**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision for 1 of 10 residents (Resident #1) reviewed for accidents and supervision.The facility failed to ensure Resident #1 did not exit the facility without staff's knowledge and ambulate approximately 100 yards down their driveway to a busy street with a speed limit of 65 MPH on 05/25/25. The facility failed to ensure staff were knowledgeable on how to properly secure the doors using the door security box located at 2 of 2 nurses' stations (both the skilled nursing and long-term care sides of the facility). Staff were identified by ADON B pressing the door release button with a key emblem instead of the round door secure button resulting in the doors not being secured. An Immediate Jeopardy (IJ) was identified on 06/25/25. The IJ Template was provided to the facility on [DATE] at 05:10 PM. While the IJ was removed on 06/26/25, the facility remained out of compliance at a scope of isolated and a severity with no actual harm with the potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of harm and/or injury due to elopement. Findings included:Review of Resident #1's face sheet dated 06/25/25 reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included Parkinson's disease (neurodegenerative disease primarily of the central nervous system, affecting both motor and non-motor systems) with Dyskinesia (uncontrolled, involuntary movements), Alzheimer's disease (a type of dementia that affects memory, thinking, and behavior), mood disorder due to known physiological condition with depressive features, and neurocognitive disorder with Lewy bodies (aka Lewy body dementia, is a type of dementia caused by protein deposits in the brain cells affecting thinking, memory, movement, sleep, and behavior). The face sheet reflected Resident #1 was discharged [DATE] at 2:09 PM after a 13-day length of stay. Review of Resident #1's discharge MDS assessment return not anticipated dated 05/25/25 reflected section A discharge status which was marked as Resident #1 being discharged to a long-term care facility with a discharge date of 05/25/25. Section C cognitive patterns reflected a BIMS score of 04 indicating severe cognitive impairment. Review of Resident #1's baseline care plan dated 05/12/25 reflected safety risks- is the resident an elopement risk? was not marked yes or no. Review of Resident #1's care plan last revised 05/25/25 reflected a focus initiated on 05/25/25 the resident is an elopement risk/wanderer related to disoriented to place. History of attempts to leave facility unattended, impaired safety awareness. Resident wanders aimlessly, significantly intrudes on privacy or activities. The care plan reflected there was no focus or interventions prior to 05/25/25 the date of the elopement. Review of Resident #1's progress notes reflected the following notes related to wandering/exit seeking behavior: - Nursing note dated 05/14/25 resident on follow up day 3/3 of new admit. He seems to be adjusting to being at facility. Does continue to wonder around. Alert to self but pleasantly confused. - Nursing advanced skill evaluation dated 05/15/25 resident wanders at night. - Nursing note dated 05/15/25 resident observed making multiple attempts to exit the facility through the secure doors. When redirected resident expressed confusion stating, I don't know what I am doing here. This nurse provided reorientation and education regarding his current medical condition and reason for admission. Resident has a feeding tube, medications and nutritional feeding were administered via tube as ordered. Despite tube feeding, resident was observed attempting to consume food from other residents' tray and requesting coffee. Staff have been providing frequent redirections and reassurance. Resident was brought to nursing station for closer observation; however, he is unable to remain seated for prolong period and frequently attempts to stand and ambulate unsafely. This nurse has made several multiple interventions to promote safety including verbal redirections. - Nursing note dated 05/15/25 Resident found in room packing his clothes and personal belongings which were laid out on his bed. When asked what he is doing he states that he is going home, and his family member is coming to pick him up. Resident educated and redirected but resident remains insistent on leaving. This nurse attempted to contact family member , resident in his room alert and verbal still expressing desires to go home.- A nursing note dated 05/17/25, Resident up in his wheelchair at this time wheeling around everywhere trying to get into other residents' rooms and trying to eat and drink everyone's food and drinks. Resident has to be reminded that he cannot eat or drink anything at this time as he is strictly to not have anything by mouth and that he has a feeding tube that hives him the foods and fluids he needs. Resident stares at nurse and just wheels off. He is very confused, but it is a pleasant confused. Resident attempting to go towards the doors and staff again has to redirect him that he cannot go out of the building as he can fall and get hurt. Resident again just stared at nurse. He is currently wheeling around the nurses station. - A nursing note dated 05/18/25, Resident is up in his wheelchair at this time rolling around and will not stay in pod 1 as it has been asked of him to do that many of times so staff can keep a better eye on him- An advanced nursing skilled evaluation note dated 05/19/25, Resident is confused. Resident is awake at night. Resident wanders at night. - A nursing progress note dated 05/19/25, Resident is up in his wheelchair at this time rolling around and will not stay in pod 1 as it has been asked of him to do that many of times so staff can keep a better eye on him and he continues to go towards the doors and into other residents rooms. He is very pleasantly confused. - An advanced skilled nursing evaluation note dated 05/20/25, safety concerns- resident has been trying to exit the doors. - An advanced skilled nursing evaluation note dated 05/21/25, resident wanders at night. - A nursing progress note dated 05/22/25, Resident has been up in his wheelchair rolling around and will not stay on pod 1 as it has been asked of him to do that many of times so staff can keep a better eye on him, and he continues to go towards the doors and into other residents' rooms. He is very pleasantly confused. - An advanced skilled nursing evaluation note dated 05/23/25, Resident is confused. Resident is awake at night. Resident wanders at night. - A nursing progress note dated 05/25/25, a family member of one of our patients alerted us to Resident #1 being in the road on [main road off property] we immediately went and got the resident and brought him back in the facility. We brought him back in the facility and placed him on 1 on 1 family member is currently here now and I informed her of his elopement and also that we are trying to find placement for him at a memory care facility. We cannot meet his needs since we are not a lock down facility or have wonder guards to prevent resident from getting out the facility and getting hurt [receiving SNF] has accepted resident and will be transporting him to their facility. - An elopement evaluation progress note dated 05/25/25, Elopement evaluation: History of elopement while at home: Yes. Wandering behavior, a pattern or goal-directed: No. Wanders aimlessly or non-goal-directed: Yes. Wandering behavior likely to affect the safety or well-being of self / others: Yes. Wandering behavior likely to affect the privacy of others: Yes. Recently admitted or re-admitted (within past 30 days) and has not accepted the situation: Yes. Elopement Score: 8.0 Actioned clinical suggestions: [no actions indicated]. - A social services progress note dated 05/25/25, Resident will be transferred to [facility] today due to his need for a secured memory care unit. He will be transported there around 02:00 PM today. [Resident #1's family member ] is aware of this plan and that she can later transfer him to another facility later on if she wishes to. - A nursing progress note dated 05/25/25, d/c'd to another facility. Record review of Resident #1's Discharge summary dated [DATE] reflected:- discharge date : [DATE].- Expected return? No. - Released to other facility.- Reason for discharge: needs a secure memory care unit.- Final summary: Resident is transferring to [facility] a secured memory care unit.Review of Resident #1's discharge planning review record dated 05/25/25 reflected: Who initiated discharge? reflected was marked Facility.If facility, if this was a facility initiated discharge, was advance notice given (either 30 days or as soon as practicable on the reason of the discharge) to the resident, resident representative, and a copy to the Ombudsman; Did the notice include all the required components (reason, effective date, location, appeal rights, Ombudsman, ID, MI info as needed) and was it presented in a manner that could be understood; and if changes were made to the notice, were recipients of the notice updated? Signatures of facility staff on the document included SW and ADON A dated 05/25/25.In an interview on 06/25/25 at 11:16 AM with LVN C she stated she was the charge nurse working with Resident #1 on the day of the elopement on 05/25/25. She stated she was alerted by another nurse and other residents family members who provided a description of seeing a resident out of the facility that matched Resident #1. LVN C stated she then went out of the facility with CNA D to retrieve Resident #1. LVN C stated once they were able to locate Resident #1, he was no longer on the property, and was found down the street that leads up to the facility sitting in his wheelchair next to the main road. LVN C stated they were not sure which door Resident #1 exited from, and that he would frequently need redirecting from trying to leave through doors in other halls leading to the side of the building. LVN C stated if they saw Resident #1 trying to elope, they would attempt to redirect him, but was not aware of any other interventions in place to prevent elopement prior to the incident on 05/25/25. LVN C stated Resident #1 was a known elopement risk based on his care notes which documented each time he wandered and displayed exit seeking behavior. In an interview on 06/25/25 at 11:48 AM with CNA D, she stated she worked with Resident #1 on 05/25/25. She stated that she was alerted by LVN C that Resident #1 had eloped and went out with her to retrieve the resident. She stated they found Resident #1 away from the facility next to a busy road in his wheelchair. CNA D stated they were unsure which door Resident #1 used to leave the facility, but no alarms were heard. CNA D stated police were around, and police asked them (LVN C and CNA D) if Resident #1 was part of their facility; police then released Resident #1 back to them with no further questions. In an interview on 06/25/25 at 12:06 PM with ADON A, he stated he was at the facility on 05/25/25 and was notified of Resident #1's elopement by LVN C after the incident occurred. ADON A stated after Resident #1 was brought back to the facility he was placed on 1:1 until he was discharged later that same day. He stated he was previously aware of Resident #1's elopement risk for a while and they had been trying to get him to a secured facility the week prior but had no takers. He stated after the incident occurred that was when the ADM advised the SW to get him out of this facility and to another facility with a secured unit that day. ADON A stated Resident #1 was not appropriate for this facility and was constantly exit seeking. ADON A stated they should never have accepted him and that due to elopement risk and dementia they were not able to keep him safe. ADON A stated they presently had other residents with a diagnosis of dementia and will keep them as long as they don't try to reach for the door. ADON A stated after the incident they discharged Resident #1 to another facility within a few hours. In an observation and interview 06/25/25 at 01:04 PM with LVN E in the 200 hall (skilled nursing side); the door to the exterior was observed easily pushed open and not secured with the electromagnetic lock. The door alarm was functional and did sound as soon as the door opened. LVN E was observed closing the door and then pushing it open to test the magnetic hold on the door which was not holding allowing the door to easily swing open. LVN E was observed shouting down the hall to other staff telling them to push the button on the lock pad located at the nurse's station. This exchange occurred multiple times as they were observed to have difficulty getting the door to secure. LVN E stated staff were to check that the doors to the exterior were secured each shift. She stated a potential negative outcome of an unsecured door for residents that wander would be residents could get out and the road is right there, they can be harmed from a car or even from someone living at the apartment complex across the street; people are weird nowadays and you never know. In an observation and interview on 06/25/25 at 01:47 PM, observations were made of the exterior doors to the long-term care side of the facility with ADON B. The doors on halls 600 and 700 were observed unsecured when checked. Both doors were observed easily swinging open; no alarm was seen on the door or was heard sounding when the door opened. ADON B stated she was not sure why the doors were unlocked. ADON B was observed going to the nurses' station and pushing the button on the lock pad to secure the doors. ADON B was then observed going back to check the 600 and 700 doors appeared to be secured after pushing the button. ADON B stated she would investigate what occurred to cause the doors to not be secured. In an interview on 06/25/25 at 02:20 PM with ADON B, she stated it was identified the door was not securing because staff were pushing the incorrect button at the nurses' station and did not know the correct way to ensure the doors were locked. She stated the button to release the doors was being pressed instead of the button to secure the doors. She stated by pressing the button to release the doors, it causes all the doors on the long-term care side to be easily opened. ADON B stated she had to complete an in-service with staff to ensure they knew how to secure the doors now that this was identified and presented surveyor with in-service completed. Review of in-service record dated 06/25/25 presented by ADON B reflected topic educate on proper way to lock door. Key on button is to unlock door, round button is to lock door. Review of the facility Wandering and Elopement policy last revised March 2019 reflected: The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. - If identified as a risk of wandering, elopement, or other safety issues the resident care plan will include strategies and interventions to maintain the resident's safety. The Administrator was notified on 06/25/25 at 05:10 PM that an IJ had been identified and an IJ template was provided.The following POR was approved on 06/26/25 at 12:30 PM and reflected the following:Plan of RemovalImmediate Threat [Immediate Jeopardy] On 06/25/2025 an abbreviated survey was initiated at facility. On 06/25/2025 the surveyor provided anImmediate Threat (IT) [Immediate Jeopardy (IJ)] Template notification that the Regulatory Services has determined that thecondition at the facility constitutes an immediate threat to resident health and safety.The notification of Immediate Threat [Immediate Jeopardy] states as follows: F689 - The facility must ensure each resident receivesadequate supervision and assistance devices to prevent accidents.The facility failed to ensure Resident #1 did not exit the facility without staff's knowledge and ambulateapproximately 100 yards down their driveway to a busy street with a speed limit of 65 MPH on 05/25/25.Action: Resident was put on 1:1 service immediately with nursing staff member by facility DON and Admin until asafe placement at a secured facility could be located and resident transferred. All residents' elopement assessmentswere verified that they were up-to-date and that the elopement binders for at risk residents, at both nurse's stationsand the front reception desk, were up to date by Interdisciplinary Team (IDT) team. All exterior facility doors were audited by maintenance for functionality and changed door codes.Completion: 6/25/25On 06/25/2025 the Administrator notified the Medical Director of Immediate Jeopardy. On 06/25/2025,all exit doors throughout the facility were assessed for proper functioning.Action: Facility nursing staff have been re-educated on procedures to unlock and lock exit doors byADON. ADONs were in-serviced by Administrator. Admin was educated by Maintenance upon onorientation of start of position. (Maintenance was educated by prior company.) Any staff who are notworking will be re-educated prior to working their next shift. New staff will be educated on orientation.Any agency nursing staff will have to read and acknowledge the in-service on the staffing portal beforeshift acceptance. Comprehension will be verified by Admin/designee where staff will have to correctlyverbalize back how to properly lock and unlock the door. This will be recorded on the facility in-service log.Start Date: 6/25/25Completion Date: 6/25/25Responsible: AdministratorAction: Facility has placed directions to lock and unlock exit doors in nurse's binder at each nurse'sstationStart Date: 06/25/25Completion Date: 06/25/25Responsible: AdministratorAction: Door locks were tested and reactivated on all exit doors by maintenance on facility monitoringtool.Start Date: 06/25/25Completion Date: 06/25/25Responsible: MaintenanceAction: Facility Nursing Staff continue to check exit doors 3 times per shift to ensure the doors are secureusing facility monitoring tool and will be monitored by ADONs for completion.Start Date: 06/25/25Completion Date: 6/25/25Responsible: AdministratorAction: Maintenance checks facility doors once weekly to ensure exit doors have no maintenance issuespreventing them from securing with facility monitoring tool.Start Date: 06/25/25Completion Date: 06/25/2025Responsible: Maintenance SupervisorAction: The QA Committee will review door alarm logs weekly for 4 weeks, then monthly.Administrator/designee will conduct unannounced door security audits 2 x week for 30 days.Start Date: 06/25/25Completion date: 06/25/25Responsible person: Administrator/designeeThe POR was monitored on 06/26/25 in the following ways: Review of the documentation for door checks on Pods 2 of 2 (both skilled nursing and long term care side) reflected Doors codes have been changed for resident safety. Do not give the code to residents that should not have it. Do not give it to family members verbally in front of residents. Listen for the alarm. Alarm for front door is reset by a button at Pod 1. You are responsible for checking the doors at least 3 times per shift to make sure front door is secured as well as the doors to your pod. You must do these rounds. No exceptions. These can be done by a nurse or a CNA but must be signed off by whoever completes it. Each of the documents on Pod 1 and Pod 2 (skilled nursing and LTC side) were identified Door check log Pod 1 and Door check log Pod 2. It included a statement, you are responsible for checking all external exit doors on your Pod 3 times per shift as well as the front door 3 times per shift. It can be done by a CNA or nurse. Day shift and night shift. Record reflected it was logged with a date, time, and signature by staff multiple times a day beginning 05/25/25 and daily through 06/26/25.Review of an in-service sheet dated 06/25/25 presented by ADM/ IDT reflected to lock doors hit circle button, to unlock doors hit the key. Directions also in binder at both nurses' stations- competency: must verbally repeat back to educator. This included various staff from different positions including laundry, dietary, nursing, housekeeping, and admin staff such as MDS, marketing, activity director etc. Included both pods. 83 staff observed have either signed off physically or were marked as completed over the phone.Review completed with document dated 06/25/25 for door audits by maintenance all exit door locks were tested and reactivated with comments no issues with locks on doors signed by MTA.Record review of QAPI ad hoc dated 06/25/25 reflected: The locks for the facility door must always be engaged. To engage the locks follow these steps: - To unlock door push the button with the key emblem- To lock press the circle button - Residents with high elopement risks should not be outside of the facility without proper supervision and you can find the resident with high elopement risks in the elopement binders at both nurses station. If a resident is leaving the facility they need to sign out at the front desk.Document included attendance and signature by ADM, ADON A, medical director via phone, BOM, SW, MDS LVN, treatment nurse, admissions, human resources, and activity director. Record review of blank logs created for maintenance/designee for weekly audits of the door. check all exterior doors for any maintenance issues that would prevent them from securing. Created for ongoing audits. An observation and record review on 06/26/25 at 02:41 PM at nurses stations observed binders that contained instructions on locking the doors. Binder reflected How to lock/unlock doors- to unlock the doors press the button with the key emblem, to engage the locks press the circle button. A bright yellow document was also placed near the lock pads that reflected:Door locks- Doors should remain locked. If visitors buzz for entrance a staff member must walk to the front, open the entrance and verify they log into visitor log. - Locking access from the nurses station must be engaged. At any time if the button is pressed with key picture on it, it unlocks multiple doors. The round reset button must be pushed to relock the doors. - In other words, if you press the key button to unlock then you must hit the reset button to relock the doors. - Keeping the doors locked is not optional. In an interview and observation on 06/26/25 at 02:41 PM with LVN F she stated she arrived at 05:30 AM for her shift and was updated by the night shift nurse on the procedure to secure the door. LVN F stated she had already also received in-service via text 06/25/25 and had to verbalize understanding over how to secure the doors and elopements. She stated interventions other than redirection for residents who are exit seeking would include make sure exterior doors are closed and secured and check rooms to ensure you know where residents are at all times. She stated if residents are exit seeking they should also be moved closer to the nurses station for observation or placed on 1:1 care. She stated residents located in the elopement binders will get extra attention to ensure they are in their rooms or monitored while out of their rooms. LVN F stated a potential negative outcome in failing to supervise residents or failing to secure the doors would be this facility is near a highway and something bad could happen to them. LVN F was able to identify the abuse coordinator and also confirmed training on abuse and neglect. LVN F was observed locating the binder that contained information on securing the doors, as well as pressing the correct button to secure the doors . In an interview and observation on 06/26/25 at 02:50 PM with CNA G she stated she was an agency staff member but worked at the facility often. She stated she received in-service 06/25/25 and additional training 06/26/25. She stated the training covered ensuring the doors were secured, how to secure them, and elopements. She stated the training was provided to her by ADON B. CNA G stated she would be able to identify if the door is secured by the green light above the door near the magnetic strip. She stated if the light was green that would mean it was secured and that the door will also make noise if it was unsecured. CNA G stated anytime she was at the nurses station she has made it a habit to press the button to ensure the doors were secured. CNA G stated if a resident attempted to elope she would redirect them, provide them education, and would notify the charge nurse right away. CNA G stated she would find information on securing the doors in the binder located at the nurses station. She confirmed training on abuse and neglect and was able to identify the abuse coordinator as the ADM. CNA G was observed correctly demonstrating which button secured the doors. CNA G stated if she needed to identify who was an elopement risk she would look at the elopement binder located at the nurses station. In an interview on 06/26/25 at 03:02 PM with RN H he stated he was an RN charge nurse. He stated he received training on 06/25/25 via a text message on securing the doors/ elopements and was asked to let them know he understood the material. He stated on 06/26/25 he also observed the doors and was shown how to properly secure them. RN H stated if he witnessed exit seeking behavior he would redirect the resident that was exit seeking, keep them within view and safe distance from doors. RN H stated if anyone needed to identify someone