**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement written policies and procedures that prohibited and prevented abuse and neglect for two of five residents (Resident #1, Resident #2) reviewed for abuse and neglect. The facility failed to ensure a safe environment free from sexual abuse when Resident #2, who had a history of inappropriate sexual behaviors, placed her hand inside Resident #1's panties. The facility's DON failed to implement interventions upon Resident #2's admission on [DATE], when LVN F informed him Resident #2 was masturbating, and after Resident #2 inappropriately touched him on his pants. The Immediate Jeopardy (IJ) was identified on 09/04/25 at 6:18 PM. The IJ template was provided to the facility's Administrator and DON on 09/04/25 at 6:18 PM. While the immediacy was removed on 09/05/25 at 6:07 PM, the facility remained out of compliance at a scope of pattern and severity level of no actual harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems, and because all their staff had not been trained on 09/05/25. These failures could affect residents by placing them at risk of abuse, physical harm, pain, mental anguish, emotional distress, and serious harm. Findings include: Resident #2 Record review of Resident #2's face sheet current as of 09/03/25, revealed a [AGE] year-old-female who was admitted to the facility on [DATE]. Resident #2 diagnoses included unspecified dementia severe with agitation (a behavioral and emotional state of dementia characterized by behaviors like restlessness, pacing, shouting, aggression, and repetitive actions), mood disorder due to known physiological condition (a mental disorder characterized by persistent changes in mood), and schizoaffective disorder bipolar type (mental health condition episodes that combines mania and depression). Review of Resident #2's Physician's Active Orders dated 08/22/25 included Psychiatric and Psychological services to evaluate and treat as needed. Record review of Resident #2's admission Comprehensive MDS, dated [DATE] revealed the following: *Section C Brief Interview for Mental Status (BIMS) revealed a score of 1 which indicated the resident's cognition was severely impaired. *Section E-Behavior: Physical behavioral symptoms directed towards other (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) occurred 1 to 3 days. Other behavioral symptoms not directed towards others (e.g., physical symptoms such as hitting or scratching self, packing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) occurred 1 to 3 days. Wandering-Presence & Frequency: Has the resident wandered? This was coded with a 0 to indicate this behavior was not exhibited. *Mobility Devices: none of the devices (cane, walker, wheelchair, limb prosthesis) were used. *Functional Abilities-Mobility: Walk 10 feet, once standing, the ability to walk at least 10 feet in a room, corridor, or similar space. This was coded an 88, which meant she had not attempted due to medical condition or safety concerns. Record review of Resident #2's Care Plan dated 08/24/25 revealed her inappropriate sexual behavior was included in her plan after she was found with her hand in Resident #1's panties on 08/23/25. This plan included: *Problem: will not exhibit socially inappropriate/disruptive behavior pattern, specifically impulsive sexual behavior. This would be addressed by approaching Resident #2 and removing her from resident's room and unsafe situations. Maintain a calm environment and calm approach to the resident. Assess whether the behavior endangers the resident and/or others and intervene if necessary. *Problem: has a history of touching other residents inappropriately: This would be addressed through staff and by redirection. *Record review of Resident #2's Event Report dated 08/23/25 indicated Resident #2 was involved in an incident alleging she had her hand down the pants of Resident #1. This incident was witnessed by LVN F, the residents were separated by CNA C and CNA DD, and Resident #2 was placed on one-to-one observation with the nursing staff (1:1, defined as a staff member constantly with the resident and documents at 15-minute intervals). Resident #2, who was in Resident #1's room when this incident occurred was removed from Resident #1's room. This report indicated Resident #2 was assessed and there were no signs of trauma. On 09/02/25 at 9:40 am FNP T gave LVN F orders for Resident #2 to have labs, Senior Psych referral and Aricept 5 mg. q hs. On 09/02/25 at 10:37 am PNP gave LVN F order for Resident #2's Remeron to be change to HS, and to change Paxil to am, and have nursing to monitor for over sedation. PNP