therapy, which was new for Resident #1. LVN I stated Resident #1 could previously walk independently and currently cannot bear weight on his broken hip. During an interview on 3/17/23 at 12:28 p.m., the DOR stated Resident #1 was currently on physical therapy and occupational therapy for his broken right hip. The DOR stated Resident #1 never required therapy before because he was ambulatory [able to walk] without any device and was independent with ADLs prior to his broken hip. The DOR stated Resident #1 was currently bed-bound at this point. He was independent, but now he's dependent. During an interview on 3/17/23 at 1:34 p.m., the Director of Marketing LVN stated his current role at the facility was a Nurse Manager due to the fact the facility did not have a DON and ADON. The Director of Marketing LVN stated the facility ensured the safety of residents in the locked unit by frequent monitoring. The Director of Marketing LVN stated if 2 residents had a physical altercation the staff would ensure the altercation doesn't happen again by monitoring continuously. When asked about the incident involving Resident #1 and Resident #2 on 2/15/23, the Director of Marketing stated he could not recall much about the incident as that was around the time he began to become more involved in nurse management. The Director of Marketing LVN stated after the incident we did our frequent monitoring and then our redirection and then provided activities on the unit. Continuing the interview on 3/17/23 at 1:34 p.m., the Director of Marketing LVN stated a resident was considered unmanageable when medication management failed to manage a resident's behavior and once that was identified the facility would find alternative placement. The Director of Marketing LVN stated Resident #2 was very nice . but he would have his spurts where if an individual invaded his space too closely, he might get a little aggressive . He was more of a verbal yelling and screaming. Just whenever his personal space was invaded. The Director of Marketing LVN stated to manage Resident #2's aggression they provided activities for him. We have an activity assistant back there [in the unit] to encourage to do activities throughout the day. The Director of Marketing LVN stated the facility had attempted to discharge Resident #2 to other nursing homes but was denied. The Director of Marketing LVN stated he was unsure if the facility ever issued a 30 day discharge notice to Resident #2. When asked about what happened between Resident #1 and Resident #2 on 3/9/23, the Director of Marketing LVN stated the facility sent out Resident #2 to the hospital for medical clearance but Resident #2 was sent back. The facility then scheduled Resident #2 to be sent out to another local hospital and when transportation arrived Resident #2 became combative, law enforcement was involved, Resident #2 was arrested and was currently not in the facility. The Director of Marketing LVN stated afterwards the facility initiated in-services on abuse, neglect, and resident-to-resident altercation. The Director of Marketing LVN stated the facility continued their current interventions from 2/15/23 for Resident #1 which included redirection, music therapy, providing more staff in the locked unit, and posting an identification marker on his Resident #1's room to help Resident #1 find where his room is. Continuing the interview on 3/17/23 at 1:34 p.m., the Director of Marketing LVN stated Resident #3 had a diagnosis of dementia, anxiety, unspecified psychosis, and persistent mood disorder. The Director of Marketing LVN stated from admission until these recent events he's been very pleasant and after Resident #3 pushed Resident #1 the facility provided redirection, a calming environment, and scheduled a psychiatric evaluation for Resident #3 after he returned to the facility on 3/12/23. The Director of Marketing LVN stated the ideal staffing in the locked unit was 1 nurse and 2 CNAs, but on 3/12/23, the locked unit was short 1 CNA. The Director of Marketing LVN stated he did not feel the short-staffing contributed to Resident #1's incident on 3/12/23. When asked about the incident on 3/12/23, the Director of Marketing LVN stated the initial report was not made to him but to the facility's former MDS Nurse who was no longer employed at the facility. The Director of Marketing LVN stated, the only thing I remember is that the resident stated he didn't do it. I know [the former MDS Nurse] set up for [Resident #3] to be sent to [a local hospital] to be evaluated for psychiatric treatment and he came back. When asked if the facility implemented new interventions for Resident #3, the Director of Marketing LVN stated, just our general intervention. Just to provide a calm environment, redirection, and continuous monitoring. When asked if they implemented anything new for the staff, the Director of Marketing LVN stated, I know they did some in-services on abuse and neglect. The Director of Marketing LVN stated Resident #1 was independent before his incident on 3/12/23. When asked if they implemented anything new for Resident #1, the Director of Marketing LVN stated, we did incorporate a lot of activities that were off the unit to change his environment for him. The Director of Marketing LVN stated, I think they did everything they could have done to ensure the safety of all residents in this facility. They followed the procedures meant to be implemented in these situations. During an interview on 3/17/23 at 