who was an elopement risk they can do so by reviewing the elopement risk binder kept at the nurses station. RN H was able to successfully explain to surveyor the proper way to secure the door via the lock pad at the nurses station. In an interview on 06/26/25 at 03:08 PM with MA I, she stated she was both a medication aide and CNA. She stated she was in-serviced 06/26/25 by the ADONs on elopement and securing the doors (how to properly ensure they are secured). MA I stated if a resident shows exit seeking behavior she has been taught to give them distractions and redirect, provide them with activities, or give them food/snacks. MA I stated if a resident was able to get out she would notify the ADM immediately and ensure she was at the residents side at all times to ensure safety while they were redirected back. MA I confirmed she was also trained on abuse and neglect, and was able to identify the ADM as the abuse coordinator. MA I was able to successfully explain to surveyor the proper way to secure the door via the lock pad at the nurses station.In an interview on 06/26/25 at 03:16 PM with HK J he stated he received training 06/25/25 by MTA on ensuring that doors are secured at all times and not opened. HK J stated if he observed any door that was unsecured he would immediately report it to the ADM or MTA. HK J stated he has also received training on abuse and neglect and provided examples. He stated the abuse coordinator was the ADM. In an interview on 06/26/25 at 03:20 PM with MA K she stated she received training that covered elopements and the doors being secured. MA K stated she gets very involved in the care of the residents so when she received the text message with the inservice information she called and asked what happened, wanted to ensure she obtained all the information needed to prevent it from occurring again. MA K stated she was a seasoned employee and would often train others or let others know who was an elopement risk. She stated there was also an elopement binder at the nurses station if you wanted to see that information. MA K stated she was trained to always check the doors to the exterior to ensure they were secured. If a resident was exit seeking to monitor them, provide redirection, check on them more frequently, and provide activities or keep them entertained. MA K stated she was also observed by ADONs checking the door and working the keypad to demonstrate understanding. MA K was able to successfully explain to surveyor the proper way to secure the door via the lock pad at the nurses station.In an interview on 06/26/25 at 03:28 PM with CNA L, she stated she received training on elopements and door security on 06/26/25 by ADON A. She stated she would make sure the light above the door was green to ensure it was locked. She stated the doors need to be checked to ensure they are secured. CNA L was able to describe how to properly secure the door and how to redirect a resident who was an elopement risk. She stated if a resident was exit seeking, she would report it to the charge nurse immediately after redirecting and ensuring the resident was safe. In an interview on 06/26/25 at 03:32 PM with ADON A, he stated he remained at the facility late 06/25/25 in order to receive training presented by the ADM on door security. He stated after training was completed on department heads they then went back and provided training to their direct staff. He stated it was his expectation that the side doors are not to be used at all unless of an emergency. He stated he expected that staff were to check them frequently and ensure they were secured through observation of the green light above the door. ADON A stated if residents begin to show exit seeking behavior he would expect that an updated elopement assessment was completed, to document the behavior in the nursing progress notes and monitor it for 3 days and ensure they are moved to a more appropriate facility if they need to. ADON A stated it was his expectation that staff redirect residents, provide activities, or try snacks to distract them. He stated both new and agency staff will be oriented and in-service on the expectations on ensuring the doors are secured, how to secure them, and elopement procedures. In an interview on 06/26/25 at 02:41 PM with the FD , she stated she received training both 06/25/25 and 06/26/26 on elopements (what to do) and securing the doors (how to properly secure them). She stated the training was presented to her by the ADM. She stated she also had a book at the front desk that indicated which residents were an elopement risks and would have to refer to it to ensure none of them were able to get out. She stated she would also ensure that all residents were properly signed out if going on pass to ensure all residents were accounted for. FD was able to explain how to correctly secure the door and explained the importance of ensuring all visitors and residents entering and exiting from the front were logging in and documented. In an interview and observation on 06/26/25 at 03:49 PM with MTA, observations were made of all exterior doors to ensure they were secured, had a functional electromagnetic lock, and alarm. The doors that were previously unsecured were e confirmed secured. The MTA stated staff should ensure the doors remained secured through regular checks. He stated he also was to complete a weekly audit of the doors magnets to ensure they were functional and hold. The MTA stated only during a fire when the fire alarm is pulled should all the doors release. The MTA stated he had knowledge on the proper way to secure the doors and provided that information to the ADM and department heads so that they could train all staff and ensure they were pressing the correct button to secure the door. In an interview on 06/26/25 at 04:18 PM with the ADM, she stated she can confirm that all staff had received training on elopements and the proper way to secure a door/ ensuring they are secured. She stated they had staff confirm they understood the material through verbal confirmation. She stated education was provided to everyone across different areas to include nursing, housekeeping, dietary, etc. The ADM stated agency staff had a form on the portal that would provide them with education on these topics prior to working, and that her new hire staff will also have it as part of their orientation in the new hire packet. The Administrator was informed the immediacy was removed on 06/26/25 at 05:20 PM. The facility remained out of compliance at a scope of isolated at a severity level of no actual harm that was not immediate due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to ensure each resident had the right to be free from abuse for 1 (Resident #1) of 5 residents reviewed for abuse. The facility failed to ensure Resident #1 was safe from sexual abuse. On 02/27/24, Resident #1 alleged she was sexually assaulted, facility staff transferred her to the hospital, and hospital staff took a sexual assault exam. On 04/16/24, the sexual assault exam results showed a presence of semen in Resident #1's brief and on and in her vagina. An IJ was identified on 05/10/24. The IJ template was provided to the facility on [DATE] at 6:24 p.m. While the IJ was removed on 05/13/24, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm because of the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk for injury, harm, psychosocial harm, and a decreased quality of life. Findings included: Record review of Resident #1's face sheet, dated 04/18/24, revealed a 73-years old female who was admitted to the facility on [DATE], readmitted on [DATE], had an RP, and had diagnoses including unspecified dementia (A group of thinking and social symptoms that interferes with daily functioning) that was mild, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, unspecified sequelae of cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), generalized anxiety disorder, contracture (A permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff) of muscle unspecified lower leg, difficulty in walking, unspecified single episode unspecified major depressive disorder, other reduced mobility, right and left knee contracture, weakness, unspecified altered mental status, cognitive communication deficit, and generalized muscle weakness. Record review of Resident #1's quarterly MDS assessment, dated 04/08/24, revealed a BIMS score of 7, indicating she had severe cognitive impairment. Record review of Resident #1's comprehensive care plan, dated 04/16/24, revealed she was at risk for psychosocial deficits/PTSD related to trauma (sexual assault). Interventions included: female only to provide care, female staff to accompany if male nurse on shift, services from a Licensed Mental Health Provider as indicated, monitor for signs and symptoms of depression, anxiety, eating disorders, sleep disturbances, and substance abuse disorder, psych services visit routinely, staff assist with recovery and avoid traumatization by ensuring immediate safety and addressing physical injuries resulting from the assault, providing medical care, including forensic evidence collection, in a sensitive manner and prioritizing well-being and minimizing further harm, and creating a safe environment for disclosure. Record review of Resident #1's progress notes revealed a note by RN C on 02/27/24 at 8:51 p.m., Resident complained of vaginal pain. Assessed residents peri area. No skin tears, bleeding nor lacerations noted. Hyperpigmentation noted (baseline) with redness from moisture of incontinence. ADON, family aware.' A note by RNC on 02/27/24 at 8:55 p.m., Entered resident room with officer for interview. Family in process of bathing resident. Family instructed to refrain from completing bath until investigation completed related to resident allegation of sexual assault. Interview completed by the officer. EMS contacted for transport for further assessment. A note by RNC on 02/27/24 at 9:55 p.m., Resident transported by EMS. Family awaiting resident at hospital. A note by ADON on 02/27/24 at 11:43 p.m., CNA alerted [ADON] that Resident #1 expressed allegations of sexual assault. Notified ADM and RDO. Law enforcement contacted; family present at time of allegation.; resident currently at hospital for further evaluation. A note by ADON on 02/28/24 at 7:07 p.m., Received nurse to nurse report from Hospital staff at 1907 (7:07 p.m.). According to the report, Resident #1 was clear of signs of sexual assault. Family and resident stated they are comfortable and feel safe related to resident returning to facility. Per report received, Resident #1 has no current complaints of pain or distress, and will be returning to the facility before 8:00 p.m. No new orders expected for Resident #1 post hospital admission. Care plan to continue. Administrator notified; RNC notified. Record review of Resident #1's POC history, from 02/24/24 through 02/27/24, revealed all CNAs who provided ADL care to Resident #1 were female except CNA A, who was a male, provided support to Resident #1 for bed mobility and supervised Resident #1's toileting on 02/26/24 at 4:56 a.m., and observed Resident #1's level of control with bowel and bladder function on 02/26/24 at 5:02 a.m. Record review of Resident #1's vital checks, from 02/26/24 through 02/28/24, revealed all staff who checked and documented vitals taken from Resident #1 were female. Record review of Resident #1's MAR and TAR, from 02/24/24 through 02/27/24, revealed all female staff worked with Resident #1. Record review of the facility's staff schedule, from 02/24/24 through 02/28/24, revealed all female staff worked on the hallway Resident #1 resided on. Record review of the facility's sign in and out sheet, from 02/20/24 through 02/27/24, revealed Resident #1's RP visited her on 02/20/24 at 8:30 p.m., 02/21/24 at 9:53 p.m., 02/23/24 at 2:18 p.m., 02/24/24 at 8:00 p.m., and 02/27/24 at 7:00 p.m. Resident #1's family member also visited her on 02/23/24 at 2:18 p.m. and 02/27/24 at 7:00 p.m. Resident #1 had no other visitors listed. Record review of the facility's provider investigation report, undated, revealed Resident #1 alleged the abuse incident occurred on 02/27/24 at an unknown time in her room. The facility self-reported the incident on 02/27/24 at 8:49 p.m. There was no alleged perpetrator and witnesses listed. The investigation summary stated, On 02/27/24, Resident #1 told CNA B and RP that she had been raped by two men. CNA B notified the ADON and the ADON went and spoke further to Resident #1. Resident #1 at this time told the ADON that it was 2 men, 1 light skinned and 1 dark skinned, but that she did not know what time it happened at. Resident #1 was asked if she wanted to go to the hospital for further examination and Resident #1 at this time stated no. RN C did complete assessment and nothing from baseline noted. Once PD arrived, Resident #1 did give more information to officers with RN C present. When asked what occurred, Resident #1 stated that 1 guy came in and was talking dirty to her and a 2nd man came in and they were talking. Resident #1 was asked what happened next and she stated that one turned her on her side and put his penis inside her, Resident #1 also stated both had put their penis inside her but it did not hurt and they got busy but not too fast. When asked for a description of the men, Resident #1 stated 1 was a little guy, light skinned in his 20's and the other was a big guy dark skinned in his 30's. When asked if they worked here at the facility, Resident #1 stated no. When asked if they were wearing scrubs or regular clothes, Resident #1 said regular clothes. Resident #1's room was located near nursing station 2 close to the nurses station and staff on pod 2 were interviewed by the ADON and staff did not see anyone with the description that was given on the two males. After interview with Resident #1, staff assisted with placing brief and hospital gown and RP left to meet Resident #1 at the hospital. Resident #1 was transferred to the hospital for further evaluation and a SANE exam. The ADON spoke to a hospital staff member, who stated Resident #1 was clear of signs of sexual assault, RP and Resident #1 stated to the ADON that they felt safe at the facility. Resident safe surveys were completed for all female residents on 02/27/24 and revealed all residents indicated they never been inappropriately touched in the facility, never seen anyone being inappropriately touched in the facility, knew who to report abuse and neglect to, and felt safe living at the facility. Staff in-services were also initiated by the ADON on 02/27/24 and revealed staff were retrained on abuse and neglect reporting and preventing. MD and Ombudsman were also notified on 02/27/24. The investigation findings were unfounded. Staff statements attached to the report revealed ADON interviewed four CNAs on the evening of 02/27/24, who were all female, and all other staff who worked on the hallways in which Resident #1 resided on and was near, which revealed they did not witness any males matching Resident #1's description of the two alleged perpetrators. RNC and a PD officer also interviewed Resident #1 with RP present on 02/27/24 at 8:55 p.m. RP was bathing her even though they were instructed not to bathe Resident #1. RP indicated they did not bathe any of Resident #1's private areas, only her top half. Statement given by Resident #1 in response to questions by PD officer were also attached and stated the following: Can you tell me what occurred? 1 guy came into room and was talking dirty to me. A 2nd man came in and they were talking. Do you know if they work here? they said they don't work here What happened next? one turned me [Resident #1] on my side and put his penis inside me Did both men put their penis in you? yes, it didn't hurt and they got busy but not too fast Did they finish? I think so Do you think they were wearing a condom? I don't know Were they wearing scrubs or regular clothes? regular clothes When did this occur? this afternoon Was it before or after your roommate left? after Can you describe them? 1 was little guy, light skinned. 1 was big guy dark skinned Do you know what age they appeared? little guy 20's, big guy 30's How was their hair? poofy During an interview on 03/08/24 at 1:27 p.m., Resident #1 revealed a tall dark-skinned male and short light-skinned male came into her room and sexually assaulted her. Resident #1 could not recall what the alleged perpetrator(s) wore and if they were visitors or staff. Resident #1 stated there were no staff in her room and her roommate was not in her room around the time of the incident. Resident #1 also stated staff last checked on her on 02/27/24 at 3:00 p.m Resident #1 could not remember the nurse or nurse aide who checked on her on 02/27/24 at 3:00 p.m. Resident #1 stated she never been sexually assaulted at the facility in the past. Resident #1 also stated she felt safe at the facility at the time of the interview. Resident #1 stated she had no concerns or issues about how staff handled the incident. Resident #1 also stated staff checked on her often. Resident #1 also stated her RP was notified of the incident. The interview was stopped because Resident #1 began to cry and was unable to answer any additional questions. An observation of the front entrance on 04/18/24 at 9:05 a.m. revealed the front entrance doors automatically opened by motion sensors. The inside of the front entrance had a keypad. The receptionist was not at the front desk. There was a camera mounted on one of the walls in the front entrance area that was blinking a green light and angled at the front entrance doors. There was a sign in and out sheet that visitors were signing before entering further into the facility. During an interview on 04/18/24 at 9:26 a.m., the ADM revealed the hospital notified staff that they did not find any results of sexual assault on Resident #1 on 02/27/24. The ADM explained the hospital staff swabbed Resident #1 and sent the sexual exam kit to the crime lab to be examined on 02/27/24. The ADM went on to explain that due to the delay in lab results because of the state's backlog, the PD received and notified the facility of the semen found in and on Resident #1 and in Resident #1's brief on 04/16/24. The ADM stated staff initiated resident safety surveys, trauma assessment on Resident #1, employee questionnaires, and in-services on abuse again after PD's notification of the sexual assault exam results. The ADM also stated a Quality Assurance meeting was arranged to discuss interventions to implement after the PD's notification of the sexual exam results in addition to the interventions implemented after Resident #1 reported the allegation on 02/27/24. The ADM also stated staff revised Resident #1's care plan to reflect Resident #1 would receive care and services from female-only caregivers. The ADM stated Resident #1's roommate told her that she felt safe at the facility, did not see anything, and did not see anything happen to Resident #1 on 02/27/24. The ADM also stated all female staff worked with Resident #1 on the day of the incident (02/27/24). The ADM stated while there were cameras in the area near Resident #1's room, the cameras were aimed at the nursing station and did not record because they were set to stream live feed. The ADM also stated staff interviewed Resident #1 again after the PD's notification of the sexual exam results, who had a similar recollection of the incident as compared to her recollection on 02/27/24. The ADM stated Resident #1 was not at the facility because the MD recommended to send her to the hospital again for another DNA test collection after staff notified the MD of the sexual assault exam results. The ADM stated Resident #1's RP initially did not want Resident #1 to go to hospital again, did not explain why and later agreed to send Resident #1 to the hospital because they did not want staff to document that they were refusing to seek medical attention for Resident #1 on 04/17/24. Her and staff did not know if Resident #1 provided another DNA sample at the hospital on [DATE] and hospital staff did not inform them if Resident #1 agreed to provide another sample. The ADM stated the PD informed her that all male staff except three male staff members volunteered to provide a DNA sample, did not indicate who were the three male staff who refused to volunteer, and there were three male staff who were unable to provide their DNA sample until 04/19/24. The ADM stated Resident #1's RP and a male family member were in Resident #1's room on 02/27/24. The ADM explained the RNC and PD observed Resident #1's RP showering Resident #1 on 02/27/24, stopped the RP from showering Resident #1, and explained to the RP that they needed to collect a sample of Resident #1's DNA. The ADM went on to explain the RP told staff that she continued to shower Resident #1 because she wanted Resident #1 to feel clean. During an interview on 04/18/24 at 10:24 a.m., Resident #1's RP revealed Resident #1 has been at the hospital since 04/17/24. RP questioned why she was not directly notified by the State Agency of Resident #1's incident, why the State Agency did not wait for the PD's sexual exam results before unsubstantiating Resident #1's allegations during the surveyor's initial visit on 03/08/24, and alleged the facility refused to provide her with their policies and procedures and investigation of the incident. When an attempt to ask the RP questions about her and a male family member visiting Resident #1 on the day Resident #1's alleged she was sexually assaulted on 02/27/24 was made, the RP stated that she was not in the mental state to answer any questions, was dealing with a lot, stated that she might be in a better headspace around 2:00 p.m. or 3:00 p.m. and advised to call back around 2:00 p.m. or 3:00 p.m. because she had questions to ask and to answer questions. RP abruptly ended the call because she was receiving another call. During an interview on 04/18/24 at 11:41 a.m., RNC revealed Resident #1's roommate left to the hospital on [DATE] at 3:30 p.m. RNC stated she informed the ADON to inform Resident #1's RP not to bathe Resident #1 after Resident #1 reported her allegation to staff and to have a nurse assess Resident #1 on 02/27/24. RNC also stated her, and the PD walked into Resident #1's room and observed Resident #1 lying in bed, undressed and being bathed by RP. RNC stated there was a male family member also present in Resident #1's room at the time. RNC explained Resident #1's RP told her and the PD that she was informed by the ADON not to bathe Resident #1 but continued to bathe Resident #1 because she wanted Resident #1 to feel clean. RNC explained Resident #1's RP was also adamant about Resident #1 not going out to hospital before the PD arrived at the facility on 02/27/24 and Resident #1 agreed to go to the hospital after the PD directly asked her if she wanted to go. During an interview on 04/18/24 at 12:15 p.m., RNC revealed a male family member visited Resident #1 a few times. RNC did not know if the three staff members worked in the facility after PD notified them of Resident #1's sexual assault exam results and if there have been any positive matches from the DNA samples collected. During an interview on 04/18/24 at 12:22 p.m., the ADM revealed she had not received any notifications from the PD regarding any positive matches from the DNA samples collected. During an interview on 04/18/24 at 12:31 p.m., the ADON revealed she could not remember who the CNA was who notified her of Resident #1's allegation and if she were the first person the CNA notified on 02/27/24. The ADON also revealed RN C might have been the staff member who notified her of Resident #1's allegation on 02/27/24 between 8:20p.m. and 8:30 p.m. The ADON explained she entered Resident #1's room and observed Resident #1's RP and a male family member in the room before RP began to give Resident #1 a shower. The ADON stated she informed Resident #1's RP not to shower Resident #1 because a nurse needed to assess Resident #1, the PD were on their way to interview Resident #1, and Resident #1 was going to be sent to the hospital for an evaluation. The ADON stated Resident #1's RP continued to give a bed bath to Resident #1 despite being told to wait. The ADON expressed something did not sit right with her about the male family member who was in Resident #1's room because she observed him linger while Resident #1's brief was changed. The ADON explained the male family member normally stepped out the room when incontinent care took place. The ADON explained she asked the male family member if he wanted to step out the room and the male family member stayed in there, did not explain why and stated, No I'm good. The ADON further explained the male family member also never hung around Resident #1's bed until 02/27/24. During an interview on 04/18/24 at 12:35 p.m., the ADM clarified four male staff have not provided a DNA sample because they were not working on the day the initial sample was collected and were scheduled to provide a sample on 04/19/24. During an interview on 04/18/24 at 12:41 p.m., the ADM revealed no male staff worked at the nursing station near Resident #1's room because the facility did not have many male staff and after PD notified them of the sexual