added the diagnosis of Alzhelmer's late onset to Resident #2's diagnosis. *The Facility Event Summary Report dated 08/23/25 indicated on 08/23/24 Resident #2 was found with her hand in Resident #1's pantie. After this incident, Resident #1 and Resident #2 were placed on 1:1 observation provided by the nursing staff. The residents were assessed and there were no signs of trauma, and the FNP and PNP were notified of this incident on 08/23/25. Review of Resident #2's Senior PsychCare dated 08/26/25 indicated the facility had requested a referral for psych services. The Senior PsychCare dated 08/26/25 indicated the PNP obtained verbal consent from FM for psych services. Record review of Resident #2's admission documents from her previous facility included the following Progress Notes: *Effective date of 08/03/25 at 8:25 PM that was marked out indicated “Late Entry”, Resident #2 was found in male resident's room sitting on the side of his bed and was playing with male resident's pubic hair that was sticking outside of his brief. The resident was removed and redirected from the room. *Effective date of 08/03/25 at 8:32 PM indicated Resident #2 was placed on 1:1 with monitoring tech, who would be with her and documenting on her progress. *Effective date of 08/03/25 at 7:56 PM indicated Resident #2 went into a male resident's room, he was slightly exposed and she was leaning over and touching him on his peri area. Staff said his brief was on but had it slightly moved to the side and he was not stopping her. Resident #2 was removed immediately and her hand washed. Resident #2 was impulsive and confused. *Effective date 07/16/25, Resident #2 was kissing a male resident, and they were immediately separated. Record review of FNP T's Progress Note dated 09/02/25 indicated Resident #2 was a [AGE] year-old lady who was transferred from a facility to her current facility. The current facility's nursing staff had reported hypersexual behavior to included that Resident #2 was found in a resident's room with her hand down female resident's pants (Resident #1). FNP T noted she would consult with the psychiatric team and check labs. During an interview on 09/03/25 at 10:40 am, Resident #2 was asked a series of questions; however, her verbal responses were not understood. Instead, Resident #2 smiled each time she was asked a question, including if she had touched Resident #1 on her private area. Resident #1 Record review of Resident #1's Face Sheet current as of 09/03/25 revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Resident #1's diagnosis included dementia mild with mood disturbances (emotional or behavioral changes, such as anxiety, apathy, depression or irritability), and anxiety disorder (intense, excessive, and persistent worry and fear about everyday situations). Record review of Resident #1's admission Comprehensive MDS, dated [DATE] revealed the following: *Section C, Brief Interview for Mental Status (BIMS) score revealed a score of 00, which indicated the resident's cognition was severely impaired. *Section E-Behavior, Physical behavioral symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) occurred 1 to 3 days. *Wandering-Presence & Frequency: Has the resident wandered? This was coded with a 0 to indicate this behavior was not exhibited. *Functional Abilities-Mobility, walk 10 feet, once standing, the ability to walk at least 10 feet in a room, corridor, or similar space. This was coded a 6, which meant she could complete this activity by herself with no assistance from a helper. Record review of Resident #1's Care Plan dated 08/12/25 included: *Problem: updated on 08/23/25 to include due to impaired cognition, Resident #1 is at risk for unwanted sexual advances from other residents. This would be addressed by ensuring client safety. *Problem, on 08/12/25 the plan included that she had physically aggressive behavior towards others. The plan included cueing resident to maintain space between self and others and assisting resident in moving self away while interacting with others. Record review of Resident #1's Observation Detail List Report noted by LVN N on 08/23/25 at 11:18 am indicated Resident #2 was witnessed with her hand down Resident #1's pants, in Resident #1's room. The nursing staff immediately entered the room and separated Resident #1 and #2. Resident #2 was placed on 1:1 observation due to this allegation. Resident #1, was assessed and she had no signs of trauma. Record review of Resident #1's Progress Notes indicated the following: *The ADON noted that on 08/26/25 Resident #1's Interdisciplinary Team met and discontinued her 1:1 observation. *The DON