3:05 p.m., the Administrator stated he had been the Administrator at the facility since early February 2023 and was currently the abuse coordinator. The Administrator stated they ensured the safety of residents in their locked unit by supervision and increased activities. The Administrator stated he did not recall if the facility had implemented any interventions for the locked unit after the incident involving Resident #1 and Resident #2 on 2/15/23. The Administrator stated he was not too familiar with Resident #2 beyond the incident between Resident #1 and Resident #2 on 3/9/23. The Administrator stated he was not aware of any new interventions for Resident #2 prior to 3/9/23. The Administrator stated he was aware the facility had attempted to discharge Resident #2 before 3/9/23 but with no success. The Administrator stated aside from in-servicing, the facility did not make any major changes after the incident between Resident #1 and Resident #2 on 3/9/23. Continuing the interview on 3/17/23 at 3:05 p.m., the Administrator stated he heard Resident #3 became aggressive towards Resident #5 prior to Resident #3 pushing over Resident #1 on 3/12/23. The Administrator stated on 3/12/23 he was notified of the incident between Resident #3 and Resident #1 and he came on-site the same day to conduct safe surveys with other residents. When asked if there were any interventions in place to ensure Resident #1's safety, the Administrator stated, just the 15-minute check thing that we've done. I'll tell you what the problem is, it's the size of the hall . Most everyone has dementia and some of those guys get into people's personal space and some people don't like it. And [Resident #1] does that. He'll enter people's personal space and these guys-they have dementia too and I assume they don't like it. The Administrator stated he was unsure if there were any considerations to place Resident #1 in another facility. When asked if he felt the facility had done everything they could to ensure Resident #1's safety, the Administrator stated, I don't think I could have done anything to make that not happen. An updated education for the facility's incident report on 3/12/23 was requested at this time. In a follow-up interview on 3/17/23 at 5:47 p.m., the Marketing Director LVN stated the facility's education on 3/9/23 carried over to the incident on 3/12/23. During an interview on 3/18/23 at 10:45 a.m. with the Administrator, this surveyor requested for a copy of a 30-day discharge for Resident #2, if one was available. In a follow-up interview on 3/18/23 at 11:03 a.m., LVN C stated she was aware Resident #3 attempted to push Resident #5 before and heard Resident #3 raised a fist at Resident #5. LVN C stated Resident #5 felt unsafe around Resident #3 and wanted to change rooms. In a follow-up interview on 3/18/23 at 11:15 a.m. with CO H, CO H stated, [Resident #1] walks and always has. That honestly is my biggest concern . He used to sit up by himself and stand and now he can't do that . Something that he's never done before that's really concerned me is that I went to move his hair out of his eyes and he flinched. And that broke my heart. He knows I'd never lay a hand on him . He sleeps a lot more. He never used to sleep during the day. He was always up and walking. During an interview on 3/18/23 at 11:59 a.m., the Assistant Activities Director stated she conducted activities for the locked unit. The Assistant Activities Director stated she was told to do more activities with the men's locked unit, but added, I'm still making it work because she was trying to balance doing activities for the men and women's locked unit. When asked about any new changes to their activities schedule, the Assistant Activities Director stated the facility started having weekly outings on Thursdays since 3/2/23. The Assistant Activities Director stated off-unit activities had been implemented since October 2022. The Assistant Activities Director state the facility's off-unit activities included coffee socials on Tuesday, and bingo on Tuesdays and Thursdays. When asked about Resident #1, the Assistant Activities Director stated the resident liked to go for walks and she would take him to walk through the dining hall and outside at least 2 or 3 times per week for 30 minutes. During an interview and record review on 3/18/23 at 12:28 p.m., the Assistant Activities Director stated she was asked to pass to this surveyor a print-out of Resident #2'nursing and physician progress notes with highlighted portions indicating the facility's unsuccessful attempts to discharge Resident #2. No 30-day discharge notice was provided with this print-out and there was no documentation in the progress notes that indicated a 30-day discharge notice was provided. Record review of a facility policy titled, Preventing Resident Abuse, dated February 2014, revealed the following, Our facility will not condone any form of resident abuse and will continually monitor our facility's policies, procedures, training programs, systems, etc., to assist in preventing resident abuse . The facility's goal is to achieve and maintain an abuse-free environment. Record review of Resident #1's signed admission agreement, dated 10/19/23, revealed the following: Each Resident has the right to be free from verbal, sexual, mental and physical abuse, corporal punishment, and involuntary seclusion. The Administrator was notified of an IJ on 3/17/23 at 5:48 p.m. and was given a copy of the IJ Tem[TRUNCATED]