assault exam results. The ADM stated she was not present when Resident #1 reported the allegation on 02/27/24. The ADM expressed she thought it was odd Resident #1's RP was not upset on 02/27/24, was adamant about not wanting Resident #1 to go to the hospital on [DATE] and told her that Resident #1 would not have been sent to the hospital again if she (ADM) had been at the facility on 04/17/24. During an interview on 04/18/24 at 1:06 p.m., RNC revealed it struck her odd Resident #1's RP continued to bathe Resident #1 despite staff telling her not to because Resident #1's POC (Resident records) revealed staff showered Resident #1 earlier in the day of 02/27/24. RNC also stated it struck her odd that Resident #1's RP did not initially want Resident #1 to go to the hospital on [DATE]. During an interview on 04/18/24 at 2:27 p.m., CNA B revealed on 02/27/24 during the 2:00 p.m. through 10:00 p.m. shift, she checked on and asked Resident #1 if she was doing okay, Resident #1 told her no, she asked Resident #1 why, Resident #1 told her that she had been raped, and she asked Resident #1 who sexually assaulted her, and Resident #1 told her two Black males. CNA B also stated Resident #1's RP and the male family member were not in room at the time Resident #1 alleged she was sexually assaulted. The can explained she immediately went to the ADON and reported Resident #1's allegation before dinner time, (CNA B indicated dinner time was between 5:00 p.m. and 6:00 p.m.). CNA B went on to explain her and CNA D performed incontinent care on Resident #1 after Resident #1 finished eating dinner. CNA B stated she observed Resident #1 was not wet during incontinent care. CNA B also stated Resident #1's RP and the male family member came in Resident #1's room [ROOM NUMBER] minutes after her and CNA D finished performing incontinent care on Resident #1. CNA B stated she was in the room when Resident #1's RP asked Resident #1 how she was doing, and Resident #1 told her RP that she had been raped. CNA B stated Resident #1's RP knew Resident #1 was confused and asked Resident #1 if she really got raped. CNA B could not remember if Resident #1's RP then went to look for the ADON or asked her to bring the ADON to her. CNA B explained she was at the nursing station with RN C when the male family member came and stated nobody could have touched Resident #1 because Resident #1's legs would have been broken. CNA B stated the ADON had RN C assessed Resident #1. CNA B could not remember if Resident #1's RP proceeded to bathe Resident #1 before or after RN C assessed Resident #1. CNA B stated the PD might have not stopped Resident #1's RP from finishing Resident #1's bath. CNA B stated she observed the male family member bringing Resident #1's RP bath supplies while the RP bathed Resident #1. CNA B explained she was not in the room when Resident #1's RP bathed Resident #1. CNA B stated she had never seen the male family member prior to 02/27/24. An attempt to contact Resident #1's RP was made on 04/18/24 at 3:12 p.m. A voicemail and call back number. Resident #1's RP did not return the call prior to exit. An attempt to contact the PD was made on 04/18/24 at 4:02 p.m. A voicemail and call back number was left. During an interview on 04/18/24 at 4:09 p.m., the ADM revealed PD asked to review the facility's video cameras aimed at the nursing station. The ADM explained PD were unable to review the video cameras because the cameras streamed live feed and did not record. The ADM stated she discussed with Resident #1's RP about Resident #1's right to install a camera in her room for video monitoring if Resident #1's roommate consented, managers conducted daily rounds and asked residents if they felt safe at the facility, and all female residents were interviewed on 02/27/24 and 04/17/24. The ADM also stated the receptionist desk had a visitor sign in and out sheet that was implemented before the alleged incident on 02/27/24. An attempt to contact RN C was made on 04/18/24 at 4:24 p. m. A voicemail and call back number was left. RN C did not return the call prior to exit. An observation of the front entrance on 04/19/24 at 9:20 a.m. revealed the receptionist was not at the front desk. There was also a sign in and out sheet that visitors were signing before entering further into the facility. During an interview on 04/19/24 at 9:28 a.m., the PD revealed she had the hospital conduct the SANE exam on Resident #1 on 02/27/24. The PD stated Resident #1's recollection of her allegation on 04/17/24 was the same as what she informed PD on 02/27/24. The PD also stated Resident #1's SANE exam found Resident #1 had semen in her vagina, on her vagina, and in her brief. The PD stated Resident #1's family told them that Resident #1 did not go out on pass and never left the facility since her readmission on [DATE]. The PD also stated all male staff except three agreed to volunteer in providing and testing their DNA to rule them out as the alleged perpetrator(s). The PD explained of the three staff who denied, two staff did not explain why they did not want to volunteer and one denied due to personal and political beliefs. The PD stated there were three male staff who were going to give a sample of their DNA on 04/19/24 because they were not in the facility when the initial sample collection was taken. The PD also stated they were waiting on Resident #1's second DNA sample to be tested and determine if the semen belonged to more than one male. The PD stated the Maintenance Director informed her that there was no camera footage to review because the cameras streamed on a live feed and did not record. The PD also stated Resident #1's RP told her that she was willing to send Resident #1 to the hospital on [DATE] after she was notified of Resident #1's SANE exam results. The PD was unable to provide a copy of the SANE exam results because Resident #1's criminal investigation was ongoing. The PD informed the surveyor that they would email the surveyor a confirmation that they reviewed Resident #1's SANE exam and the results were positive. Record review of an email from the PD, dated 04/19/24 at 10:30 a.m., revealed the following, Hello, I am the Detective who's assigned the case pertaining to [Resident #1]. During our investigation, swabs from [Resident #1's] sexual assault exam were sent to the Crime Lab and came back with the presence of semen being positive in her vaginal swabs and in the crotch of her [brief]. Our investigation will remain open, and we will continue our investigation until the suspect/suspects are found. During an interview on 04/19/24 at 11:23 a.m., the ADM revealed residents and residents' family/RP had the keypad code for the front entrance. The ADM explained there were no restricted visiting hours because residents have the right to have visitors whenever they wanted. The ADM further explained the front entrance doors remained unlocked during the hours the receptionist occupied the front desk and were locked outside the receptionist's hours. During an interview on 04/19/24 at 11:28 a.m., the Receptionist revealed she worked Monday through Friday from 8:00 a.m. through 5:00 p.m. The Receptionist stated there were managers on duty who worked during the weekends at the front desk. The Receptionist also stated the front entrance door was locked outside her working hours. The Receptionist explained visitors would use the intercom system, which notified the nursing stations when there was a visitor and the nursing station had access to unlock the front door entrance. The Receptionist further explained residents and residents' family/RP also had the keypad code to unlock the front entrance door. During an interview on 04/19/24 at 11:35 a.m., CNA D revealed she never had a resident allege they were sexually abused. CNA D stated she reported to a nurse or the ADM if she received any reports related to abuse. CNA D stated she checked on residents every two hours. CNA D stated she never worked with Resident #1. CNA D also stated she never popped into a resident's room whenever residents' had family/RP in the room because she tried to give them space, but she did pop in to ensure residents were doing okay. CNA D did not know if the cameras aimed at the nursing station near Resident #1's room worked. CNA D stated the front entrance door had an intercom system that notified staff at the nursing station if there were visitors outside normal business hours. An observation of the nursing station near Resident #1's room on 04/19/24 at 11:40 a.m. revealed there were two cameras mounted and aimed at the nursing station. There were also three staff occupying the nursing station. During an interview on 04/19/24 at 11:42 a.m., CNA E revealed she never had a resident allege they were sexually abused. CNA E stated she reported to human resources if she received any reports related to abuse. CNA E stated she checked on residents every two hours. CNA E stated she worked with Resident #1 and Resident #1 never reported abuse to her. CNA E also stated she had only seen Resident #1's RP visit and in Resident #1's room. CNA E explained she has never seen a male visit Resident #1 or in Resident #1's room. CNA E stated she popped into residents' rooms whenever residents' family/RP were in the room. CNA E did not know if the cameras aimed at the nursing station near Resident #1's room worked. CNA E stated the front entrance door had an intercom system that notified staff at the nursing station if there were visitors outside normal business hours. During an interview on 04/19/24 at 11:49 a.m., CNA F revealed she worked at the facility for one month. CNA F stated she never had a resident allege they were sexually abused. CNA F also stated she reported to the ADM if she received any reports related to abuse. CNA F stated she checked on residents in their rooms every two hours. CNA F did not know if the cameras aimed at the nursing station near Resident #1's room worked. CNA F also stated the front entrance door had an intercom system that notified staff at the nursing station if there were visitors outside normal business hours. During an interview on 04/19/24 at 11:55 a.m., Resident #2 revealed she was Resident #1's roommate. Resident #2 stated she often observed Resident #1 scream all night and staff did not see or check on her or Resident #1. Resident #2 stated Resident #1 told staff someone came, pulled her clothes down and raped her. Resident #2 could not remember what day Resident #1 told staff about the incident. Resident #2 stated Resident #1 started telling her about the rape two weeks ago. Resident #2 stated Resident #1 never told her who raped her. Resident #2 also stated Resident #1's RP and a male family member visited Resident #1. Resident #2 stated she did not observe anything happen to Resident #1 because she often went out the room. Resident #2 stated she never observed any males come into her and Resident #1's shared room other than the male family member who visited Resident #1. Resident #2 also stated she never observed any male residents come into her and Resident #1's shared room. During an interview on 04/19/24 at 12:12 p.m., Charge Nurse G revealed she never had a resident allege they were sexually abused. Charge Nurse G stated she also has never seen any male caregivers work in the hallways or nursing station near Resident #1's room. Charge Nurse G also stated she reported to the ADM if she received any reports related to abuse. Charge Nurse G stated she checked on residents in their rooms every two hours. Charge Nurse G also stated she had CNAs round when they first come in and start their shifts, during their shifts, and just before the end of their shifts. Charge Nurse G stated there were no gaps in staff coverage. Charge Nurse G also stated she never observed visitors in Resident #1's room. Charge Nurse G did not know if the cameras aimed at the nursing station near Resident #1's room were in operable condition. Charge Nurse G stated the front entrance door had an intercom system that notified staff at the nursing station if there were visitors outside normal business hours and staff had access from the nursing station to unlock the front entrance door. During an interview on 04/19/24 at 12:13 p.m., Charge Nurse H revealed Resident #1 alleged on 04/17/24 that she was sexually assaulted by two white men and explained that one male fingered her, and the other male watched. Charge Nurse H stated Resident #1 had an altered mental status. Charge Nurse H also stated she had never seen any male caregivers work on the hallways or nursing station near Resident #1's room. Charge Nurse H stated she reported to the ADM if she received any reports related to abuse. Charge Nurse H stated she checked on resident in room every two hours. Charge Nurse H stated she had CNAs round when they first come in and start t[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that the residents' environment remained as free of accident hazards as was possible in 6 (room [ROOM NUMBER], 504, 506, 701, 707, and 801) of 38 resident room sinks and 1 (600 Hall Shower) of 2 resident shower rooms reviewed for hot water in the facility's 500 - 800 hallways. The facility failed to maintain resident use hot water at safe and comfortable temperatures (between 100-110). Resident use hot water was not reliably controlled and ranged from between 117.1 F and 145.0 F in reviewed locations. These failures resulted in an Immediate Jeopardy (IJ) situation on 03/12/2024. While the IJ was removed on 03/13/2024 the facility remained out of compliance at a severity level of no actual harm at a scope of pattern due to staff needing more time to monitor the plan of removal for effectiveness. This failure could place residents at risk for sustaining scalding injuries when using resident-use / resident accessible hot water. Findings included: Review of Resident #73's Face Sheet dated 02/21/2024 reflected that she was admitted to the facility on [DATE] with the following diagnosis: NSTEMI (less severe form of a heart attack because it inflicts less damage to the heart) and Dementia (impaired ability to remember, think, or make decisions that interfere with doing everyday activities). Review of Quarterly MDS Assessment for Resident #73 dated 11/18/2023 reflected a BIMS score of 9 indicating moderate cognitive impairment. Review of Resident #68's Face sheet dated 02/22/2024 reflected that he was admitted to the facility on [DATE] with the following diagnosis: Vascular Dementia (problems with reasoning, planning, judgement, memory and other thought processes caused by brain damage from impaired blood flow to the brain), Acute Congestive Heart Failure (the heart is beating but cannot deliver enough oxygen to meet the body's needs). Review of the Annual MDS Assessment for Resident #68 dated 10/29/23 reflected a BIMS score of 15 indicating normal cognitive abilities. His physical assessment reflected he was independent in performing all his ADLs. Observation on 02/21/2024 at 7:38 AM, the hot water from the sink in room [ROOM NUMBER], which was occupied by Resident #73 was checked with a digital thermometer and found to be 130.5 F. Observation on 02/21/2024 at 8:43 AM, the hot water from the sink in room [ROOM NUMBER], which was occupied by Resident #68 was checked with a digital thermometer and found to be 145.0 F. Observation on 02/21/2024 at 9:50 AM, the hot water from the sink in room [ROOM NUMBER] was checked with a digital thermometer and found to be 137.3 F. Observation on 02/21/2024 at 9:53 AM, the hot water from the sink in room [ROOM NUMBER] was checked with a digital thermometer and found to be 117.1 F. The shower head in the room was also checked and found to be 133.5 F. Observation on 02/21/2024 at 9:55 AM, the hot water was checked in the 600-hallway shower room at the shower head with a digital thermometer and found to be 133.5 F. Interview and observation on 02/21/2024 from 10:10 AM until 10:43 AM with the facility's Maintenance Director. The Maintenance Director stated that they want to maintain a safe water temperature in the facility of between 107 F and 110 F. The Maintenance Director stated that they perform water temperature tests of three to four random rooms and try to do so daily or at least every other day. The Maintenance Director stated that if the reading does show high they do not adjust the boiler immediately because the temperatures can fluctuate but will make adjustments if it becomes a pattern and at temperatures of 115 F and above. The Maintenance Director stated that elevated water temperatures could result in skin burns to residents but was not able to state to what degree and exposure time required. The Maintenance Director stated that the facility has two boilers for resident rooms in the 500 - 800 hallways. The Maintenance Director showed Surveyor the mechanical room with the two boilers for the 500 - 800 hallways. Boiler 1 displayed a digital tank temperature of 136 F and a set point (The temperature of the thermostat in order to maintain the desired temperature) of 149 F. Boiler 2 displayed a digital tank temperature of 135 F and a set point of 150 F. The thermometer past the hot water regulator for resident rooms displayed 136 F. The Maintenance Director stated that they have had some issues with the 500 - 800 boilers, which is why their set points are high. The Maintenance Director stated that the amount of hot water that is pushed into the system is controlled by an adjustable regulator past the boilers. The Maintenance Director stated that when they do their water temperature test in the rooms they do so with a digital thermometer and leave it under the water until the temperatures stops increasing. room [ROOM NUMBER] sink hot water was tested and displayed 137.0 F, which was verified with Surveyor's thermometer that displayed 137.4. room [ROOM NUMBER] sink hot water was tested and displayed 136.0 F. room [ROOM NUMBER] sink hot water was tested and displayed 137.8 F. room [ROOM NUMBER] sink hot water was tested and displayed 130.8 F. The Maintenance Director stated that he was going immediately to adjust the regulator for the 500 - 800 hallways to lower the temperatures and would continue to monitor. In an interview on 02/21/2024 at 11:37 AM, the Administrator stated that they wanted water temperatures to be between 106 F and 109 F. The Administrator stated that elevated water temperatures could result in a resident's skin being burned. At 12:00 PM, the ADMINISTRATOR stated that to her knowledge no resident had been burned by hot water during her time in the facility but told Surveyor to speak with the ADON who has worked in the facility longer. In an interview on 02/21/2024 at 12:04 PM, the ADON stated that elevated water temperatures in resident rooms could result in skin burns. The ADON stated that she had been with the facility for over three years and that no resident during that time had sustained a skin burn due to hot water. Observation on 02/21/2024 at 4:49 PM, the hot water from the sink in room [ROOM NUMBER] was checked with a digital thermometer and found to be 123.1 F down from 137.3 at 9:50 AM. Observation on 02/21/2024 at 4:55 PM, the hot water from the sink in room [ROOM NUMBER] was checked with a digital thermometer and found to be 124.7 F down from 137.0 F at 10:32 AM. Observation on 02/22/2024 at 9:37 AM, the hot water from the sink in room [ROOM NUMBER] was checked with a digital thermometer and found to be at 108.3 F and the shower head at 107.2 F. Interview and Observation on 02/22/2024 at 9:55 AM, the Maintenance Director stated that the facility boilers were now being adjusted via the tank settings and not by way of the regulator. Hallway 500 - 800 tank 1 now displayed a temperature of 115 F and a set point of 123 F. Hallway 500 - 800 tank 2 now displayed a temperature of 119 F and a set point of 125 F. The temperature after the regulator now displayed 110 F. Observation on 02/22/2024 at 5:42 PM, the hot water was checked in the 600-hallway shower room at the shower head and displayed a temperature of 100.6 F. Observation on 02/22/2024 at 5:49 PM, the hot water from the sink in room [ROOM NUMBER] was checked with a digital thermometer and found to now be at 116.6 down from 145.0 F on 02/21/2024 at 8:43 AM. Observation on 02/22/2024 at 7:01 PM, the hot water from the sink in room [ROOM NUMBER] was checked with a digital thermometer and found to now be at 110.5 F and 94.6 F at the shower head. Review of facility water temperature log indicated the following recorded dates and room hot water temperatures in Fahrenheit. February 13, 2024, Rooms 712 at 110, 710 at 112, 708 at 113, and 604 at 112. February 16, 2024, Rooms 604 at 109, 602 at 104, and 712 -at 110, February 16, 2024, Rooms 713 at 110 Review of facility's Maintenance Manual for 2024, dated November 2023 revealed, Maintenance Checklist, Daily Tasks 4. Test water temperatures on a different resident room each day and update log. TEST WATER TEMPERATURE: Test (4) different rooms each day, Ensure patient room water temperatures are between 100 to 110 degrees Fahrenheit, Check resident rooms at the end of each wing on a rotating basis, Let the water run for a least three minutes before taking your reading. Record Results in the Water Temperature Log: Note any discrepancies, Adjust water heater settings as required, Retest as necessary. Review of the facility's Grievance log did not reveal any complaints of water temperature being too hot. Review of facility's incident and accidents did not reveal any injuries to residents due to hot water. Review of the current undated American Burn Association Scald Injury Prevention Educator's Guide provided the following information: .although scald burns can happen to anyone, .older adults and people with disabilities are the most likely to incur such injuries .High Risk groups .Older Adults .Older adults, .have thinner skin so hot liquids cause deeper burns with even brief exposure. Their ability to feel heat may be decreased due to certain medical conditions or medications so they may not realize water is too hot until injury has occurred. Because they have poor microcirculation, heat is removed from burned tissue rather slowly compared to younger adults . People With Disabilities or Special Needs .Individuals who may have physical, mental or emotional challenges or require some type of assistance from caregivers are at high risk for all types of burn injuries including scalds sensory impairments can result in decreased sensation especially to the hands .so the person may not realize if something is too hot. Changes in a person ' s perception, memory, judgment or awareness may hinder the person ' s ability to recognize a dangerous situation .or respond appropriately to remove themselves from danger . Further review of the Guide revealed that 100-degree F water was a safe temperature for bathing. Water at 120 degrees F would cause a third-degree burn (full thickness burn) in 5 minutes and 124 degrees F water would cause a third-degree burn in 3 minutes. The Guide further documented that water at 127 degrees F caused third degree burns in 1 minute, 133 degrees F in 15 seconds, and 140 degrees F in 5 seconds. The Administrator was notified of the Immediate Jeopardy on 03/12/2024 at 11:51 AM and the IJ template was provided. The Administrator expressed understanding of the Immediate Jeopardy and a Plan of Removal was requested. The Plan of Removal was approved as follows: SURVEY TYPE: Annual Survey SURVEY DATE: 3/12/2024. Plan for REMOVAL Plan to remove immediate jeopardy. The facility failed to ensure residents had safe water temperatures in their bathroom sinks and shower rooms. F689 On 3/12/2024 the Administrator and Assistant Director of Nursing notified the Medical Director of immediate jeopardy. On 3/12/2024 Maintenance Director/Designee checked all residents' bathroom sinks, shower rooms, and all resident accessible water sources in the facility to make sure water temperatures were below 110.1F. On 3/12/2024 Regional Nurse Consultant/Designee checked all residents for any skin burns and document in EHR under progress notes for each resident. No residents were identified who had any skin burns. The Medical Director was updated on the assessments. COO (Chief Operating Officer) completed 1:1 in-service with Administrator on Water Temperature policy and Regional Nurse consultant completed 1:1 in-service with Assistants Director of Nursing on Water temperature policy, reporting any concerns or complaints, including water temperatures to Administrator upon discovery, and on risk factors for scalding/burns in the elderly, signs and symptoms of burns, and changes in condition on 3/12/2024. On 3/12/2024 Administrator completed in-services with Maintenance Director and IDT (Interdisciplinary team) water temperatures in residents' rooms, showers, and all resident accessible water sources to be below 110.1 and checking water temperatures daily. On 3/12/2024 Assistant Director of Nursing/Designee in-service staff on reporting any concerns or complaints regarding water temperatures to Maintenance Director or Administrator upon discovery. Direct Care staff will be in-serviced by ADON/Designee on risk factors for scalding/burns in the elderly, signs and symptoms of burns, and changes in condition. All staff, including the Agency, newly hired staff, and PRN will receive in-service and will not be allowed to start work until completed regarding reporting complaints and concerns from residents . The administrator will ensure all staff have completed in-services and training prior to starting work. The training will be completed by 3/12/2024. Ad-Hoc QAPI meeting was held on 3/12/2024, with the Medical Director, NHA (Nursing Home Administrator), Regional Nurse Consultant, Assistant Director of Nursing, and MDS Coordinator to review the deficiency and the plan for removal of immediacy. Starting on 3/12/2024, Maintenance Director/Designee will check all residents' rooms and shower rooms in the facility water temperatures daily Monday to Friday, and Manager on Duty Saturday and Sunday x 1 month. The findings will be immediately brought up to the Administrator for further action, if necessary, as an on-going process. The Administrator/designee will monitor compliance by completing an audit of five (5) residents' rooms/shower rooms per week for four (4) weeks to make sure water temperatures stay below 110.1F. This will be initiated on 3/12/2024. Any identified concerns 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 for the next 2 months. The Administrator will be responsible for ensuring this plan is completed on 3/12/2024. The RDO will provide oversight of Administrator to ensure that the items on the plan of removal are reviewed and completed. The Plan of Removal was monitored from 03/12/2024-03/13/2024 and is as follows: In observations on 03/13/2024 Water Temperatures in Resident Rooms were as follows: 1:57 pm room [ROOM NUMBER] - 85 degrees 2:00 pm room [ROOM NUMBER] - 92 degrees 2:04 pm room [ROOM NUMBER] - 100 degrees 2:10 pm room [ROOM NUMBER] - 92 degrees 2:13 pm room [ROOM NUMBER] - 100 degrees 2:16 pm room - 601 - 102 degrees 2:20 pm room [ROOM NUMBER] - 103 degrees 2:24 pm room [ROOM NUMBER] - 102 degrees 2:28 pm The boiler temperatures for hallways 5 - 8 was 104 degrees. 