noted that on 08/23/25 Resident #1 (who was on 1:1 observation) was involved in an incident in which resident (Resident #2) was witnessed with her hand down resident #1's pants in Resident #1's room. Nursing staff entered the room, separated Resident #1 and #2, and removed Resident #2 from Resident #1's room. Resident #1 was assessed and there were no signs of trauma. *The DON noted on 08/22/25 that Resident #1 (who was the aggressor) was involved in an altercation with Resident #9, by slapping her on her back. Resident #9 responded by slapping Resident #1 in the face near her eye. The residents were separated and Resident #1 was placed on 1:1 observation until she could be cleared by psychiatric services. During an observation on 09/03/25 at 10:45 am revealed Resident #2 entered Resident # 7's room, and there were no CNAs present in the area. LVN L, who was at the end of the hallway, was notified that Resident #2 was in Resident #7's room. LVN L went to Resident #2, who was in Resident #7's room, and redirected and escorted her to leave the room and go to the dining/lobby area. During an interview on 09/03/25 at 11:15 AM, Resident #1 indicated nobody hurt her and she could not recall being touched on her body by Resident #2. During an interview on 09/05/25 at 11:23 AM, FM S indicated he was informed that Resident #1 was touched on the buttock by a resident but never informed that she was fondled in her private area by a resident. During an interview on 09/04/25 at 3:04 PM, CNA A indicated she started her shift on 08/22/25 at 6 PM and worked until 6 am on 08/23/25. During this shift, CNA A said she was assigned as Resident #1's 1:1 observation, which meant she had to watch her closely and keep her out of residents' room. CNA A said before she left the faciity on [DATE] at 6 am, she informed a CNA, whose name she could not recall, that she was leaving and transferring her observation to the next shift. CNA A said Resident #1 was asleep in her bed when she left. During an interview on 09/03/25 at 10:46 AM, CNA C indicated on 08/23/25 she was working with CNA P; however, CNA O, who was assigned as Resident #1's 1:1 observation had not started her shift at 6 am, instead she started at 7 am. CNA C said her and CNA P provided ADL care to the residents to get them ready for breakfast. CNA C said she saw Resident #1 in the dining/lobby area and saw Resident #2 going into Resident #1's room, where she sat and fell asleep on Resident #1's recliner. CNA C said she did not redirect Resident #2 to leave Resident #1's room because she has a history of becoming upset, and because Resident #1 was not in her room. CNA C said she did not see Resident #1 return to her room, while Resident #2 slept on her recliner. CNA C said she was unaware that Resident #2 had to be watched closer due to inappropriate sexual behavior, and she knew Resident #1 had behaviors of aggression and was supposed to be watched closer per FM's request. During an interview on 09/04/25 at 10:48 AM, CNA P indicated she worked on 08/23/25 and was directed by DON to keep an eye on Resident #1 due to inappropriate touching; however, she was not assigned as her 1:1 observation. CNA P said she worked with CNA C and they assisted residents with their ADLs to get them ready for breakfast. CNA P said CNA O was supposed to start her shift at 6 am and carry out Resident #1's 1:1 observation; however, she did not arrive until 7 AM. CNA P said she assisted Resident #1 with her ADLs and took her to the dining table because Resident #2 had entered Resident #1's room. CNA P said it was easier to take Resident #1 out of her room than Resident #2, which was why she allowed Resident #2 to stay in the room. CNA P said she informed LVN F, who was administering medications, that she was leaving Resident #2 in Resident #1's room. CNA P said at approximately 7 AM CNA O entered the memory unit and asked for the whereabouts of Resident #1 and replied that Resident #1 was supposed to be in the dining area. And that's when, LVN F yelled out for staff to get Resident #2 because she was foundling Resident #1 in her room and asked who was Resident #1's 1:1 observation. CNA P said she entered Resident #1's room and saw Resident #1 standing with her pants unbuckled and in front of Resident #2, who was sitting on the recliner and holding Resident #1 by her wrist. CNA P said earlier in the morning, she dressed Resident #1 and left her pants unbuckled because they did not fit her. CNA P said upon the start of her shift on 08/23/25 at 6 am, she knew Resident #1 was on 1:1 observation; however, she was not assigned to her and continued to care for the