2:32 pm The boiler temperatures for hallways 1 - 4 was 109 degrees. In an interview on 3-13-24 at 3:01 PM the ADM stated she was in-serviced by the COO about water temperatures. The temperature should not exceed 110.1 degrees. The risk factor if it does exceed this temperature is potential burns. This population is more at risk because elderly have thinner skin. Residents might not understand how to adjust the temperature settings, they might have a diagnosis that makes them more susceptible to getting burned. Residents might have nerve issues and they might not feel the burn and residents are slower in movement. They reviewed protocols that staff need to notify maintenance if residents have complaints that water is too hot or staff feel water is too hot. On 3-13-24 at 3:12 pm the Regional Nurse Consultant was in-serviced by COO. They reviewed the policy about the water temperatures. The water temperatures should be below 110. If staff feels temperatures were too high the resident should be assessed by a nurse and the nurse would tell the ADM and maintenance. CNAs can also tell ADM and maintenance but if CNAs are concerned about skin damage, they need to inform a nurse. She in-serviced the ADONs about water temperatures, burns and change in condition. In an interview on 03/13/24 at 11:59 am the Maintenance Manager said he went into all resident rooms and checked the water temperatures and confirmed that they were at temperatures of 110.1 and below. In an interview on 3-13-24 at 12:20 pm the SW was in-serviced on water temperatures. If the water is too high, over 110, she lets the maintenance director know. Hot water can harm elderly residents' skin because it is much more sensitive. The water can burn their hands. Their hands are more sensitive to the heat and could cause blisters. In an interview on 3-13-24 at 12:37 pm the ADON stated he was in-serviced recently by the corporate office and learned the temperatures should be between 100and not over 110 and thermostats should not be set higher than 110. If someone complains that water was hot to notify maintenance so water temperature can be checked. If a resident has redness or blistering they need to notify MD. It is important to have temperatures regulated to prevent burns. Because of residents' age group, their skin is more sensitive and need temperatures to be regulated. In an interview on 3-13-24 at 12:44 pm LVN P was in-serviced recently that discussed proper water temperatures. Water temperatures should be between 100 and 110 to prevent burns. The skin of the elderly is very fragile, and they can blister easily. In an interview on 3-13-24 at 12:49 pm Housekeeper R stated he was in-serviced about hot water and the need to report if a resident was burned. He should report to maintenance immediately if someone is burned because water temperature might be too high. Water temperatures in resident rooms should not be higher than 110. He has to be more particular about water temperature with the elderly because they have sensitive skin. In an interview on 3-13-24 at 1:01 pm CNA Q stated she was in-served about water temperature. The water should be 110 or lower. If she notices that resident has a blister or hot water burn, she should notify the nurse. If she notices that water temperature is too high, notify ADM and maintenance. Check water before residents come into contact with the water because they have sensitive skin like a baby. Sometimes residents react more slowly and that is a risk factor to being burned with hot water. In an interview on 3-13-24 at 1:05 PM CNA S stated she was in-serviced about water temperature. She said water should not be higher then 110, and should be 101 to 110 for residents. If the water was too hot they would have red spots on their body because they are more sensitive and if they see something like that, tell the nurse on duty. Residents are more susceptible to being burned because they get burned easier than younger people. In an interview on 3-13-24 at 1:29 pm LVN T stated she was in-serviced about the water temperatures in the facility. When they test the water temperature prior to resident going to shower, if it is too hot, notify management and maintenance. The temperature should not be above 110. This is important for the elderly because their skin is thinner and more fragile. In an interview on 3-13-24 at 1:13 PM CNA U stated she attended an in-service about hot water and if the resident gets burned. They discussed that the water temperature should be not over 110. If temperatures are over 110 the residents can get burns and blisters and sores. The skin of the elderly is softer and more tender so it is important that water temperature is not over 110. In an interview on 3-13-24 at 1:19 PM CNA E stated she was in-serviced about the water temperature. The water temperature should not be higher than 110 and if a resident gets scorched, report to the nurse. If she thinks the temperature is higher than 110 report to maintenance and the ADM. Residents' skin is not as tough as hers and residents' skin burns more easily. In an interview on 3-13-24 at 1:33 PM LVN W stated she was in-serviced about the temperature of water. When the resident complains about the temperature report immediately. The temperature of water should not be higher than 110. If she thinks the water is hotter tell the administrator and the maintenance person. The skin of the elderly was very thin and they can burn easily. In an interview on 3-13-24 at 1:37 pm LVN W -she was in-serviced recently. She said the water temperature should be 110 or below. If the water is too hot do not give resident a bath and notify maintenance. Because the residents are older, the hot water can burn their skin because their skin is thin. In an interview on 03/13/2024 at 3:26 pm the Resident in room [ROOM NUMBER] (where water temperature was too high), he said he did not receive any burns or injury from the water being too high. He said he knew how to adjust the water. In an interview on 3-13-24 at 3:33 pm COO stated she started the in-services and interviewed the regional nurse consultant and the AD. In the in-service she reviewed water temperature safety. They discussed that water temperatures can't be over 110. They discuss that the elderly have skin that is thinner and high water temperatures can harm the elderly. The elderly might have communication issues and not be able to communicate if the water is too hot. It is important to do skin checks if a resident is exposed to high water temperatures. They discussed how exposure to warm or hot water can affect the residents in the facility and how cognition and movement are involved when residents water temperature is too high. Reviewed the following inservices: 1. 1:1 in-service with Administrator on Water Temperature policy and Regional Nurse consultant 2. 1:1 in-service with Assistants Director of Nursing on Water temperature policy, reporting any concerns or complaints, including water temperatures to Administrator upon discovery, and on risk factors for scalding/burns in the elderly, signs and symptoms of burns, and changes in condition 3. Administrator in-services with Maintenance Director and IDT (Interdisciplinary team) water temperatures in residents' rooms, showers, and all resident accessible water sources to be below 110.1 and checking water temperatures daily 4. Assistant Director of Nursing/Designee in-services to staff on reporting any concerns or complaints regarding water temperatures to Maintenance Director or Administrator upon discovery. 5. Direct Care staff in-services by ADON/Designee on risk factors for scalding/burns in the elderly, signs and symptoms of burns, and changes in condition. 6. RNC in-service to ADONs on water temperature policy, reporting concerns or complaints including water temperatures to Administrator upon discovery, and on risk factors for scalding/burns in the elderly, signs and symptoms of burns, and changes in condition While the IJ was removed on 03/13/2024 the facility remained out of compliance at a severity level of no actual harm at a scope of pattern due to staff needing more time to monitor the plan of removal for effectiveness.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure residents had the right to be free from neglect for 1 (Resident #1) of 13 residents reviewed for neglect in that: The facility failed to provide goods and services to Resident #1 that are necessary to ensuring Resident #1's bed wheels were locked on 10/16/23. Resident #1, who the facility knew was legally blind, rolled out of bed and fell on the ground. Resident #1 was transported by emergency medical services to the hospital on [DATE]. Hospital x-rays revealed Resident #1 had a intertrochanteric fracture of right femur. An IJ was identified on 11/10/23. The IJ template was provided to the facility on [DATE] at 7:38 p.m. While the IJ was removed on 11/11/23, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that was not immediate jeopardy because of the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of pain, injury, hospitalization, and a diminished quality of life. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including unspecified fracture of right femur (hip), need for assistance with personal care, vascular dementia (a condition caused by a lack of blood flow and deprivation of oxygen to parts of the brain) without behavioral, psychotic, or mood disturbances, history of anxiety, age-related osteoporosis (a condition in which bones become weak and brittle), pain in unspecified hip, difficulty in walking, repeated falls, other lack of coordination, generalized muscle weakness, other abnormalities of gait and mobility, weakness, unsteadiness on feet, unspecified visual loss, and legal blindness. Review of Resident #1's quarterly MDS, revised on 09/19/23, reflected a BIMS score of 7, indicating a severely impaired cognition, he required limited assistance of one person with bed mobility and transfers, and he had no falls since admission. Review of Resident #1's quarterly care plan, revised on 09/13/23, reflected he was at risk for falls due to being legally blind. There were no interventions related to keeping the bed brakes locked or bed rails. There was an intervention of increased staff supervision with intensity based on Resident #1's need. Review of Resident #1's progress notes, dated 10/16/23 at 10:29 a.m. and documented by LVN A, reflected the following: This nurse heard some yelling while receiving report. The nurse that I was receiving report from checked on it and said everything was fine. After I finished receiving report, I heard a yelling from the same area. I checked on it and noted Resident #1 laying down beside his bed on the floor. Resident #1 had 2 pillows under his head and his knees were bent. CNA and myself assisted Resident #1 back into his bed and placed his pillows under his head again. When I asked Resident #1 what happened, he stated he rolled out of the bed due to the bed moving. I locked the bed in place. Resident #1 complained of pain in the right hip and stated, I think i bruised my pelvic bone. Vitals signs were normal. Resident #1 stated he had a 4 out of 10 for pain in the hip. There was some redness on the skin around the right hip area. This nurse notified ADON of the situation. The NP asked Resident #1 if he wanted to go to the hospital. He denied. This nurse received order for X-ray of Resident #1's right hip. Neuro initiated. 72 hour monitoring initiated. Attempted to contact RP but there is no RP on file. Review of Resident #1's progress notes, dated 10/16/23 at 10:48 a.m. and documented by Charge Nurse, reflected the following: X-ray tech in facility to x-ray Resident #1. Right hip, awaiting results. Review of Resident #1's progress notes, dated 10/16/23 at 1:17 p.m. and documented by ADON, reflected the following: Resident #1's right hip x-ray returned within normal limits. Resident #1 notified. Review of Resident #1's progress notes, from 10/17/23 through 10/18/23 and documented by LVN B, reflected there were no other fall incidents. There were also no progress notes from 10/18/23 through 10/25/23. Review of Resident #1's progress notes, dated 10/26/23 at 5:02 a.m. and documented by NP, reflected the following: Received a call from nursing that Resident #1 is complaining of left leg/hip pain. Resident #1 is own RP and is telling nursing that he demands to go to the hospital and if they will not send him, he will call transport and send himself. Resident #1 had been receiving Tylenol on a regular basis but continues to have pain. Review of Resident #1's progress notes, dated 10/26/23 at 7:16 a.m. and documented by LVN C, reflected the following: Resident #1 reported that he was in excruciating pain in left leg and was unable to extend leg. Stated that he wanted to go to hospital. NP did offer X-ray and Resident #1 declined said he wanted to go to ER. I did notify and spoke with NP who was familiar with Resident #1 and did video call. I did mention to NP that Resident #1 was given acetaminophen 650mg and was not effective. No noted swelling or redness noted to left leg when checked. EMS notified. Resident #1 did depart with transport at 5:20 a.m. Resident #1 is his own RP. Face sheet, MDS, and out of hospital DNR given to EMS. DON made aware at end of shift. Review of Resident #1's post-fall observation report, dated 10/16/23 at 4:37 p.m. and documented on 10/27/23 at 4:41 p.m. by ADON, reflected Resident #1 had an unwitnessed fall in his room. Per the nurse's report, Resident #1 stated his bed shifted and he rolled out of the bed onto the floor. Resident #1 was in bed, alert, and oriented prior to the fall. Resident #1's ambulatory status was unable to ambulate. Resident #1 wore yellow non-skid socks at time of fall. Resident #1 took nine or more medications and received antihypertensives (a class of drugs used to prevent high blood pressure complications). Resident #1 had no falls in the last 90 days. Resident #1's bed was not locked was listed as a potential factor that could have contributed to the fall. Review of Resident #1's provider investigation report documented by ADM on 10/26/23 reflected the incident date/time was unknown and the date reported to State Agency was on 10/26/23 at 12:55 p.m. Resident #1 required extensive assistance with functional ability, having a BIMS score of 7, legal blindness, weakness, pain, lack of coordination, interviewable, not independently ambulatory, and had capacity to make informed decisions. There were no witnesses to Resident #1's incident. On 10/26/23 at approximately 5:00 p.m., Resident #1 told the nurse he was in excruciating pain in his left leg, he was assessed, was unable to extend his leg, had no redness or swelling, given pain medication, was offered a mobile x-ray, declined the offer, insisted on going to the hospital, was transported to the hospital, x-rayed, and had a right hip fracture . On 10/16/23, Resident #1 rolled out of bed, at the time complained of right hip pain, mobile x-ray came out to the facility, and the results were negative. Investigation findings were inconclusive. Review of Resident #1's portable x-ray report, dated 10/16/23, there was no evidence of acute fracture to his right hip and pelvis. Review of Resident #1's hospital records, dated 10/26/23, reflected Resident #1 had comminuted intertrochanteric fracture of right femur. Resident #1 told hospital staff that he sustained the injury after a ground level fall a week ago when trying to get out of bed. Resident #1 also told hospital staff he had immediate hip pain after his fall and x-rays were taken at the facility, but no fracture was identified. Resident #1 told hospital staff that his hip continued to hurt so he was taken to the hospital on [DATE], where further x-rays were performed, and intertrochanteric fracture of right femur was discovered. Resident #1 was a household ambulator (a person who required assistance entering and exiting structures and had difficulty climbing stairs in the home) with a blind stick, but he told hospital staff he had been mostly in bed for the past six months. Review of Resident #1's active orders on 11/10/23 reflected there were no orders related to ensuring Resident #1's bed was locked and bed rails. Review of Resident #1's MAR from 10/01/23 through 10/31/23 reflected his pain level was 0/10 from 10/16/23 through 10/17/23, 3/10 on 10/18/23, and 0/10 from 10/19/23 through 10/25/23. Resident #1's pain levels were not recorded on 10/26/23 due to him going to the hospital. Resident #1 was given one methocarbamol 500 mg tablet twice a day, which was provided on 10/25/23 and 10/26/23 . Resident #1 was monitored for bruising, change in mental status/condition, pain, or other injuries related to fall every shift from 10/16/23 through 10/19/23. During an interview on 11/10/23 at 11:04 a.m., Charge Nurse stated she was trained and often in-serviced on neglect and falls by the DON and ADON. Charge Nurse also stated she was recently in-serviced on the topics at the beginning of this week and last week. Charge Nurse stated the ADM was the abuse and neglect coordinator. Charge Nurse also stated she never had to report and was comfortable reporting neglect. Charge Nurse stated she worked with Resident #1 in the past. Charge Nurse also stated Resident #1 never fell at the facility during the time she worked with him. Charge Nurse stated if a resident was on the ground, she was trained to assess the resident, check the resident's vitals, obtain help from another staff member, put the resident back in bed if safe to do so, and contact EMS if she suspected the resident sustained a fracture. Charge Nurse also stated residents were checked on every two hours by CNAs and LVNs. During an observation and interview on 11/10/23 beginning at 1:09 p.m., Resident #1 was lying on his back in his bed. Resident #1 was clean, comfortable, and had his call light next to him. Resident #1 had bed bars installed on his bed near the headboard and the bed wheels were locked. Resident #1 had a purple-colored bruise on his right forearm. Resident #1 stated he slipped, fell out of bed, and broke his hip three weeks ago. Resident #1 stated the bed was moving when he was trying to reposition himself in bed. Resident #1 stated he did not know his bed was not locked, why his bed was not locked, and when and who unlocked his bed. Resident #1 stated he was legally blind. Resident #1 stated on the day of his fall incident, he yelled for help when he was on the ground. Resident #1 stated staff x-rayed him at the facility and he had no fractures. Resident #1 stated a week and a half later, he felt more pain, was sent to hospital, x-rayed, and had a fracture. Resident #1 stated he never fell at the facility or had any other incidents between 10/16/23 and 10/26/23. Resident #1 stated he was on the floor for an hour and a half until staff came in his room to help him. Resident #1 stated he had no bed rails on his bed on the day he rolled out of bed and fell on the ground. Resident #1 stated he never fell out of bed in the past prior to the fall incident. Resident #1 stated staff did not check on him and he could only get staff to come check on him when he pressed his call light for assistance. Resident #1 stated staff took 3 hours to answer his call light. Resident #1 stated he did not file a grievance about staffing because the SW was not available and did not know what she was doing. During an interview on 11/10/23 at 2:25 p.m., DON stated she was trained on abuse, neglect, and falls. DON also stated the ADM was the abuse and neglect coordinator. DON stated she trained staff to notify a nurse, make sure the resident was safe, a nurse would assess the resident's condition if a resident was on the ground. DON also stated if the resident expressed pain, she trained staff to notify the resident's MD and request an x-ray. DON stated if staff suspected the resident sustained a fracture, she trained them to send the resident to the hospital to be x-rayed and further evaluated. DON also stated she trained staff to administer pain medication and/or treatment to the resident if they are able to do such, conduct neurological checks on the resident, and notify the resident's RP of the fall. DON stated CNAs and LVNs checked on residents every hour or more. DON also stated any staff member could check on a resident. DON stated she was notified by a nurse that Resident #1 was on the floor on 10/16/23. DON also stated Resident #1 expressed he was experiencing pain in his right hip and staff wanted to send him out, but he refused to go to the hospital. DON stated staff ordered a mobile x-ray for Resident #1, in which his x-ray results were negative for fracture on 10/16/23. DON also stated on 10/26/23, Resident #1 expressed he was experiencing pain in his left side and staff sent him out based on his telehealth visit with the NP. DON stated the hospital ordered an x-ray Resident #1, in which his x-ray results were positive for a right hip fracture . DON also stated she did not know if Resident #1 expressed experiencing pain between 10/17/23 and 10/25/23. DON stated she could not recall if Resident #1 had any other falls prior to 10/16/23. DON also stated she never received complaints about residents left on floor after a fall. During an interview on 11/10/23 at 3:45 p.m., DON stated staff unlocked residents' beds whenever they performed incontinent care or moved the bed to get something that fell underneath it. DON also stated she could not remember if Resident #1 had a mobility bar installed on his bed prior to 10/16/23. DON stated LVN A was supposed to work on 11/07/23, but he did not show up for work. DON stated she made multiple attempts to contact LVN A, but he did not return any of her calls or text messages. During an interview on 11/10/23 at 4:21 p.m., DON stated she and the ADONs verbalized to all staff about locking residents' beds following Resident #1's incident on 10/16/23. DON also stated she did not document her and the ADONs verbalizing to all staff about locking residents' beds. DON stated the CNAs, LVNs, MAs trained each other on how to lock and unlock residents' beds. DON also stated management staff did not train nursing staff how and when to unlock and lock residents' beds. DON stated there were no staff designated to oversee and ensure residents' beds were locked. DON also stated the facility did not have a policy and procedure on locking and unlocking residents' beds. DON stated she did not know why Resident #1's bed was unlocked and did not know who left his bed unlocked on 10/16/23. During an interview on 11/10/23 at 4:53 p.m., ADM stated there was no training given to staff that specifically highlighted how and when to lock and unlock residents' beds. ADM also stated Resident #1's incident was used as an example and scenario during the fall prevention and intervention, abuse, and neglect in-services given to staff. ADM stated housekeeping staff unlocked and locked residents' beds when they cleaned residents' rooms. ADM also stated CNAs and LVNs unlocked and locked residents' beds when transferring residents with a Hoyer lift. ADM stated she did not know why Resident #1's bed was unlocked and did not know who left his bed unlocked on 10/16/23. During an interview on 11/10/23 at 5:41 p.m., MS stated he was not sure if he ever had a service order to check or repair a resident's bed because it did not lock. MS also stated housekeeping staff sometimes moved residents' beds when they cleaned residents' rooms. MS stated he believed he repaired Resident #1's bed remote control that raised and lowered his bed. MS also stated he never had to replace a lock or residents' bed because it did not unlock and lock. An attempt to interview LVN A was made on 11/10/23 at 5:54 p.m., but LVN A did not return the surveyor's call prior to exit. During an interview on 11/10/23 at 6:05 p.m., Charge Nurse stated she did not know what happened on 10/16/23. Charge Nurse also stated she heard about Resident #1's unwitnessed fall after other staff responded to it on 10/16/23. Charge Nurse stated there was an LVN who checked on Resident #1 before LVN A, but she did not know who it was. Charge Nurse also stated LVNs, and CNAs unlocked and locked residents' beds when transferring a resident using a Hoyer lift . Charge Nurse stated housekeeping unlocked and locked residents' beds when they cleaned residents' rooms. During an interview on 11/10/23 at 6:37 p.m., CNA C stated she was trained and in-serviced on abuse, neglect, and falls and was recently in-serviced on the topics last week. CNA C also stated the ADM was the abuse and neglect coordinator. CNA C stated she was comfortable reporting abuse and neglect. CNA C also stated she never had to unlock and move a resident's bed. CNA C stated she knew how to unlock and lock resident's bed. CNA C also stated she was not trained by management staff on how to unlock and lock residents' beds. CNA C stated she was trained by another CNA on how to unlock and lock residents' beds. CNA C also stated she never observed housekeeping staff unlock and move residents' beds. Review of the facility's incident log from 10/1/23 through 11/10/23 reflected Resident #1 had an unwitnessed fall in his room on 10/16/23 at 6:10 a.m. Review of the facility's maintenance log from October 2023 through November 2023 reflected MS replaced Resident #1's missing bed remote on 10/31/23. There were no other service orders related to Resident #1's bed. Review of facility's in-services reflected staff were trained on one-to-one observation on, abuse, neglect, falls, redirecting agitated residents and call lights on 10/25/23 and 10/26/23 and diffusing aggressive behaviors, abuse, and neglect on 10/04/23. Review of the facility falls and fall risk managing policy and procedure revised in December 2007 reflected the following: Policy Statement: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Policy Interpretation and Implementation: Prioritizing Approaches to Managing Falls and Fall Risk 1. The staff, with the input of the Attending Physician, will identify appropriate interventions to reduce the risk of falls. If a systematic evaluation of a resident's fall risk identifies several possible interventions, the staff may choose to prioritize interventions (i.e., to try one or a few at a time, rather than many at once). 2. Examples of initial approaches might include exercise and balance training or a rearrangement of room furniture. 6. In conjunction with the Attending Physician, staff will identify and implement relevant interventions (e.g., hip padding or treatment of osteoporosis, as applicable) to try to minimize serious consequences of falling. Monitoring Subsequent Falls and Fall Risk 1. The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling. 2. If interventions have been successful in preventing falling, staff will continue the interventions or reconsider whether these measures are still needed if a problem that required the intervention (e.g., dizziness or weakness) has resolved. 3. The staff and/or physician will document the basis for conclusions that specific irreversible risk factors exist that continue to present a risk for falling or injury due to falls. Review of the facility's analyzing occurrences of abuse, neglect, mistreatment and theft/misappropriation of resident property policy and procedure revised in November 2010 reflected the following: Policy Statement: All occurrences of abuse, neglect, mistreatment, injuries of unknown source and theft or misappropriation of resident property will be analyzed by the Quality Assessment and Assurance Committee to determine if system changes need to be made. Policy Interpretation and Implementation 1. The Quality Assessment and Assurance Committee will review all reports of abuse, neglect, mistreatment, injuries of unknown source, and theft or misappropriation of resident property during their regularly scheduled meetings. 2. Reviews of each occurrence will be made to determine if policies, procedures, or facility systems need to be modified to prevent further incidents of abuse or theft. 3. The QAA committee will determine through a coordinated effort: a. If a thorough investigation is conducted. b. Whether the resident is protected. c. Whether an analysis was conducted as to why the situation occurred. d. Risk factors that contributed to the abuse (e.g., history of aggressive behaviors, environmental factors); and e. Whether there is further need for systemic action such as: i. Insight on needed revision to the policies and procedures that prohibit and prevent abuse/neglect/misappropriation/exploitation ii. Increased training on specific components of identifying and reporting that staff may not be aware of or are confused about, iii. Efforts to educate residents and their families about how to report any alleged violations without fear of repercussions, iv. Measures to verify the implementation of corrective actions and timeframes, and v. Tracking patterns of similar occurrences. 4. The Quality Assessment and Assurance Committee will provide the Administrator with a written report of its findings and recommendations. The Administrator will review such recommendations and act accordingly. 5. Copies of any changes to our abuse prevention program policies and procedures will be provided to residents and facility staff as established by facility policy and training programs. Review of the facility's preventing resident abuse policy and procedure revised in November 2010 reflected the following: Policy Statement: 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. Policy Interpretation and Implementation: a. Our facility's goal is to achieve and maintain an abuse-free environment. b. Our abuse prevention/intervention program includes, but is not necessarily limited to, the following: c. Training all staff and practitioners how to resolve conflicts appropriately. f. The facility will identify, correct, and intervene in situations in which abuse, neglect and/or misappropriation of resident property is more likely to occur. h. Involving the resident/family group council in developing, monitoring, and evaluating the facility's abuse prevention program. m. Assessing, care planning, and monitoring residents with needs and behaviors that may lead to conflict or neglect. r. Identifying areas within the facility that may make abuse and/or neglect more likely to occur and monitoring these areas regularly. Review of the facility's abuse prevention program policy and procedure revised November 2010 reflected the following: Policy Statement: Our residents have the right to be free from abuse, neglect, exploitation, or mistreatment, including injuries of unknown sources, and misapprop1iation of resident property, corporal punishment, and involuntary seclusion. Policy Interpretation and Implementation: 3. Comprehensive policies and procedures have been developed to aid our facility in preventing abuse, neglect, or mistreatment of our residents. Our abuse prevention program provides policies and procedures that govern, as a minimum: a. Establishing a safe environment. b. Identifying, correcting and intervening in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is more likely 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. a. Addressing features of the physical environment that may make abuse, neglect, exploitation, and misappropriation of resident property more likely to occur; and b. Assigning responsibility for the supervision of staff on all shifts for identifying inappropriate staff behaviors. d. Mandated staff training/orientation programs that include such topics as abuse prevention, identification and reporting of abuse, stress management, dealing with violent behavior or catastrophic reactions, etc. j. An ongoing review and analysis of abuse incidents/Coordination with QAPI; and k. The implementation of changes to prevent future occurrences of abuse. Review of the facility's recognizing signs and symptoms of abuse/neglect policy and procedure revised in April 2012 reflected the following: Policy Statement: Our facility will not condone any form of resident abuse or neglect. To aid in abuse prevention, all personnel are to report any signs or symptoms of abuse/neglect to their supervisor or to the Director of Nursing Services immediately. Policy Interpretation and Implementation: 2. Neglect is defined as failure to provide goods and services a necessary to avoid physical harm, mental anguish, or mental illness. 3. The following are some examples of actual abuse/neglect and signs and symptoms of abuse/neglect that should be promptly reported. However, this listing is not all-inclusive. Other signs and symptoms or actual abuse/neglect may be apparent. When it doubt, report it. Signs of/Actual Physical Neglect: Inadequate provision of care. Leaving someone unattended who needs supervision. Possible signs/symptoms of psychological abuse/neglect: Anger. Review of the facility's bed safety policy and procedure revised in December 2007 reflected the following: Policy: Our facility shall strive to provide a safe sleeping environment for the resident. Policy Interpretation and Implementation: 1. The resident's sleeping environment shall be assessed by the interdisciplinary team, considering the resident's safety, medical conditions, comfort, and freedom of movement, as well as input from resident and family regarding previous sleeping habits and bed environment. 2. To try to prevent deaths/injuries from the beds and related equipment (including the frame, mattress, side rails, headboard, footboard, and bed accessories), The facility shall promote the following approaches: a. Inspection by maintenance staff of all beds and related equipment as part of our regular bed safety program to identify risks and problems including potential entrapment risks. b. Review that gaps within the bed system are within the dimensions established by the FDA (Note: The review shall consider situations that could be caused by the resident's weight, movement, or bed position.). c. Ensure that when bed system components are worn and need to be replaced, components meet manufacturer specifications. d. Ensure that bed side rails are properly installed using the manufacturer's instructions and other pertinent safety guidance to ensure proper fit (e.g., avoid bowing, ensure proper distance from the headboard, and footboard, etc.); and e. Identify additional safety measures for residents who have been identified as having a higher than usual risk for injury including entrapment (e.g., altered mental status, restlessness, etc.). 3. The maintenance department shall provide a copy of inspections to the Administrator and report results to the QA Committee for appropriate action. Copies of the inspection results and QA Committee recommendations shall be maintained by the Administrator and/or Safety Committee. 4. The facility's education and training activities will include instruction about risk factors for resident injury due to beds, and strategies for reducing risk factors for injury, including entrapment. 5. If side rails are used, there shall be an interdisciplinary assessment of the resident, consultation with the Attending Physician, and input from the resident and/or legal representative. 6. The staff shall obtain consent for the use of side rails from the resident or the resident's legal representative prior to their use. 7. After appropriate review and consent as specified above, side rails may be used at the resident's request to increase the resident's sense of security (e.g., if he/she has a fear of falling, his/her movement is compromised, or he/she is used to sleeping in a larger bed). 8. Side rails may be used if assessment and consultation with the Attending Physician has determined that they are needed to help manage a medical symptom or condition, or to help the resident reposition or move in bed and transfer, and no other reasonable alternatives can be identified. 9. Before using side rails for any reason, the staff shall inform the resident and family about the benefits and potential hazards associated with side rails. 10. When using side rails for any reason, the staff shall take measures to reduce related risks. 11. Side rails shall not be used as protective restraints. Should a protective restraint be used. our facility's protocol for the use of restraints shall be followed. 12. The use of physical restraint on individuals in bed shall be limited to situations where they are needed to treat a resident's medical symptoms, and only after being reviewed by authorized individuals. 13. The staff shall report to the Director of Nursing and Administrator any deaths, serious illnesses and/or injuries resulting from a problem associated with a bed and related equipment including the bed frame, bed side rails, and mattresses. The Administrator shall ensure that reports are made to the Food and Drug Administration or other appropriate agencies, in accordance with pe1tinent laws and regulations including the Safe Medical Devices Act. This failure resulted in the identification of an IJ on 11/10/23 at 3:51 p.m. The ADM was notified and provided with the IJ template on 11/10/23 at 7:38 p.m. The following Plan of Removal was submitted by the facility and accepted on 11/11/23 at 1:36 p.m.: Plan to remove immediate jeopardy. The facility failed to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The facility failed to lock R1's bed. All residents residing in the facility can be affected by this deficiency. On 11/10/2023 the Administrator and Director of Nursing notified the Medical Director of immediate jeopardy. On 11/10/2023 Maintenance Director/Designee checked all the occupied beds in the facility to make sure they were locked. On 11/10/2023 Director of Nursing/Designee checked all residents that are currently in the facility for safety while in bed, including making sure all beds are locked. No other residents were identified who had injuries due to unlocked beds while occupying the bed. Medical Director was updated of the assessments. On 11/10/2023 Administrator/Designee completed in-services with nursing staff and housekeeping on how to lock and unlock patients' beds and abuse and neglect prevention. All staff, including Agency, new hire staff, and PRN will be in-service and will not be allowed to start work till done so. Administrator will ensure all staff completed in-services and training prior to start working. The training will be completed by 11/10/2023. Ad-Hoc QAPI meeting was held on 11/10/2023, with the Medical Director, NHA (Nursing Home Administrator), Director of Nursing, Assistant Director of Nursing, and MDS Coordinator to review the deficiency and the plan for removal of immediacy. Starting on 11/10/2023, Maintenance Direc[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure the resident environment remained free of accidents and hazards and each resident received adequate supervision and assistance devices to prevent accidents for 1 (Resident #1) of 11 residents reviewed for falls in that: 1. The facility failed to ensure Resident #1's bed wheels were locked on 10/16/23. Resident #1, who was legally blind, rolled out of bed and fell on the ground. Resident #1 was transported by emergency medical services to the hospital on [DATE]. Hospital x-rays revealed Resident #1 had a intertrochanteric fracture of right femur. 2. The facility failed to investigate and determine who unlocked Resident #1's bed. 3. The facility failed to train staff on how and when to unlock and lock residents' beds. 4. The facility failed to maintain a policy and procedure for how and when to unlock and lock residents' beds. 5. The facility failed to provide oversight to ensure staff were locking residents' beds. An IJ was identified on 11/10/23. The IJ template was provided to the facility on [DATE] at 7:38 p.m. While the IJ was removed on 11/11/23, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that was not immediate jeopardy because of the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of accidents, hazards, pain, injury, hospitalization, and a diminished quality of life. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including unspecified fracture of right femur (hip), need for assistance with personal care, vascular dementia (a condition caused by a lack of blood flow and deprivation of oxygen to parts of the brain) without behavioral, psychotic, or mood disturbances, history of anxiety, age-related osteoporosis (a condition in which bones become weak and brittle), pain in unspecified hip, difficulty in walking, repeated falls, other lack of coordination, generalized muscle weakness, other abnormalities of gait and mobility, weakness, unsteadiness on feet, unspecified visual loss, and legal blindness. Review of Resident #1's quarterly MDS, revised on 09/19/23, reflected a BIMS score of 7, indicating a severely impaired cognition, he required limited assistance of one person with bed mobility and transfers, and he had no falls since admission. Review of Resident #1's quarterly care plan, revised on 09/13/23, reflected he was at risk for falls due to being legally blind. There were no interventions related to keeping the bed brakes locked or bed rails. There was an intervention of increased staff supervision with intensity based on Resident #1's need. Review of Resident #1's progress notes, dated 10/16/23 at 10:29 a.m. and documented by LVN A, reflected the following: This nurse heard some yelling while receiving report. The nurse that I was receiving report from checked on it and said everything was fine. After I finished receiving report, I heard a yelling from the same area. I checked on it and noted Resident #1 laying down beside his bed on the floor. Resident #1 had 2 pillows under his head and his knees were bent. CNA and myself assisted Resident #1 back into his bed and placed his pillows under his head again. When I asked Resident #1 what happened, he stated he rolled out of the bed due to the bed moving. I locked the bed in place. Resident #1 complained of pain in the right hip and stated, I think i bruised my pelvic bone. Vitals signs were normal. Resident #1 stated he had a 4 out of 10 for pain in the hip. There was some redness on the skin around the right hip area. This nurse notified ADON of the situation. The NP asked Resident #1 if he wanted to go to the hospital. He denied. This nurse received order for X-ray of Resident #1's right hip. Neuro initiated. 72 hour monitoring initiated. Attempted to contact RP but there is no RP on file. Review of Resident #1's progress notes, dated 10/16/23 at 10:48 a.m. and documented by Charge Nurse, reflected the following: X-ray tech in facility to x-ray Resident #1. Right hip, awaiting results. Review of Resident #1's progress notes, dated 10/16/23 at 1:17 p.m. and documented by ADON, reflected the following: Resident #1's right hip x-ray returned within normal limits. Resident #1 notified. Review of Resident #1's progress notes, from 10/17/23 through 10/18/23 and documented by LVN B, reflected there were no other fall incidents. There were also no progress notes from 10/18/23 through 10/25/23. Review of Resident #1's progress notes, dated 10/26/23 at 5:02 a.m. and documented by NP, reflected the following: Received a call from nursing that Resident #1 is complaining of left leg/hip pain. Resident #1 is own RP and is telling nursing that he demands to go to the hospital and if they will not send him, he will call transport and send himself. Resident #1 had been receiving Tylenol on a regular basis but continues to have pain. Review of Resident #1's progress notes, dated 10/26/23 at 7:16 a.m. and documented by LVN C, reflected the following: Resident #1 reported that he was in excruciating pain in left leg and was unable to extend leg. Stated that he wanted to go to hospital. NP did offer X-ray and Resident #1 declined said he wanted to go to ER. I did notify and spoke with NP who was familiar with Resident #1 and did video call. I did mention to NP that Resident #1 was given acetaminophen 650mg and was not effective. No noted swelling or redness noted to left leg when checked. EMS notified. Resident #1 did depart with transport at 5:20 a.m. Resident #1 is his own RP. Face sheet, MDS, and out of hospital DNR given to EMS. DON made aware at end of shift. Review of Resident #1's post-fall observation report, dated 10/16/23 at 4:37 p.m. and documented on 10/27/23 at 4:41 p.m. by ADON, reflected Resident #1 had an unwitnessed fall in his room. Per the nurse's report, Resident #1 stated his bed shifted and he rolled out of the bed onto the floor. Resident #1 was in bed, alert, and oriented prior to the fall. Resident #1's ambulatory status was unable to ambulate. Resident #1 wore yellow non-skid socks at time of fall. Resident #1 took nine or more medications and received antihypertensives (a class of drugs used to prevent high blood pressure complications). Resident #1 had no falls in the last 90 days. Resident #1's bed was not locked was listed as a potential factor that could have contributed to the fall. Review of Resident #1's provider investigation report documented by ADM on 10/26/23 reflected the incident date/time was unknown and the date reported to State Agency was on 10/26/23 at 12:55 p.m. Resident #1 required extensive assistance with functional ability, having a BIMS score of 7, legal blindness, weakness, pain, lack of coordination, interviewable, not independently ambulatory, and had capacity to make informed decisions. There were no witnesses to Resident #1's incident. On 10/26/23 at approximately 5:00 p.m., Resident #1 told the nurse he was in excruciating pain in his left leg, was assessed, was unable to extend his leg, had no redness or swelling, given pain medication, was offered a mobile x-ray, declined the offer, insisted on going to the hospital, was transported to the hospital, x-rayed, and had a right hip fracture . On 10/16/23, Resident #1 rolled out of bed, at the time complained of right hip pain, mobile x-ray came out to the facility, and the results were negative. Investigation findings were inconclusive. Review of Resident #1's portable x-ray report, dated 10/16/23, there was no evidence of acute fracture to his right hip and pelvis. Review of Resident #1's hospital records, dated 10/26/23, reflected Resident #1 had a intertrochanteric fracture of right femur. Resident #1 told hospital staff that he sustained the injury after a ground level fall a week ago when trying to get out of bed. Resident #1 also told hospital staff he had immediate hip pain after his fall and x-rays were taken at the facility, but no fracture was identified. Resident #1 told hospital staff that his hip continued to hurt so he was taken to the hospital on [DATE], where further x-rays were performed, and the right femur fracture was discovered. Resident #1 was a household ambulator (a person who required assistance entering and exiting structures and had difficulty climbing stairs in the home) with a blind stick, but he told hospital staff he had been mostly in bed for the past six months. Review of Resident #1's active orders on 11/10/23 reflected there were no orders related to ensuring Resident #1's bed was locked and bed rails. Review of Resident #1's MAR from 10/01/23 through 10/31/23 reflected his pain level was 0/10 from 10/16/23 through 10/17/23, 3/10 on 10/18/23, and 0/10 from 10/19/23 through 10/25/23. Resident #1's pain levels were not recorded on 10/26/23 due to him going to the hospital. Resident #1 was given one methocarbamol 500 mg tablet twice a day, which was provided on 10/25/23 and 10/26/23 . Resident #1 was monitored for bruising, change in mental status/condition, pain, or other injuries related to fall every shift from 10/16/23 through 10/19/23. During an interview on 11/10/23 at 11:04 a.m., Charge Nurse stated she was trained and often in-serviced on neglect and falls by the DON and ADON. Charge Nurse also stated she was recently in-serviced on the topics at the beginning of this week and last week. Charge Nurse stated the ADM was the abuse and neglect coordinator. Charge Nurse also stated she never had to report and was comfortable reporting neglect. Charge Nurse stated she worked with Resident #1 in the past. Charge Nurse also stated Resident #1 never fell at the facility during the time she worked with him. Charge Nurse stated if a resident was on the ground, she was trained to assess the resident, check the resident's vitals, obtain help from another staff member, put the resident back in bed if safe to do so, and contact EMS if she suspected the resident sustained a fracture. Charge Nurse