residents. CNA P said she was unaware that Resident #2 had a history of sexual behaviors. At 1:34 PM CNA P stated she had never implemented 1:1 observation for anyone. She stated she was working on 08/23/25 and does not recall anyone informing her that they were leaving, and that they had been the 1:1 observation for Resident # 1. She stated on 08/23/25 she was the person who assisted Resident #1 with dressing and then sat her at the dining room table. During an interview on 9/04/25 at 1:30 PM LVN L stated they are informed by the DON or the ADON that a resident is on 1:1 supervision. She stated that 1:1 supervision is a level of supervision that means that the staff is like the resident's “shadow” or like their “leash”. She stated 1:1 supervision means that the staff must be close enough to verbally and physically intervene. She stated she was not responsible for assigning staff to 1:1 supervision. LVN L stated the DON or the ADON would make those assignments. She stated she is unaware of any documentation that staff must complete while they were on 1:1 supervision with residents. She stated the DON or ADON would be the person to let them (staff) know when the resident is no longer on 1:1 supervision. She stated the PNP was the only person that could take the resident off 1:1 supervision. She stated she had not had any special training but from her nursing experience she knew what 1:1 supervision looked like. During an interview on 09/05/25 at 10:35 AM, LVN F indicated on 08/23/25 she was in the hallway parallel to Resident #1's doorway as she prepared the next medication administration, when she witnessed Resident #1 standing in front of her recliner rocking back and forth, and Resident #2's hand inside her pantie. Resident #2, who was inside Resident #1's room, was sitting on Resident #1's recliner as she fondled Resident #1. LVN F said she said she yelled out to the CNAs “come get them” and questioned who was assigned as Resident #1's 1:1 observation. LVN F indicated she had not been given the responsibility of assigning 1:1 staff to residents in need of closer supervision, which had been the responsibility of DON and ADON. LVN F stated on 08/22/25 Resident #2 was a new admission to the facility. LVN F said she entered Resident #2's room and saw her masturbating. LVN F said she called the previous facility and spoke to LVN DD, who informed her Resident #2 had a history of being sexually inappropriate with the male residents, because she would go into their rooms and touch their private parts, and that's why she was transferred out of the facility. LVN F said she informed the DON that Resident #2 was masturbating; therefore, she could not conduct her heat-to-toe assessment, and that's when the DON entered her room and Resident #2 grabbed his pants. LVN F said Resident #2 was not assigned special supervision; however, Resident #1 had been on 1:1 observation since 08/21/25 due to an incident of aggression. During an interview on 09/04/21 at 1:41 PM, The DON said on 08/22/24 Resident #2 was admitted to the facility, and when he assessed her in the room by himself, she went for his belt buckle and he had to move her hand away. The DON said he asked LVN F to supervise Resident #2's assessment and nothing else happened during this assessment. The DON said he was unaware Resident #2 had a history of inappropriate sexual behaviors prior to her admission to the facility; however, he was informed that Resident #2 had to move from her previous facility due to being the victim of unwanted sexual advances by the male residents. The DON indicated if a resident has an incident of aggression the charge nurse will notify him, and then he will direct them to keep them separated and to place the aggression on 1:1 observation and would not be removed unit the resident's assessed by psych services. The DON said the facility's central office reviewed Resident #2's file and directed the facility to accept her as a new admission. The DON confirmed on 08/23/25 Resident #1 was on 1:1 observation due to hitting a resident on 08/22/25. The DON said a CNA should have been within arm's reach of Resident #1, which would have prevented Resident #1 from being inappropriately touched by Resident #2. The DON said he and his staff were unaware that Resident #2 had a history of inappropriate sexual behaviors. The DON said on 08/23/25 he was informed by LVN F Resident #2 had her hand inside Resident #2's pants, and Resident #1 did not have a 1:1 observation at the time of this incident. During an interview on 09/04/25 at 10:48 AM, CNA E indicated she was unaware Resident #2 had a history of inappropriate