also stated residents were checked on every two hours by CNAs and LVNs. During an observation and interview on 11/10/23 beginning at 1:09 p.m., Resident #1 was lying on his back in his bed. Resident #1 was clean, comfortable, and had his call light next to him. Resident #1 had bed bars installed on his bed near the headboard and the bed wheels were locked. Resident #1 had a purple-colored bruise on his right forearm. Resident #1 stated he slipped, fell out of bed, and broke his hip three weeks ago. Resident #1 stated the bed was moving when he was trying to reposition himself in bed. Resident #1 stated he did not know his bed was not locked, why his bed was not locked, and when and who unlocked his bed. Resident #1 stated he was legally blind. Resident #1 stated on the day of his fall incident, he yelled for help when he was on the ground. Resident #1 stated staff x-rayed him at the facility and he had no fractures. Resident #1 stated a week and a half later, he felt more pain, was sent to hospital, x-rayed, and had a fracture. Resident #1 stated he never fell at the facility or had any other incidents between 10/16/23 and 10/26/23. Resident #1 stated he was on the floor for an hour and a half until staff came in his room to help him. Resident #1 stated he had no bed rails on his bed on the day he rolled out of bed and fell on the ground. Resident #1 stated he never fell out of bed in the past prior to the fall incident. Resident #1 stated staff did not check on him and he could only get staff to come check on him when he pressed his call light for assistance. Resident #1 stated staff took 3 hours to answer his call light. Resident #1 stated he did not file a grievance about staffing because the SW was not available and did not know what she was doing. During an interview on 11/10/23 at 2:25 p.m., DON stated she was trained on abuse, neglect, and falls. DON also stated the ADM was the abuse and neglect coordinator. DON stated she trained staff to notify a nurse, make sure the resident was safe, a nurse would assess the resident's condition if a resident was on the ground. DON also stated if the resident expressed pain, she trained staff to notify the resident's MD and request an x-ray. DON stated if staff suspected the resident sustained a fracture, she trained them to send the resident to the hospital to be x-rayed and further evaluated. DON also stated she trained staff to administer pain medication and/or treatment to the resident if they are able to do such, conduct neurological checks on the resident, and notify the resident's RP of the fall. DON stated CNAs and LVNs checked on residents every hour or more. DON also stated any staff member could check on a resident. DON stated she was notified by a nurse that Resident #1 was on the floor on 10/16/23. DON also stated Resident #1 expressed he was experiencing pain in his right hip and staff wanted to send him out, but he refused to go to the hospital. DON stated staff ordered a mobile x-ray for Resident #1, in which his x-ray results were negative for fracture on 10/16/23. DON also stated on 10/26/23, Resident #1 expressed he was experiencing pain in his left side and staff sent him out based on his telehealth visit with the NP. DON stated the hospital ordered an x-ray Resident #1, in which his x-ray results were positive for a right hip fracture . DON also stated she did not know if Resident #1 expressed experiencing pain between 10/17/23 and 10/25/23. DON stated she could not recall if Resident #1 had any other falls prior to 10/16/23. DON also stated she never received complaints about residents left on floor after a fall. During an interview on 11/10/23 at 3:45 p.m., DON stated staff unlocked residents' beds whenever they performed incontinent care or moved the bed to get something that fell underneath it. DON also stated she could not remember if Resident #1 had a mobility bar installed on his bed prior to 10/16/23. DON stated LVN A was supposed to work on 11/07/23, but he did not show up for work. DON stated she made multiple attempts to contact LVN A, but he did not return any of her calls or text messages. During an interview on 11/10/23 at 4:21 p.m., DON stated she and the ADONs verbalized to all staff about locking residents' beds following Resident #1's incident on 10/16/23. DON also stated she did not document her and the ADONs verbalizing to all staff about locking residents' beds. DON stated the CNAs, LVNs, MAs trained each other on how to lock and unlock residents' beds. DON also stated management staff did not train nursing staff how and when to unlock and lock residents' beds. DON stated there were no staff designated to oversee and ensure residents' beds were locked. DON also stated the facility did not have a policy and procedure on locking and unlocking residents' beds. DON stated she did not know why Resident #1's bed was unlocked and did not know who left his bed unlocked on 10/16/23. During an interview on 11/10/23 at 4:53 p.m., ADM stated there was no training given to staff that specifically highlighted how and when to lock and unlock residents' beds. ADM also stated Resident #1's incident was used as an example and scenario during the fall prevention and intervention, abuse, and neglect in-services given to staff. ADM stated housekeeping staff unlocked and locked residents' beds when they cleaned residents' rooms. ADM also stated CNAs and LVNs unlocked and locked residents' beds when transferring residents with a Hoyer lift. ADM stated she did not know why Resident #1's bed was unlocked and did not know who left his bed unlocked on 10/16/23. During an interview on 11/10/23 at 5:41 p.m. , MS stated he was not sure if he ever had a service order to check or repair a resident's bed because it did not lock. MS also stated housekeeping staff sometimes moved residents' beds when they cleaned residents' rooms. MS stated he believed he repaired Resident #1's bed remote control that raised and lowered his bed. MS also stated he never had to replace a lock or residents' bed because it did not unlock and lock. An attempt to interview LVN A was made on 11/10/23 at 5:54 p.m., but LVN A did not return the surveyor's call prior to exit. During an interview on 11/10/23 at 6:05 p.m., Charge Nurse stated she did not know what happened on 10/16/23. Charge Nurse also stated she heard about Resident #1's unwitnessed fall after other staff responded to it on 10/16/23. Charge Nurse stated there was an LVN who checked on Resident #1 before LVN A, but she did not know who it was. Charge Nurse also stated LVNs and CNAs unlocked and locked residents' beds when transferring a resident using a Hoyer lift. Charge Nurse stated housekeeping unlocked and locked residents' beds when they cleaned residents' rooms . During an interview on 11/10/23 at 6:37 p.m., CNA C stated she was trained and in-serviced on abuse, neglect, and falls and was recently in-serviced on the topics last week. CNA C also stated the ADM was the abuse and neglect coordinator. CNA C stated she was comfortable reporting abuse and neglect. CNA C also stated she never had to unlock and move a resident's bed. CNA C stated she knew how to unlock and lock resident's bed. CNA C also stated she was not trained by management staff on how to unlock and lock residents' beds. CNA C stated she was trained by another CNA on how to unlock and lock residents' beds. CNA C also stated she never observed housekeeping staff unlock and move residents' beds. Review of the facility's incident log from 10/1/23 through 11/10/23 reflected Resident #1 had an unwitnessed fall in his room on 10/16/23 at 6:10 a.m. Review of the facility's maintenance log from October 2023 through November 2023 reflected MS replaced Resident #1's missing bed remote on 10/31/23. There were no other service orders related to Resident #1's bed. Review of facility's in-services reflected staff were trained on one-to-one observation, abuse, neglect, falls, redirecting agitated residents and call lights on 10/25/23 and 10/26/23 and diffusing aggressive behaviors, abuse, and neglect on 10/04/23. Review of the facility falls and fall risk managing policy and procedure revised in December 2007 reflected the following: Policy Statement: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Policy Interpretation and Implementation: Prioritizing Approaches to Managing Falls and Fall Risk 1. The staff, with the input of the Attending Physician, will identify appropriate interventions to reduce the risk of falls. If a systematic evaluation of a resident's fall risk identifies several possible interventions, the staff may choose to prioritize interventions (i.e., to try one or a few at a time, rather than many at once). 2. Examples of initial approaches might include exercise and balance training or a rearrangement of room furniture. 6. In conjunction with the Attending Physician, staff will identify and implement relevant interventions (e.g., hip padding or treatment of osteoporosis, as applicable) to try to minimize serious consequences of falling. Monitoring Subsequent Falls and Fall Risk 1. The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling. 2. If interventions have been successful in preventing falling, staff will continue the interventions or reconsider whether these measures are still needed if a problem that required the intervention (e.g., dizziness or weakness) has resolved. 3. The staff and/or physician will document the basis for conclusions that specific irreversible risk factors exist that continue to present a risk for falling or injury due to falls. Review of the facility's accidents and incidents investigating and reporting policy and procedure revised in April 2013 reflected the following: Policy Statement: All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the Administrator. Policy Interpretation and Implementation: 1. The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident. 3. This facility is in compliance with current rules and regulations governing accidents and/or incidents involving a medical device. 5. The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall complete a Report of Incident/Accident form and submit the original to the Director of Nursing Services within 24 hours of the incident or accident. 6. The Director of Nursing shall ensure that the Administrator receives a copy of the Report of Incident/Accident form for each occurrence. Review of the facility's bed safety policy and procedure revised in December 2007 reflected the following: Policy: Our facility shall strive to provide a safe sleeping environment for the resident. Policy Interpretation and Implementation: 1. The resident's sleeping environment shall be assessed by the interdisciplinary team, considering the resident's safety, medical conditions, comfort, and freedom of movement, as well as input from resident and family regarding previous sleeping habits and bed environment. 2. To try to prevent deaths/injuries from the beds and related equipment (including the frame, mattress, side rails, headboard, footboard, and bed accessories), The facility shall promote the following approaches: a. Inspection by maintenance staff of all beds and related equipment as part of our regular bed safety program to identify risks and problems including potential entrapment risks. b. Review that gaps within the bed system are within the dimensions established by the FDA (Note: The review shall consider situations that could be caused by the resident's weight, movement, or bed position.). c. Ensure that when bed system components are worn and need to be replaced, components meet manufacturer specifications. d. Ensure that bed side rails are properly installed using the manufacturer's instructions and other pertinent safety guidance to ensure proper fit (e.g., avoid bowing, ensure proper distance from the headboard, and footboard, etc.); and e. Identify additional safety measures for residents who have been identified as having a higher than usual risk for injury including entrapment (e.g., altered mental status, restlessness, etc.). 3. The maintenance department shall provide a copy of inspections to the Administrator and report results to the QA Committee for appropriate action. Copies of the inspection results and QA Committee recommendations shall be maintained by the Administrator and/or Safety Committee. 4. The facility's education and training activities will include instruction about risk factors for resident injury due to beds, and strategies for reducing risk factors for injury, including entrapment. 5. If side rails are used, there shall be an interdisciplinary assessment of the resident, consultation with the Attending Physician, and input from the resident and/or legal representative. 6. The staff shall obtain consent for the use of side rails from the resident or the resident's legal representative prior to their use. 7. After appropriate review and consent as specified above, side rails may be used at the resident's request to increase the resident's sense of security (e.g., if he/she has a fear of falling, his/her movement is compromised, or he/she is used to sleeping in a larger bed). 8. Side rails may be used if assessment and consultation with the Attending Physician has determined that they are needed to help manage a medical symptom or condition, or to help the resident reposition or move in bed and transfer, and no other reasonable alternatives can be identified. 9. Before using side rails for any reason, the staff shall inform the resident and family about the benefits and potential hazards associated with side rails. 10. When using side rails for any reason, the staff shall take measures to reduce related risks. 11. Side rails shall not be used as protective restraints. Should a protective restraint be used. our facility's protocol for the use of restraints shall be followed. 12. The use of physical restraint on individuals in bed shall be limited to situations where they are needed to treat a resident's medical symptoms, and only after being reviewed by authorized individuals. 13. The staff shall report to the Director of Nursing and Administrator any deaths, serious illnesses and/or injuries resulting from a problem associated with a bed and related equipment including the bed frame, bed side rails, and mattresses. The Administrator shall ensure that reports are made to the Food and Drug Administration or other appropriate agencies, in accordance with pe1tinent laws and regulations including the Safe Medical Devices Act. This failure resulted in the identification of an IJ on 11/10/23 at 3:51 p.m. The ADM was notified and provided with the IJ template on 11/10/23 at 7:38 p.m. The following Plan of Removal was submitted by the facility and accepted on 11/11/23 at 1:36 p.m.: Plan to remove immediate jeopardy. The facility failed to lock Resident #l's bed. Resident #l rolled out of bed, fell on the ground, and fractured his right hip. All residents residing in the facility can be affected by this deficiency. On 11/10/2023 the Administrator and Director of Nursing notified the Medical Director of immediate jeopardy. On 11/10/2023 Maintenance Director/Designee checked all the occupied beds in the facility to make sure they were locked. On 11/10/2023 Director of Nursing/Designee checked all residents that are currently in the facility for safety while in bed, including making sure all beds are locked. No other residents were identified who had injuries due to unlocked beds while occupying the bed. Medical Director was updated of the assessments. On 11/10/2023 Administrator/Designee completed in-services with nursing staff and housekeeping on how to lock and unlock patients' beds. All staff, including Agency, new hire staff, and PRN will be in-service and will not be allowed to start work till done so. Administrator will ensure all staff completed in-services and training prior to start working. The training will be completed by 11/10/2023. Ad-Hoc QAPI meeting was held on 11/10/2023, with the Medical Director, NHA (Nursing Home Administrator), Director of Nursing, Assistant Director of Nursing, and MDS Coordinator to review the deficiency and the plan for removal of immediacy. Starting on 11/10/2023, Maintenance Director/Designee will check all beds in the facility to be locked while in use or if patient is occupying the bed daily Monday to Friday, and Manager on Duty Saturday and Sunday x 1 month. The staff assigned to the resident will check the bed throughout their shift. If a bed is found unlocked, 1:1 in-service will be completed immediately with staff who are assigned to the resident and bed will be locked immediately. The findings will be immediately brought up to the Administrator for further action, if necessary, as an on-going process. The Administrator/designee will monitor compliance by completing an audit of five (5) residents per week for four (4) weeks to make sure beds are locked while patients are in beds. This will be initiated on 11/10/2023. Any identified concerns 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 for the next 2 months. The Administrator will be responsible for ensuring this plan is completed on 11/10/2023. The RDO will provide oversight of Administrator to ensure that the items on the plan of removal are reviewed and completed. The survey team monitored the Plan of Removal on 11/11/23 as followed: Review of Resident #1's face sheet, progress notes, and care plan reflected RNC reviewed his health records to ensure staff revised and updated his records to reflect his incident on 10/16/23, follow-ups were conducted, and revisions were made. During interviews on 11/11/23 from 5:53 p.m. through 6:03 p.m., 3 LVNs, 1 Agency LVN, 1 Agency RN, and 2 CNAs all stated they were in-serviced on abuse, neglect, and unlocking/locking residents' beds before they started their shifts. During an interview on 11/11/23 at 5:56 p.m., RNC stated she in-serviced the ADM and DON on abuse, neglect, and unlocking/locking residents' beds on 11/10/23 by telephone. During an interview on 11/11/23 at 6:06 p.m., ADON stated she conducted and completed the facility's weekly DON/Designee review of 5 residents per week for 4 weeks on 11/10/23. ADON also stated the beds were locked and there was no action needed/taken for the 5 residents' beds. ADON stated she attended a QAPI meeting on 11/10/23 to discuss the plan of removal for the F689 IJ. ADON also stated she was in-serviced on abuse, neglect, and unlocking/locking residents' beds on 11/10/23 by the DON. An attempt to interview MD was made on 11/11/23 at 6:09 p.m., but MD did not return the surveyor's call prior to exit. During an interview on 11/11/23 at 6:10 p.m., DON stated she was in-serviced on abuse, neglect, and unlocking/locking residents' beds on 11/10/23 by the RNC. DON also stated she in-serviced staff on 11/10/23, 11/11/23 and in-servicing was ongoing until all staff were trained prior to starting their work shifts. DON stated she notified and updated the MD on 11/10/23. DON also stated she attended a QAPI meeting on 11/10/23. DON stated she completed the facility's daily census report on 11/10/23, checked all residents' beds, and ensured the beds were locked. DON stated the RNC reviewed Resident #1's face sheet, progress notes and care plan to ensure staff revised and updated his records to reflect his incident on 10/16/23, follow-ups were conducted, and revisions were made. During an interview on 11/11/23 at 6:16 p.m., HR stated she completed the facility's daily census report on 11/11/23, checked all residents' beds, and ensured the beds were locked. HR also stated she was in-serviced on abuse, neglect, and unlocking/locking residents' beds on 11/10/23 by the ADM and DON. HR stated she attended a QAPI meeting on 11/10/23 and attended the Report of Employee Education on 11/10/23 that was presented by the RNC regarding safety, hazards, bed locking and abuse and neglect. Review of the facility's Report of Employee Education from 11/10/23 reflected SW presented to 5 resident council members subjects regarding safety, hazards, and bed locks on 11/10/23. RNC presented to DON, TN, HR, BOM, SW, and ADM subjects regarding safety, hazards, bed locking and abuse and neglect. Review of the facility's in-services reflected staff were trained on locking and unlocking residents' beds, abuse, and neglect by DON an ADM by in person and over the phone on 11/10/23. Review of the facility's undated notification document reflected MD was notified of the F689 IJ on 11/10/23 by ADM and DON. Review of the facility's QAPI Improvement Plan reflected DON, BOM, ADON, SW, TN, HR, ADM, and MD were present and held a QAPI meeting on 11/10/23 at 8:00 p.m. Review of the facility's daily census reports from 11/10/23 through 11/11/23 reflected all residents' beds were checked to ensure they were locked on 11/10/23 by DON and on 11/11/23 by HR. Review of the facility's weekly DON/Designee review of 5 residents per week for 4 weeks reflected 5 residents' beds were checked to ensure they were locked on 11/10/23 by ADON. 1 of the 5 residents' beds checked was Resident #1. There was no action needed/taken fo[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the residents were free from abuse for 2 (Residents #1 and #2) of 7 residents reviewed for abuse. The facility failed to ensure Residents #1 and #2 were protected from verbal abuse including verbally aggressive behavior, such as cursing, insulting, and intimidation from Residents #3 and #4. Residents #1 and #2 suffered continual negative psychosocial outcomes including fear, anxiety, feelings of hopelessness, and withdrawal from former social patterns. An IJ was identified on 10/20/23. The IJ template was provided to the facility on [DATE] at 9:57 PM. While the IJ was removed on 10/21/23 at 10:48 AM, the facility remained out of compliance at a scope of pattern and a severity level of actual harm that is not immediate to resident health or safety due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. The failure placed all residents in the facility at risk for verbal abuse, and severe negative psychosocial outcomes which could prevent them from achieving their highest practicable physical, mental, and psychosocial well-being. Findings included: Record review of Resident #1's undated face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] with a diagnosis of depression (sad). Record review of Resident #1's quarterly MDS dated [DATE] revealed: Section C for Brief Interview for Mental Status score revealed a score of 15, which indicated the resident's cognition was intact. Record review of Resident #2's undated face sheet revealed that he was a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of a general anxiety disorder (produces fear, worry, and a constant feeling of being overwhelmed). Record review of Resident #2's quarterly MDS dated [DATE] revealed: Section C for Brief Interview for Mental Status score revealed no score. Record review of Resident #3's undated face sheet revealed that he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including vascular dementia (disrupts blood flow to the brain and affects memory, thinking, and behavior), psychotic disturbance mood (episodes of depression), mood disturbance (feelings of distress, sadness, or symptoms of depression and anxiety), anxiety (increased alertness, fear, and rapid heartbeat), and major depressive disorder (sadness). Record review of Resident #3's quarterly MDS dated [DATE] revealed: Section C for Brief Interview for Mental Status score revealed a score of 15, which indicated the resident's cognition was intact. Section E Behavior Symptom - presence and frequency revealed a 0 for verbal behavioral symptoms directed toward others, and other behavioral symptoms not directed toward others; that indicated that the behaviors were not present. Record Review of Resident #3's care plan dated 09/26/23 revealed Resident #3 had a history of aggressive behavior toward another resident. Interventions included to intervene as needed to protect the rights and safety of others. Approach and speak in a calm manner; divert attention; and remove from the situation and take to another location as needed. Record review of the facility's incident report printed 10/20/2023 revealed: 08/12/23 authored by LVN E at 0:30 AM aggressive combative behavior 09/03/23 authored by LVN A at 7:30 AM aggressive behavior 09/21/23 authored by LVN B at 8:30 PM resident-to-resident altercation Record review of Resident #3's progress note printed 10/21/23 revealed: -09/03/23 at 7:30 AM Nurse Note authored by LVN A ,Resident got into a verbal altercation with another resident while receiving his morning medication. The resident was yelling at another resident because he didn't like the way he was being approached. This nurse separated the two residents by bringing one resident to the dining room. RP and ADON notified. -09/21/23 at 7:50 PM Nurse Note authored by LNV B, Resident claims that another resident ran over his leg with automatic wheelchair resident stated that he punched that resident in the right side of his jaw. No injuries noted to the resident left lower leg where he stated that the injury took place. RP made aware. Incident between residents was unwitnessed. NP notified no new orders received at this time. No c/o pain voiced at this time. -10/12/23 at 7:14 PM