sexual behavior. During an interview on 09/04/25 at 11:41 PM, the admission Coordinator indicated Resident #2 was approved as a transfer to the facility by their Central Intake Team. This approval was sent to her via an email on 08/21/25, and Resident #2 was admitted to the facility on [DATE]. admission Coordinator said she did not review Resident #2's notes in the admission packet and confirmed Resident #2's admission transfer notes included 3 incidents of inappropriate sexual behavior (08/03/25 x 2 and 07/16/25). During an interview on 09/04/25 at 12:05 PM, the SW indicated she was unaware Resident #2 had a history of inappropriate sexual behavior; however, after Resident #2 touched Resident #1 inappropriately, she was placed on 1:1 observation. During an interview on 09/04/25 at 12:35 PM, the MDS Coordinator indicated she was unaware Resident #2 had a history of inappropriate sexual behavior; however, after Resident #2 touched Resident #1 inappropriately, she was placed on 1:1 observation. The MDS Coordinator said she does not assign residents 1:1 observation, nor does she include 1:1 or watch closely in a resident's care plan. The MDS Coordinator said she did not include Resident #1's inappropriate sexual behavior in her care plan, because she was not informed during her admission. During an interview on 09/04/25 at 1:19 PM, FNP U indicated on 08/21/25 she was informed Resident #1 had an incident of aggression, and that's when she was placed on 1:1 observation, until psych services could evaluate her. After this incident, FNP U said she was informed Resident #1 was inappropriately touched by Resident #2, who put her hand in her pants. FNP U said on 08/23/25 Resident #1 was supposed to be on 1:1 observation, and Resident #2 should not have had the opportunity to put her hand in her pants. The facility must ensure each resident receives adequate supervision and assistance to prevent this type of accident from happening. During an interview on 09/04/25 at 2:18 PM, the Administrator indicated he received an email that at the previous facility that the male residents were after Resident #2 sexually; therefore, she was approved by his central office to admit Resident #2. The administrator said he did not review Resident #2's file upon her admission to the facility. The Administrator indicated that the facility's investigation indicated LVN F witnessed Resident #2 with her hand inside Resident #1's panties. The Administrator said CNA A, who was assigned as Resident #1's 1:1 observation, should not have left her shift until she was replaced by a staff. During an interview on 09/04/25 at 3:47 PM, PNP indicated Resident #2 had a history of inappropriate sexual behavior, because on 08/22//25 LVN F found her masturbating, and she touched the DON on his pants during her assessment. PNP said he ordered Paxil that had to go through the facility's physician because she had not been approved for psych services. On 08/26/25 PNP said he received the approval for Resident #2's psych services. PNP said he was informed by the DON that Resident #2 had not displayed inappropriate sexual activity; therefore, PNP dc the need for 1:1 observation because the Paxil was showing good results. PNP said as of 09/04/25, he had not sent the facility his notes on his assessment with Resident #2. During an interview on 09/05/25 at 10:35 AM, FNP T indicated Resident #2, who had a history of inappropriate sexual behaviors, should have been assigned a 1:1 observation or watched closely for 3 to 5 days , and should have had her inappropriate sexual behaviors care planned for her safety and the safety of others. FNP T said the observations should have been noted every 15 minutes for 72 hours, because they did not know if the resident will could be violent or hypersexual. FNP T said if Resident #1 was on 1:1 observation, then Resident #2 should never have had the opportunity to put her hand inside Resident #1's pants and panties. During an interview on 9/05/25 at 12:59 PM the DON stated that on 08/23/25 Resident #2 was placed on 1:1 supervision but they did not have documentation of that action. He stated because of the IJ they will now keep documentation of all residents who were placed on 1:1 supervision. He stated because of the IJ all residents in the secure unit were assessed by him and the SDON with no negative findings. He stated the ADON conducted safe surveys with no negative findings. He stated when the IJ was called on 09/04/25 the IDT team that included the department heads (the ADM, DON, BOM, Admissions Coordinator, HR, the DM, HK Supervisor, MDS Coordinator, and the ADM) trained all the staff on the