Nurse Note authored by LVN B, Staff witnessed resident yelling at another resident outside stating that the resident slammed his bedroom door and woke him up. This writer was at the nurse station and did not hear a door slam. Resident was outside this AM when the writer arrived to work and came in the facility 30 min later. This resident finally started to walk towards the back of the facility. -10/12/23 at 7:25 PM Nurse Note authored by LVN B, Resident approached nurse station where 2 staff members and a resident were at. Resident accused another resident of making a comment. Staff asked what he was referring to, and resident starting arguing with resident stating that she made some comment and I'm tired of it. Other resident told this resident to leave her alone, she never said anything towards him and the resident continued to argue and walk down the hallway. Resident walked in to another room to conversate. Record review of Resident #4's undated face sheet revealed that he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including altered mental status (change in mental function), bipolar disorder (shift in mood), and major depressive disorder(sadness). Record review of Resident #4's quarterly MDS dated [DATE] revealed: Section C for Brief Interview for Mental Status score revealed a score of 09, which indicated the resident's cognition was moderately impaired. Section E Behavior Symptom - presence and frequency revealed a 2 for verbal behavioral symptoms directed towards others, and other behavioral symptoms not directed toward others; that indicated that the behaviors were present. Record review of Resident #4's care plan dated 08/16/23 revealed Resident #4 had a behavior problem related to aggressive behavior toward other staff and residents. Interventions were to intervene as needed to protect the rights and safety of others; approach and speak in a calm manner; divert attention; and remove from the situation and take to another location as needed. Record review of the facility incident report dated 09/03/23 authored by LVN A at 7:30 AM revealed an incident with Resident #4 aggressive behavior/yelling. Record review of Resident #4's progress note revealed: -10/12/23 8:32 AM Nurse Note authored by LVN B, Resident was in the dining room and threw away another resident plate of food. Other resident was walking asking dietary staff for jelly and was not seated at the table at the time. Other resident confronted this resident and this resident states you weren't sitting there and this what I do you crazy motherfucker. Staff attempted to separate residents from arguing and assisting them to walk away and this resident walks out in the dining room and states, Everyone know what I do here so quit yelling with your crazy motherfucking ass. Attempted to redirect resident to not talk to other residents in that manner and resident walks away swearing. Record review of the facility's concerns/grievances form dated 8/23/23 revealed Resident #1 made a complaint against Resident #3 and Resident #4. The form reflected Resident # 1 stated that [Residents #3 and # 4] are calling me a faggot because I am gay and make comments about my sexuality. Plan to resolve the DON and ADM offered Resident #1 to change rooms so Resident # 1 would not have to frequently see Resident #3 and Resident #4. Resident #1 refused the room change. No resolution to the name-calling behavior with Resident # 3 and Resident #4. An interview on 10/20/23 at 3:00 PM was attempted in Resident #3's room. While trying to ask questions Resident #3 was verbally aggressive and loud with the surveyor. Resident #3 was very upset and stated that the surveyor was just like the rest of them and stated, don't do anything. The surveyor exited Resident #3's room and immediately started speaking with the ADON. Resident #3 came into the hall by the nurse's station, being very loud and verbally aggressive while the surveyor was speaking with the ADON. Resident #3 followed the ADON and surveyor down the hall. The surveyor and ADON asked Resident #3 to calm down as she didn't want the other residents to get upset. When the surveyor was on the phone in the conference room communicating the events to the program manager Resident #3 entered the conference room speaking loudly with his cell phone to his ear. Resident #3 was advised by the surveyor she was taking a call and he left the conference room. An interview on 10/20/23 at 4:30 PM revealed Resident #1 and Resident #2 came to the conference room where the surveyor was seated and wanted to let the surveyor know what they observed with Resident #3. Resident #1 and Resident 2 observed the incident with the surveyor. Resident #1 and Resident #2 stated that was the behavior that Resident #3 displayed with them. Resident #1 and Resident #2 both appeared frantic and spoke very fast in a frightened tone. Resident #1 and Resident #2 stated they observed how Resident #3 was loud with the surveyor and followed the surveyor, and was very hostile. Resident #1 and Resident #2 both stated they would be retaliated against because staff saw them waiting to talk with the surveyor. Resident #1 and Resident #2 stated they were tired of the name-calling, being cursed at, and being harassed by Resident #3 and Resident #4. Resident # 1 stated he filed a grievance sometime back in August 2022, (could not recall the day) and the only thing offered was a room exchange. Resident #1 stated why would a room change fix the problem as he would still have to see Resident #3 and Resident #4. Resident #1 stated Resident #3 and Resident #4 walked the entire facility daily. Resident #1 and Resident #2 stated nothing had been done and they both had made several complaints to the ADM and DON. Resident #1 and Resident #2 both stated management was not doing anything about Resident #3 and Resident #4 and they both did not feel safe at the facility. Resident #1 and Resident #2 both stated they were fearful of Resident #3 and Resident #4 because they called out of their names and were followed behind saying vulgar things. Resident #2 stated Resident #3 and Resident #4 would walk behind her and call her a bitch and a hoe. Resident #2 stated that was very degrading to think of her as those things. Resident #2 stated the harassment of being called out of her name had made her emotionally down. Resident #2 stated when Resident # 3 and Resident #4 were saying vulgar things about her she started to think about how people really felt about her. Resident #2 stated that Resident #3 and Resident #4 walked around the facility a lot and just last night 10-19-23 were saying cuss words towards her. Resident #2 stated it was intimidating and very uncomfortable. Resident #3 and Resident #4 had been getting away with it for too long and it had to be stopped. Resident #2 did not feel the facility was protecting her and with Resident #3 and Resident #4's behaviors she was in fear. Resident #2 stated Resident #3 and Resident #4's behavior would get worse and somebody may eventually get hurt. Resident #1 stated that name-calling and harassment of his sexuality had been happening for almost a year now. The behavior with Resident #3 and Resident #4 started in December 2022 (could not recall the date). Resident #3 and Resident #4 would call him names such as fagots, sissy, gay, and horrible profanity towards him. Resident #1 stated that had affected him emotionally because that was who he was and he could not change who he was. Resident #1 did not feel comfortable as he was in a wheelchair, and Resident #3 and Resident #4 followed behind him talking trash about him and calling him names. Resident #1 was afraid of Resident #3 and Resident #4 and he felt the facility was making it worse by not doing anything about it. Resident #1 told the DON and ADM several times about Resident #3 and Resident #4's behaviors. When Resident #1 was by himself and not with Resident #2 they were even worse because they said things such as they will beat the [NAME] up. When Resident #1 was not with Resident #2 they were both in their rooms to avoid Resident #3 and Resident #4. Resident #1 and Resident #2 avoided being followed around and being imitated by Resident #3 and Resident #4. Resident #1 and Resident #2 stated that it was not safe for them at the facility because someone would eventually get hurt. Resident #1 and Resident #2 were not comfortable with it and it made them not want to be at the facility any longer, but they had no other place to go. Resident #1 stated he was involved in an incident months back on hall 800 could not recall the date) with Resident #3 where he had hit him He stated the state agency had investigated the incident and he had spoken with a surveyor. An interview on 10/20/23 at 5:00 PM the DON stated when the grievance was made back in August on the 23rd, 2023, Resident #1 had made a complaint that Resident #3 and Resident #4 had been calling him names. The DON offered a room change so he would not frequently see Resident #3 and Resident #4, and Resident #1 declined. The DON stated no residents ever came to her saying they were not safe. The DON stated Resident #1 had not made any further concerns or complaints. Resident #3 and Resident #4 were talked to and nothing else was said to her after. The DON stated Resident #1 was at the front all day and never said anything to her about safety concerns. The DON stated she did not witness the incident with Resident #2 and Resident #3 during the mock trial resident council meeting. The DON stated there were not any witnesses that Resident #3 was calling Resident #2 out of her name. An interview on 10/20/23 at 5:17 PM the ADM stated that Resident #4 and Resident #5 were care planned for behaviors and interventions to redirect, seeing psych services, and taking medications for behaviors. The ADM stated that Resident #3 and Resident #4 did not like Resident #1. The ADM stated she knew about that name-calling when Resident #1 filed a grievance back in August 2023. Resident #1 was given the option to move rooms and he declined. The ADM stated Resident #4 and Resident #5 were talked to by the DON. The DON had talked to Resident #2 on 10-19-23 about the incident in the resident council mock meeting where Resident #4 had supposedly cursed Resident #2 out. The ADM stated corporate did not tell them anything like that happened in the meeting. The ADM stated it was known that Resident #1, Resident #3, and Resident #4 did not like each other The ADM stated that Resident #1 would say things back to Resident #3 and Resident #4 as well. The ADM stated no residents had mentioned anything to her about not being safe at the facility. An interview on 10/20/23 at 6:00 PM the ADON stated around September 2023 date (unknown) Resident #2 overheard Resident #3 fussing with nursing staff and Resident #2 felt nervous about it. Resident #2 did not mention any concern about her safety. The ADON stated no report was made due to Resident #2 not mentioning she was scared. The ADON stated she knew Resident #1 made a grievance about Resident #3 and Resident #4 calling him names. The ADON stated no one had made any complaints or concerns to her since the incident. An interview on 10/20/23 at 6:05 PM LVN A stated Resident # 3 and Resident # 4 used foul language while talking. LVN A stated he had observed behaviors from resident to resident. LVN A recalled Resident #3 was in a verbal altercation with a resident while receiving his medication. Resident #3 was yelling at the other resident. LVN A redirected them by taking one resident to the dining room. LVN A stated state came in and investigated an incident with Resident #3. An interview on 10/20/23 at 7:00 PM revealed Resident #4 did call Resident # 1 names because he didn't like Resident # 1 or Resident #1's sexuality. Resident #4 stated that he had called Resident #1 even worse things as he stated he just don't like the [NAME]. Resident #4 started using vulgar profanity while talking about Resident #1. Record review of the facility's abuse policy revised August 2006 reflected, Our residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion. On 10/20/23 at 9:57 PM, the ADM and DON were informed that an Immediate Jeopardy (IJ) for abuse was identified and were provided the Immediate Jeopardy template. On 10/21/23 at 10:48 AM the following plan of removal was accepted: Plan for REMOVAL Plan to remove immediate jeopardy. The facility failed to ensure 2 residents were free from verbal abuse. Resident #1 and Resident #2 are experiencing verbal and emotional abuse by Resident #3 and Resident #4 resulting in the residents feeling unsafe at the facility. All residents residing in the facility can be affected by this deficiency. F600 On 10/20/2023 the Administrator and Director of Nursing notified the Medical Director of the immediate jeopardy. On 10/20/2023 the Director of Nursing/Designee assessed the resident (R1) and resident (R2) for any changes in condition, provided emotional support - no findings, the MD notified and responsible party. Resident (R3) and resident (R4) were placed 1: 1 for supervision till evaluated by behavioral services. Staff will be with Residents #3 and #4 at all times, within sight during their stay at the facility; staff will be trained on 1:1 supervision as assigned. The Administrator or Director of Nursing will assign staff to complete 1: 1 supervision. On 10/20/2023 the Administrator/Designee completed safe surveys on all residents in the facility - no other allegations of abuse or fear/not feeling safe in the facility due to those residents. The Medical Director was notified; the Ombudsman was notified. No changes in condition were noted. If patient is not feeling safe, staff will stay with the resident to reassure they are safe and cared for, behavioral services and/or social services will provide emotional support. The DON/Designee will be responsible to train staff on the weekends. On 10/20/2023 the [NAME] President of Clinical Operations (VPCO) completed an in-service with the Director of Nursing and Administrator on abuse and neglect prevention. Starting on 10/20/2023 the Director of Nursing/Designee will initiate in-service with staff on abuse and neglect preventions, keep residents safe, identifying signs and symptoms of fear or feeling not safe and re-direct, assure patients' safety and support. All staff, including agency, new hire staff, and PRN will be in-service and will not be allowed to start work till done so. The Administrator will ensure all staff completed in-services and training prior to start working. The training will be completed by 10/21/2023. Ad-Hoc QAPI meeting was held on 10/20/2023, with the Medical Director, NHA (Nursing Home Administrator), Director of Nursing, Assistant Director of Nursing, Regional Nurse Consultant, and MOS (sic) Coordinator to review the deficiency and the plan for removal of immediacy. Starting on 10/20/2023, IDT (Interdisciplinary team), including the Administrator, Director of Nursing, Assistant Director of Nursing, and MOS (sic) Coordinator will meet with all residents to determine of any allegations of abuse or feeling not safe while in the facility daily Monday to Friday, and Manager on Duty Saturday and Sunday x 1 month. The findings will be immediately brought up to the Administrator for further action, if necessary, as an on-going process. If action is needed, the Administrator/Designee will meet with the resident and make sure patient feels safe and provide emotional support, including involving behavioral services and/or social services, and the Medical Director and responsible party will be notified, and if allegation of abuse is identified, the Administrator will notify the appropriate authority. The Director of Nursing/designee will monitor compliance by completing an audit of five (5) residents per week for four (4) weeks for allegation of abuse or not feeling safe while in the facility. This will be initiated on 10/20/2023. Any identified concerns 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 for the next 2 months. 10/20/2023 RDO will provide physical oversight at facility weekly x 4 weeks and then monthly x 2 months. The Administrator/Designee met with the resident council on 10/20/23 and then monthly to review abuse prevention policy and patients' safety while in the facility. The Administrator will be responsible for ensuring this plan is completed on 10/21/2023. The RDO will provide oversight of Administrator to ensure that the items on the plan of removal are reviewed and completed. POR monitoring: Record review of in service on de-escalation techniques, abuse, and neglect started on 10/20/23 and completed on 10/21/23. An observation on 10/21/23 at 1:15 PM revealed Resident #3 in a 1-to-1 with CNA A outside of Resident #3's room. An observation on 10/21/23 at 1:35 PM revealed Resident #4 in a 1-to-1 with LVN F outside of the facility taking a walk. An observation on 10/21/23 at 1:40 PM revealed Resident #3 in a 1-to-1 with CNA A outside of Resident #3's room. An observation on 10/21/23 at 2:10 PM revealed Resident #3 in a 1-to-1 with CNA A walking to Resident #3's room. An observation on 10/21/23 at 2:15 PM revealed Resident #4 in a 1-to-1 with LVN F walking by the nurse station. An observation on 10/21/23 at 2:30 PM revealed Resident #3 in a 1-to-1 with CNA A walking by the nurse station. An observation on 10/21/23 at 2:35 PM revealed Resident #4 in a 1-to-1 with LVN F outside Resident #4's room. An observation on 10/21/23 at 2:45 PM revealed Resident #3 in a 1-to-1 with CNA A walking by the conference room. An observation on 10/21/23 at 2:48 PM revealed Resident #4 in a 1-to-1 with LVN F walking throughout the halls. An interview on 10/21/23 at 1:15 PM CNA A stated he was trained on abuse and neglect and de-escalation on 10/21/23. CNA A know the signs of abuse and know to report it to abuse coordinator, and make sure residents are safe. CNA A was able to identify the signs of abuse and gave examples. An interview on 10/21/23 at 1:30 PM RN A stated she was trained on abuse, neglect, and de-escalation on 10/21/23. RN A know the signs of abuse, and neglect, know to report to abuse coordinator . RN A stated she was trained on how to handle aggressiveness by calming the residents to remain safe. An interview on 10/21/23 at 1:36 PM CMA A stated she was trained on abuse, neglect, and de-escalation before the start of her 6 AM shift. CMA A stated, know the signs of abuse and neglect, know to report immediately to the abuse coordinator if witnessed, and know how to handle aggressive residents by calming them down. An interview on 10/21/23 at 2:09 PM LVN F stated she was trained on abuse and neglect on 10/21/23. LVN F stated that she knew the signs of abuse and neglect and know who to report it to immediately to the abuse coordinator. Record review of safe surveys of all residents was conducted on 10/20/23. On 10/21/23 The Administrator was informed the IJ was removed 10/21/23 at 10:48 AM However, the facility remained out of compliance at actual harm that is not immediate and a scope of a pattern due to the facility's need to monitor the evaluate the 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 pharmaceutical services (including procedures that assure the accurate administering of all drugs and biologicals) to meet the needs of each resident for 1 of 1 residents reviewed for medication administration. The facility failed to identify Resident #1 had been cheeking or pocketing his medication during medication pass on multiple occassions without staff kowledge and it is unknown if Resident #1 took any of the pills. An IJ was identified on 08/15/2023 . While the IJ was removed on 08/16/2023 at 7:45 PM, the facility remained out of compliance at a severity level of no actual harm that is not immediate jeopardy at a scope of isolated, due to the facility's need to evaluate the effectiveness of the corrective systems. This deficient practice placed residents at risk to from suffer serious harm, serious impairment, or death from drug, alcohol interactions, and prescription narcotic pain medication interaction. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including Rhabdomyolysis (damaged muscle tissue releases its proteins and electrolytes into the blood. and can damage the heart and kidneys and cause permanent disability or even death, chronic alcohol usage is one of the leading causes of rhabdomyolysis due to the effects of drinking on muscular tissues), Enterocolitis due to Clostridium difficile (a disturbance of the normal bacterial flora of the colon, colonization by C difficile, and the release of toxins that cause mucosal inflammation and damage), other lack of coordination, acute kidney failure, alcoholic fatty liver, metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood), alcohol use, unspecified with other alcohol-induced disorder, and other seizures. Review of Resident #1's quarterly MDS assessment, dated 05/24/2023 reflected a BIMS score of 10 (suggesting moderate cognitive impairment) and was admitted to the facility after an acute hospitalization. R#1 received PRN pain medications or was offered and declined. Pain assessment interview reflected R#1 revealed that R#1 had had no pain or hurting at any time in the last 5 days. R# 1 received opioid medication 7 for the last 7 days. Review of R#1's quarterly care plan problem start date 08/29/2022 reflected Cognitive Loss/Dementia - Resident #1 had cognitive loss or alteration in thought processes as evidenced by impaired decision making, cognition worsening in the evening. Review of R#1's quarterly care plan problem start date 08/14/2022 reflected R#1 had drug and alcohol seeking behavior. R#1 had been suspected by staff of being intoxicated while in facility. Review of R#1's hospital records received from the facility dated 06/09/2022 revealed patient brought into hospital and found to be intoxicated at an alcohol level above 200 (a person may experience blackouts). R#1 was admitted to the facility on [DATE]. Interview on 08/15/2023 at 12:24 pm with the ADM revealed a charge nurse caught a resident (Resident #1) with two 1.75-liter bottles of Bacardi whiskey. ADM revealed she was nsure how R#1 obtained the alcohol because he does not have any income. The facility does not have an alcohol policy and R#1 is on pain medication; narcotics. It was revealed that the NP placed an order for R#1 to go to the emergency room for a toxicology screen (refers to various tests that determine the type and approximate amount of legal and illegal drugs a person has taken). but the emergency medics refused to take R#1 and stated it was not an emergency. NP placed R#1's narcotic pain medications on hold for 48 hours. R#1 received Tylenol for pain. Interview on 08/15/2023 at 1:17 pm with the CN revealed she found R#1 with two 1.75-liter bottles of Bacardi. One bottle was empty and the second was one 2/3 empty. CN revealed that R#1 was upset because his medication was changed, and normally he understood and was fine, but he was angry and cursing her out and had not previously exhibited this behavior. CN revealed R#1's speech was a little slurred. CN said the medication aide reported to her that R#1 said something inappropriate to her and the medication aide reported she smelled alcohol on R#1's breath. CN revealed that this was not R#1's baseline (state of behavior which is steady in form and frequency). CN revealed that when she went to his room, she found a cup full of Robaxin (a muscle relaxer that works by blocking nerve impulses (or pain sensations) that are sent to your brain) and in a suitcase, 2 bottles of Bacardi. The CN revealed she called the DON and NP. CN revealed she did not know how many Robaxin pills were in R#1's possession but she observed a 30 ml. cup full of pills. When asked CN how she knew what pills were in the cup she revealed they matched the pills with what he was already taking; the Robaxin. CN revealed she did not know how R#1 got that many Robaxin. She did not ask him. When asked about the alcohol, he said he and a friend were outside drinking, but did not tell her how he obtained the alcohol. CN revealed she told the DON about both the Robaxin and the alcohol, but no one asked her about how R#1 got the Robaxin. CN revealed she had not previously seen R#1 with stored Robaxin or any other medications and was not aware of any previous incidents involving alcohol. Interview on 08/15/2023 at 2:00 pm with R#1 revealed he just had one cup of the Bacardi and he was not drunk. He revealed he had the liquor in his room for a while but hid it in a suitcase. When asked where he obtained the Robaxin, he said from the facility. When asked how he obtained so many of the Robaxin, he said he kept the muscle relaxers in his mouth (referred to by the pharamacist at cheeking or pocketing - an attempt to not swallow prescribed medication by concealing it in the mouth for purposes of diverting, hording , and swallowed his other medications, He stored the Robaxin in a container in his room. He said when given his medication from the staff, the staff did watch him swallow his medication. When asked why he cheeked or pocketed the Robaxin, R#1 said he had no intent to harm himself and the CN made, a mountain out of a mole hill. R#1 revealed he brought the alcohol with him and had been drinking it over time, Interview on 