ANE policy, 1:1 supervision (to include what it meant, the transfer process, how close they needed to be, when they could leave and documentation), and the Resident-to Resident Policy. He stated that residents who are placed on 1:1 supervision will need to ensure that they are close enough to intervene. He stated if the resident is sleeping the staff can be outside of the door and check every 15 minutes and use a flashlight so that the resident is not disturbed. He stated the 1:1 would be randomly checked to ensure that the documentation is up to date, staff are within the right distance and interventions are being followed. He stated during the week he and the ADON would do the random audits for 1:1 supervision but on the weekend, he had a RN supervisor. He stated he gave staff the opportunity to ask questions if they needed to. He stated Admissions was trained on reviewing the paperwork prior to accepting a resident in the facility. He stated before any resident is admitted to the facility their admission paperwork will be reviewed by the appropriate people in the IDT. He stated they did participate in a QAPI meeting that addressed all the components of the IJ. Record review of the facility's Abuse, Neglect and Exploitation revised on 08/05/25 indicated “it is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, . “Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercation. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitate or enabled through the use of technology.” “Criminal sexual abuse is serious bodily injury/harm shall be considered to have occurred if the conduct causing the injury is conducted described in section 2241 (relating to aggravated sexual abuse) or section 2242 (relating to sexual abuse of Title 18, United States Cod, or any similar offense under State law. In other works , serious bodily injury includes sexual intercourse with a resident by force or incapacitation or through threats of harm to the resident or others or any sexual act involving a child. Serious bodily injury also includes sexual intercourse with a resident who is incapable of declining to participate in the sexual act or lac the ability to understand the nature of the sexual act.” “Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that ae necessary to avoid physical harm, pain , mental anguish, or emotional distress. “Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury of harm. The Administrator and DON were notified on 09/04/25 at 6:18 PM that an IJ situation was identified due to the above failures and the IJ template was provided. The following Plan of Removal was accepted on 09/05/2025 at 10:46AM: “Plan of Removal 09/05/2025 Per the information provided in the IJ template given to the facility Administrator and DON on 09/04/25 at 6:18 PM The facility failed to ensure a safe environment free from sexual abuse when Resident #2, who had a history of inappropriate sexual behaviors, placed her hand inside Resident #1's panties. The facility's DON failed to implement interventions upon Resident #2's admission on [DATE], when LVN F informed him Resident #2 was masturbating, and after Resident #2 inappropriately touched him on his pants. Residents residing in the memory unit received a skin assessment and/or a safe survey on 8/23/2025 with no additional negative findings.Person(s) Responsible: Charge Nurse, social services, and/or designee Date: 8/26/2025 Education provided to Administrator and Director of Nursing on the Abuse & Neglect Policy, 1:1 (employees should remain on 1:1, when placed on 1:1, without fail, until 1:1 is discontinued), Resident-to-Resident Policy, reviewing admission paperwork and care planning/educating staff, when needed, on sexual behaviors and interventions.Person(s) Responsible: Regional [NAME] President of Operations and/or Regional Nurse Consultant Date: 8/23/2025 All staff educated on the Abuse & Neglect Policy, 1:1 (employees should remain on 1:1, when placed on 1:1, without fail, until 1:1 is discontinued), and Resident-to-Resident Policy.Schedules will be reviewed and the Administrator, Director of Nursing, and/or a Designated staff member will be responsible to ensure all staff will be educated prior to working their next shift.Person(s) Responsible: Administrator, Director of Nursing, and/or Designee. Date: 9/4/2025 Referrals/admissions will be reviewed prior to admission to ensure high risk history, such as sexual or physical aggression, and care plans/interventions will be put into place and staff will be communicated with prior to/at admission. Care plans can be found in Matrix in the plan of care.Person(s) Responsible: admission