08/15/2023 at 4:37 pm with the facility's Pharmacist revealed that both Robaxin and alcohol cause sedation and decreased stimulation of the central nervous system. She said it wasnot a good idea to mix the two substances and muscle relaxers and alcohol are on occasion, combined as a form of drug abuse. She revealed she was not sure if the combination would be lethal, but it was not a good combination. She revealed that cheeking or pocketing pills was a drug seeking behavior. Interview on 08/15/2023 at 5:22 pm with the NP revealed that R#1 told her that prior to his admission to the facility, he would drink alcohol because of pain. She revealed she knew he was in pain, but if he drank an unknown amount of alcohol, consumed an unknown number of cheeked or pocketed prescription medication on top of the prescribed pain medication given, he was putting her in a pickle. It is the facility's responsibility to keep him safe, but he could notbe kept safe if the facility did not know the number of drugs and the amount of alcohol he had consumed. NP revealed R#1 was made a conscious decision to consume alcohol and cheek or pocket medications. When asked if there was an immediate concern for R#1's wellbeing, NP said there was immediacy the second the consumption of an unknown amount of alcohol and muscle relaxers occurred. NP said, regarding the muscle relaxers, who is say if he was going to horde 50 of them. Review of progress note psychiatric evaluation dated 08/14/2023 reflected R#1 had a history of alcohol use. Staff reported he had alcohol problems and recently was intoxicated; pain medication were held for 24 hours. He denied drinking a lot of alcoholic drink. He acknowledged he had a bottle of alcohol drink in his room, but reported he did not drink it all the time. Resident #1 denied ever getting drunk or intoxicated And that reporting staff lied against him. Resident #1 reported his last drink was yesterday . He was sad because his pain medication was held. I didn't take any alcohol, the nurse came to my room and found alcohol and decided to make claim that I am drunk, but I am not. Resident #1 reported anxiety because he is in pain and did not receive his pain medicine. Reported poor sleep and I can't sleep because I am in pain, and I don't have my pain medicine. Review of physician order report dated 08/12/2023, open ended order, reflected may alter medication by crushing, opening, or administering in fluid or food unless contraindicated. Review of progress note dated 08/15/2023 revealed R#1 admitted to hiding liquor in his room and drinking while in the facility and had a friend who signed him out of the facility and took him to buy liquor. Review of order for central acting skeletal muscle relaxant 750 mg. not crushed start dated 01/13/2023 end dated 08/14/2023 three times a day. Review of order start date 06/26/2023 open ended and on hold from 08/14/2023 through 08/15/2023 for hydrocodone-acetaminophen Schedule II tablet (high potential for abuse which may lead to severe psychological or physical dependence); 5-325 mg. amount 1 tab; oral, not to exceed 3,000 mg. in 24-hour period every 4 hours. Review of facility's policy dated December 2012 reflected the director of nursing services will supervise and direct all nursing personnel who administer medications and/or have related functions, medications must be administered in accordance with the orders, including any required time frame, medications must be administered within one (1) hour of their prescribed time, unless otherwise specified. On 08/15/23 at 7:21 PM an Immediate Jeopardy (IJ) was identified. The ADM was notified and provided the IJ Template, and a Plan of Removal (POR) was requested at that time. The following Plan of Removal was submitted by the facility and was accepted on 08/16/2023 at 7:08 PM: On 08/15/2023 an abbreviated survey was initiated at the facility. On 08/15/2023 the surveyor provided an Immediate Jeopardy (IJ) Template notification that Regulatory Services determined that the condition at the facility constituted an immediate threat to resident health and safety. Plan to remove immediate jeopardy. The facility failed to have adequate supervision to prevent potential accidents. Residents with alcohol and/or drug dependency have the potential to suffer serious harm, serious impairment or death from drug interactions. F689 On 8/15/2023 at 7:21pm the IJ was called; the Administrator notified Medical Director of immediate jeopardy. On 8/15/2023 Director of Nursing/Designee assessed the resident (R1) for any changes in condition - no findings, MD notified and Responsible party. On 8/15/2023 Director of Nursing/Designee assessed all residents in the facility who have alcohol and/or drug dependency for any changes in condition, including pocketing medications. No Changes in condition noted. On 8/15/2023 RNC (Regional Nurse Consultant) will complete in-service with Director of Nursing, Assistant Director of Nursing, and Administrator on alcohol and/or drug dependency and medication administration, including monitoring resident during medication administration by asking resident to open their mouth to visualize medication were ingested and confirmation from resident that medication has been ingested, and identifying residents who pocket their medications in the mouth, MD notification, and update Care Plan, alcohol storage will only be allowed at nursing station in secure area and provided to residents as ordered by Physician. When a resident goes out of the facility and upon return staff will interview and observe resident for any alcohol products on-hand and secure at the nursing station. On 8/15/2023 DON/Designee reviewed all residents in the facility who have alcohol and/or drug dependency for pocketing medication - no other resident was identified to pocket medications. Starting 8/16/2023 IDT will review all new admissions and residents identified as alcohol and/or drug dependent for pocketing medications and update the Care Plan for pocketing medications interventions during morning meeting Monday through Friday for 1 month. Starting on 8/15/2023 the Director of Nursing/Designee will initiate in-service with nurses and Medication Aides, including new hires, PRN, and agency staff on adequate supervision of a resident with Alcohol and/or Drug dependencies during medication administration by monitoring patient for swallowing medications and verbal or visual confirmation of ingestion, MD notifications, and alcohol storage will only be allowed at nursing station in secure area. Ad-Hoc QAPI meeting was held on 8/15/2023, with the Medical Director, NHA (Nursing Home Administrator), Director of Nursing, Assistant Director of Nursing, Regional Nurse Consultant, and MDS Coordinator to review the deficiency and the plan for removal of immediacy. Starting on 8/15/2023, IDT (Interdisciplinary team), including Administrator, Director of Nursing, Assistant Director of Nursing, and MDS Coordinator will review current and admitted residents with diagnosis of alcohol and/or drug dependency for behaviors of pocketing medications and ensure updated Care Plan for medication administrations/behaviors of pocketing medications daily Monday to Friday, and Manager on Duty Saturday and Sunday x 1 month. The findings will be immediately brought up to the Administrator for further action, if necessary, as an on-going process. The Director of Nursing/designee will monitor compliance by completing an audit of five (5) residents per week for four (4) weeks who have diagnosis of alcohol and/or drug dependency for pocketing medications and presence of care plan addressing pocketing medications. This will be initiated on 8/15/2023. Any identified concerns 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 for the next 2 months. 8/15/2023 RNC will provide physical oversight at facility weekly x 4 weeks and then monthly x 2 months. Administrator/Designee will meet with resident council on 8/16/23 and then monthly after to review substance abuse policy and procedure, including alcohol storage at nursing station and process of nursing checking residents for pocketing medications. The Administrator will be responsible for ensuring this plan is completed on 8/15/2023. The RDO will provide oversight of Administrator to ensure that the items on the plan of removal are reviewed and completed. Monitoring of the Plan of Removal from 06/07/2023 - 06/12/2023 included the following: Reviewed documentation of assessment of all residents in the facility who have alcohol and/or drug dependency for changes in condition, including pocketing medications. Reviewed in-service and in-service materials and interviewed DON, ADON, and ADM who confirmed they attend the in-service on alcohol and/or drug dependency and medication administration, including monitoring resident during medication administration by asking resident to open their mouth to visualize medication were ingested and confirmation from resident that medication has been ingested, and identifying residents who pocket their medications in the mouth Interview with Medication Aides who confirmed they attended an in-service staff on adequate supervision of a resident with Alcohol and/or Drug dependencies during medication administration by monitoring patient for swallowing medications and verbal or visual confirmation of ingestion, MD notifications, and alcohol storage will only be allowed at nursing station in secure area. Interview with LVN who said she attended an in-service and discussed pocketing medications and that residents should have an order from the doctor on if they can consume alcohol. She said the in-service was helpful and made her realize that she needed to be more observant. Reviewed Ad-Hoc QAPI meeting notes that reflected on 8/15/2023 a meeting with the Medical Director, NHA (Nursing Home Administrator), Director of Nursing, Assistant Director of Nursing, Regional Nurse Consultant, and MDS Coordinator to reviewed the deficiency and the plan for removal of immediacy. Reviewed the 8/15/2023 monitoring audit of five (5) residents who had diagnosis of alcohol and/or drug dependency for pocketing medications and presence of care plan addressing pocketing medications that was to be on 8/15/2023. The ADM was informed the Immediate Jeopardy was removed on 08/16/2023 at 7:45 PM. The facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy identified and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, for one (Resident #1) of two residents reviewed for quality of care, in that: The facility failed to monitor PT/INR values to ensure anticoagulant medication daily dosage was appropriate for Resident #1. An IJ was identified on 07/19/2023. The IJ template was provided to the facility on [DATE] at 6:12 PM. While the IJ was removed on 07/21/2023, the facility remained out of compliance at a scope of isolated with no actual harm with the potential for more than minimal harm that was not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed resident at risk of heart attack, stroke, deep vein thrombosis (occurs when a blood clot (thrombus) forms in one or more of the deep veins in the body, usually in the legs) or pulmonary embolism (a sudden blockage in your pulmonary arteries, the blood vessels that send blood to your lungs), and death. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including myocardial infarction (decreased or complete cessation of blood flow to a portion of the myocardium (muscular tissue of the heart). myocardial infarction may be silent, and go undetected, or can be a catastrophic event leading to hemodynamic deterioration (any cardiovascular condition that affects how well your blood flows) and sudden death), primary, epilepsy (a disorder of the brain characterized by repeated seizures), conversion disorder with seizures or convulsions, cognitive communication deficit, dementia, presence of prosthetic heart valve (mechanical valve), acquired hemophilia (bleeding disorder in which the blood does not clot properly), and hypertension (when the pressure in your blood vessels is too high). Review of Resident #1's MDS assessment revealed a BIMS score of 99 revealed Resident #1 chose not to participate, or 4 or more items in the score were coded 0 because Resident #1 chose not to answer or gave a nonsensical response. Section N of her MDS indicated that she received anticoagulants 7 days. Review of Resident #1's quarterly care plan, created 05/19/2023, reflected no care plan for Resident #1's diagnosis of epilepsy, seizure activity or anticoagulant therapy (having the effect of inhibiting the coagulation (process of blood changing to a solid or semi-solid state) of the blood). Record review of Resident #1's physician orders dated 5/21/23 revealed an order for PT/INR to be drawn daily until INR greater than 2.5 then PT/INR to be drawn every other day. Record review for Resident #1 revealed 8 different lab results for PT/INR dated 5/22/23 revealed INR of 2.5, PT/INR dated 5/23/23 revealed INR of 2.0, PT/INR dated 6/15/23 revealed INR of 1.1, PT/INR dated 6/22/23 revealed INR of 2.1, PT/INR dated 6/27/23 revealed INR of 2.2, PT/INR dated 6/30/23 revealed INR of 1.7, PT/INR dated 7/10/23 revealed INR of 2.5, PT/INR dated 7/17/23 revealed INR of 1.8. Review of Resident #1's progress notes dated 06/17/2023 reflected dining room staff called for nurse to go to the dining room. Resident #1 was found in her chair having had a seizure. Resident #1 was lowered to the floor and continued to have a seizure for a total of 5 minutes. Review of Resident #1's progress notes dated 06/25/2023 reflected Resident #1 had seizure activity when she fell out of her wheelchair, Resident #1 stated she hit her head. Review of Resident #1's progress notes dated 06/27/2023 reflected nurse called into Resident #1's room and found Resident #1 lying on the floor between her bed and the wall. Note reflected that Resident #1 told the med tech she felt like she was going to have a seizure. Note reflected that Med tech reported he turned around and he found Resident #1 on the floor. Note reflected that prior to the fall Resident #1 was sitting in her chair. When evaluated Resident #1 did not respond to her name and had her eyes closed. Note reflected that Resident #1 had a history of seizures. Review of Resident #1's progress notes dated 06/28/2023 reflected S/P seizure/fall yesterday and sent to the emergency room. Review of Resident #1's progress notes dated 07/02/2023 reflected nurse notified by staff that Resident #1 was on the floor and when at Resident #1's room she was found lying on her back between her bed and the wall. Resident #1 appeared to have had a seizure, was not responding to questions asked as usual and seemed slow to respond. Resident #1 complained of mild pain to a back, left hip area and head and was not able to perform range of motion. Resident #1 on anticoagulant therapy. Review of Resident #1's progress notes dated 07/05/2023 reflected Resident #1 had a seizure and hit her head on the table. Resident #1 was assessed and denied any pain. Note reflected staff would continue to monitor and all safety measure remain in place. Review of Resident #1's progress notes dated 07/11/2023 1:36 PM reflected Resident #1 was having lunch in dining room and began having a seizure. Seizure lasted approximately 3 minutes. Review of Resident #1's progress notes dated 07/11/2023 4:36 PM reflected Resident #1 was observed lying on floor unconscious, breathing normally. Review of Resident #1's progress notes dated 07/13/2023 reflected staff in dining room yelled for help and nurse found Resident #1 on the floor in prone position. Appeared to have had an absent seizure, Resident #1 was in and out of consciousness. Resident complained of pain to her head, no visible injury noted. Resident #1 was on Coumadin. Review of Resident #1's progress notes dated 07/17/2023 reflected Resident #1 found slumped over in a rocking chair outside. It seemed like the resident had a seizure. Review of Resident #1's progress notes dated 07/18/2023 12:56 PM reflected Resident #1 had a Grand Mal seizure (a loss of consciousness and violent muscle contractions) with episode lasting approximately 20 minutes. Review of Resident #1's progress notes dated 07/18/2023 8:00 PM reflected Resident #1 was found in room laying on floor next to air conditioning unit. Resident #1 said she had a seizure and hit her head. Resident #1 assessed with no apparent markings. In an interview on 7/19/23 at 4:35 PM, the DON stated if someone had a history of stroke and prosthetic valve replacement and coumadin is not being monitored or treated properly, they could have blood clots, stroke, and death. She said if an order for PT/INR stated to do labs daily until INR is greater than 2.5, labs should be done daily until INR reached 2.6. She said Resident #1 did not have an INR greater than 2.5 since she had lived in facility and PT/INR should have been checked daily. She said she did not know why PT/INR had only been checked 8 times in the 59 days Resident#1 had lab work ordered. She said the lab order in Resident #1's chart was not the order they were using but she could not produce an alternative order. Record review of facility Lab and Diagnostic Test Results - Clinical Protocol reflected the physician will identify and order diagnostic and lab testing based on diagnostic and monitoring needs and the staff will process test requisitions and arrange for tests. A nurse will review all lab and diagnostic test results and the individual's current condition and any recent changes in status, including vital signs and mental status, major diagnoses, pertinent current medications, other recent pertinent lab work, actions already taken to address results and treat the resident. Nurses will review how test results might relate to the individual's current status, treatments, or medications. On 07/19/23 at 6:12 PM an Immediate Jeopardy (IJ) was identified. The ADM was notified and provided the IJ Template and a Plan of Removal (POR) was requested at that time. The following Plan of Removal was submitted by the facility and was accepted on 07/21/2023 at 1:19 PM: On 07/18/2023 an abbreviated survey was initiated at the facility. On 07/19/2023 the surveyor provided an Immediate Jeopardy (IJ) Template notification that Regulatory Services determined that the condition at the facility constituted an immediate threat to resident health and safety. Plan to remove immediate jeopardy. Based on the comprehensive assessment of a resident, ensure that resident receives treatment and care in accordance with professional standards of practice. The facility failed to ensure proper PT/INR Coumadin therapy for Resident #1. Residents who are prescribed Coumadin, and not being monitored or treated properly, have potential for serious injury, serious harm, serious impairment, or death. For 1 of 1 resident, it could cause failure of prosthetic heart valve, excessive bleeding, stroke, and death. 2 residents on Coumadin therapy in the facility could be affected by this deficient practice. F684 On 7/19/2023 @ 20:00 the Administrator and Director of Nurses notified Medical Director of immediate jeopardy. On 7/19/2023 VPCS (Vice President of Clinical Services, RN) completed in-service with Director of Nursing and Assistant Directors of Nursing on Coumadin Therapy, including medications that require lab monitoring for dosage adjustments and therapeutic effectiveness, monitoring and assessing residents for changes in condition and follow MD orders for medication dose and appropriate lab draws, and communication on lab results. On 7/19/2023 Director of Nursing/Designee assessed the Resident 1 for any changes in condition, MD notified and Responsible party. Coumadin order and PT/INR lab work reviewed with MD and orders updated for Resident 1 in EHR. On 7/19/2023 Director of Nursing/Designee assessed all residents who are on Coumadin Therapy for any changes in condition, check their Coumadin order and PT/INR lab work order. No changes in condition noted. Director of Nursing/Designee assessed residents who are on medications that require lab monitoring for dosage adjustments and therapeutic effectiveness for any changes in condition - none noted. MD notified. Starting on 7/19/2023 the Director of Nursing/Designee will initiate in-service with nurses, including new hires, PRN, and agency nurses on Coumadin Therapy, physician orders and PT/INR lab draws tracking and communication, including medications that require lab monitoring for dosage adjustments and therapeutic effectiveness. Ad-Hoc QAPI meeting was held on 7/19/2023, with the Medical Director, NHA (Nursing Home Administrator), Director of Nursing, Assistant Director of Nursing, RRC (Regional Reimbursement Consultant), and VPCS (Vice President of Clinical Services) to review the deficiency and the plan for removal of immediacy. IDT will review all current and new admissions/re-admissions for Coumadin Therapy and physician orders for dosages and PT/INR lab work and medications that require lab monitoring for dosage adjustments and therapeutic effectiveness starting 7/19/2023 during Morning meeting Monday through Friday x 1 month to make sure Coumadin Therapy Protocol is followed, including Checking Coumadin order, PT/INR and medication specific Lab test order and results documentation, communication to physician results and any changes in condition, update orders in EHR and administration of medication as ordered. The findings will be immediately brought up to the Administrator for further action, if necessary. On 7/19/2023 the RNC (Regional Nurse Consultant) will start reviewing residents on Coumadin therapy and medications that require lab monitoring for dosage adjustments and therapeutic effectiveness for compliance to make sure Medication Orders, PT/INR and medication specific lab draws orders, and side effect monitoring orders are in EHR as ordered by physicians and completed, including medication administration and lab draws for four (4) weeks followed by monthly x 2 months. 7/19/2023 RNC/Designee will provide physical oversight at facility weekly x 4 weeks and then monthly x 2 months. The Director of Nursing/designee will monitor compliance by completing a random audit of 5 residents in the facility who are on Coumadin Therapy/medications that require lab monitoring for dosage adjustments and therapeutic effectiveness weekly for four (4) weeks. This will be initiated on 7/19/2023. Any identified concerns 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 for next 2 months. The Administrator will be responsible for ensuring this plan is completed on 7/19/2023. The RDO will provide oversight of Administrator to ensure that the items on the plan of removal are reviewed and completed. Monitoring of the Plan of Removal from 07/19/2023 - 07/21/2023 included the following: Reviewed the in-service, titled, PT/INR Q Monday, documentation, MARS/TARS, Orders and Abuse and Neglect dated 07/19/2023 given by [NAME] President of Clinical Services, RN that addressed Coumadin Therapy, including medications that require lab monitoring for dosage adjustments and therapeutic effectiveness, monitoring and assessing residents for changes in condition and following MD orders for medication dose and appropriate lab draws, and communication on lab results. Interview on 07/21/2023 at 4:00 PM with the DON confirmed she completed the in-service titled, Medication REeruiring Lag Monitoring, PT/INR, Coumadin/Warfarin flowsheet, Labs, Documentation, Seizure Precautions, MARS/TARS, Order, Observations, Contacting the Providers, Fire Safety, and Abuse and Neglect given by [NAME] President of Clinical Services, RN on 07/19/2023. Interview on 07/21/2023 at 4:38 PM with one of the two facility ADONs confirmed she completed the above referenced in-service given by [NAME] President of Clinical Services, RN on 07/19/2023. Interview on 07/21/2023 at 5:49 PM with the second of the two facility ADONs confirmed she completed the above reference in-service given by [NAME] President of Clinical Services, RN on 07/19/2023. Reviewed Resident #1's progress notes entered by the DON on 07/19/2023 that reflected Resident #1 was assessed for any changes in condition and if so, that the MD and Responsible party were notified. Confirmed Resident #1's Coumadin order and PT/INR lab work was reviewed with MD and orders updated for Resident #1 in EHR. Interviewed PRN LVN, ADON, facility LVN, and agency nurse who stated they participated, understood, and felt comfortable with the information given in the above referenced 07/19/2023 in-service given by the DON on Coumadin Therapy, physician orders and PT/INR lab draws tracking and communication, including medications that require lab monitoring for dosage adjustments and therapeutic effectiveness. Reviewed the Ad-Hoc QAPI meeting notes dated 07/19/2023, with the Medical Director, NHA (Nursing Home Administrator), Director of Nursing, Assistant Director of Nursing, RRC (Regional Reimbursement Consultant), and VPCS (Vice President of Clinical Services) to review the deficiency and the plan for removal of immediacy. The ADM and DON were informed the Immediate Jeopardy was removed on 07/21/2023 at 1:19 PM. The facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy identified and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.