Coordinator, Administrator, Director of Nursing, Assistant Director of Nursing, and/or Designee Date: 9/4/2025 When residents are placed on 1:1, Administrator, Director of Nursing, Assistant Director of Nursing, and/or Designee will spot check, daily, Monday-Friday and a designee such as a charge nurse and/or weekend supervisor will spot check, daily, Saturday and Sunday, to ensure staff are following policy and education provided.Person(s) Responsible: Administrator, Director of Nursing, Assistant Director of Nursing, and/or DesigneeDate: 9/4/2025 QAPI— Action: Ad hoc QAPI performed with Medical Director, notified of the Immediate Jeopardy template and the facility's plan to remove it. No additional recommendations at this time. Person(s) Responsible: AdministratorDate: 9/4/2025 On 09/05/25 the state surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: During an interview on 09/05/25 at 11:09 AM, the DON said the in-services indicated observation levels will be implemented by CNAs, nurses, ADONs, DON, SW, and other staff (activity director, housekeepers, and office staff as needed. During an interview on 09/05/25 the admission Coordinator was in-serviced to ensure referrals for new admissions are reviewed prior to admission. If a resident is identified with a history of sexual or physical aggression, this will be care planned to include interventions for staff to follow. During an interview on 9/05/25 at 12:59 PM the DON stated that on 08/23/25 Resident #2 was placed on 1:1 supervision but they did not have documentation of that action. He stated because of the IJ they will now keep documentation of all residents who were placed on 1:1 supervision. He stated because of the IJ all resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement written policies and procedures that prohibited and prevented abuse, neglect, and exploitation of residents and misappropriation of resident property for two of five residents (Resident #1, Resident #2) reviewed for abuse, neglect, and exploitation. The facility failed to implement their policies and procedures for identifying and addressing at admission Resident #2's history of inappropriate sexual behavior to prevent Resident #2, from placing her hand inside Resident #1's pantie. The Immediate Jeopardy (IJ) was identified on 09/04/25 at 6:18 PM. The IJ template was provided to the facility's Administrator and DON on 09/04/25 at 6:18 PM. While the immediacy was removed on 09/05/25 at 6:07 PM, the facility remained out of compliance at a scope of pattern and severity level of no actual harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems, and because all their staff had not been trained on 09/05/25. These failures could affect all residents by placing them at risk of abuse, physical harm, pain, mental anguish, emotional distress, and serious harm.Findings include: Resident #2Record review of Resident #2's face sheet current as of 09/03/25, revealed a [AGE] year-old-female who was admitted to the facility on [DATE]. Resident #2 diagnoses included unspecified dementia severe with agitation (a behavioral and emotional state of dementia characterized by behaviors like restlessness, pacing, shouting, aggression, and repetitive actions), mood disorder due to known physiological condition (a mental disorder characterized by persistent changes in mood), and schizoaffective disorder bipolar type (mental health condition episodes that combines mania and depression). Review of Resident #2's Physician's Active Orders dated 08/22/25 included Psychiatric and Psychological services to evaluate and treat as needed. Record review of Resident #2's admission Comprehensive MDS, dated [DATE] revealed the following: *Section C Brief Interview for Mental Status (BIMS) revealed a score of 1 which indicated the resident's cognition was severely impaired. *Section E-Behavior: Physical behavioral symptoms directed towards other (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) occurred 1 to 3 days. Other behavioral symptoms not directed towards others (e.g., physical symptoms such as hitting or scratching self, packing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) occurred 1 to 3 days. Wandering-Presence & Frequency: Has the resident wandered? This was coded with a 0 to indicate this behavior was not exhibited. *Mobility Devices: none of the devices (cane, walker, wheelchair, limb prosthesis) were used. *Functional Abilities-Mobility: Walk 10 feet, once standing, the ability to walk at least 10 feet in a room, corridor, or similar space. This was coded an 88, which meant she had not attempted due to medical condition or safety concerns. Record review of Resident #2's Care Plan dated 08/24/25 revealed her inappropriate sexual behavior was included in her plan after she was found with her hand in Resident #1's panties on 08/23/25. This plan included: *Problem: will not exhibit socially inappropriate/disruptive behavior pattern, specifically impulsive sexual behavior. This would be addressed by approaching Resident #2 and removing her from resident's room and unsafe situations. Maintain a calm environment and calm approach to the resident. Assess whether the behavior endangers the resident and/or others and intervene if necessary. *Problem: has a history of touching other residents inappropriately: This would be addressed through staff and by redirection. *Record review of Resident #2's Event Report dated 08/23/25 indicated Resident #2 was involved in an incident alleging she had her hand down the pants of Resident #1. This incident was witnessed by LVN F, the residents were separated by CNA C and CNA DD, and Resident #2 was placed on one-to-one observation with the nursing staff (1:1, defined as a staff member constantly with the resident and documents at 15-minute intervals). Resident #2, who was in Resident #1's room when this incident occurred was removed from Resident #1's room. This report indicated Resident #2 was assessed and there were no signs of trauma. On 09/02/25 at 9:40 am FNP T gave LVN F orders for Resident #2 to have labs, Senior Psych referral and Aricept 5 mg. q hs. On 09/02/25 at 10:37 am PNP gave LVN F order for Resident #2's Remeron to be change to HS, and to change Paxil to am, and have nursing to monitor for over sedation. PNP added the diagnosis of Alzhelmer's late onset to Resident #2's diagnosis. *The Facility Event Summary Report dated 08/23/25 indicated on 08/23/24 Resident #2 was found with her hand in Resident #1's pantie. After this incident, Resident #1 and Resident #2 were placed on 1:1 observation provided by the nursing staff. The residents were assessed and there were no signs of trauma, and the FNP and PNP were notified of this incident on 08/23/25. Review of Resident #2's Senior PsychCare dated 08/26/25 indicated the facility had requested a referral for psych services. The Senior PsychCare dated 08/26/25 indicated the PNP obtained verbal consent from FM for psych services. Record review of Resident #2's admission documents from her previous facility included the following Progress Notes: *Effective date of 08/03/25 at 8:25 PM that was marked out indicated Late Entry, Resident #2 was found in male resident's room sitting on the side of his bed and was playing with male resident's pubic hair that was sticking outside of his brief. The resident was removed and redirected from the room. *Effective date of 08/03/25 at 8:32 PM indicated Resident #2 was placed on 1:1 with monitoring tech, who would be with her and documenting on her progress. *Effective date of 08/03/25 at 7:56 PM indicated Resident #2 went into a male resident's room, he was slightly exposed and she was leaning over and touching him on his peri area. Staff said his brief was on but had it slightly moved to the side and he was not stopping her. Resident #2 was removed immediately and her hand washed. Resident #2 was impulsive and confused. *Effective date 07/16/25, Resident #2 was kissing a male resident, and they were immediately separated. Record review of FNP T's Progress Note dated 09/02/25 indicated Resident #2 was a [AGE] year-old lady who was transferred from a facility to her current facility. The current facility's nursing staff had reported hypersexual behavior to included that Resident #2 was found in a resident's room with her hand down female resident's pants (Resident #1). FNP T noted she would consult with the psychiatric team and check labs. During an interview on 09/03/25 at 10:40 am, Resident #2 was asked a series of questions; however, her verbal responses were not understood. Instead, Resident #2 smiled each time she was asked a question, including if she had touched Resident #1 on her private area. During an interview on 09/04/25 at 3:47 PM, PNP indicated Resident #2 had a history of inappropriate sexual behavior, because on 08/22//25 LVN F found her masturbating, and she touched the DON on his pants during her assessment. PNP said he ordered Paxil that had to go through the facility's physician because she had not been approved for psych services. On 08/26/25 PNP said he received the approval for Resident #2's psych services. PNP said he was informed by the DON that Resident #2 had not displayed inappropriate sexual activity; therefore, PNP dc the need for 1:1 observation because the Paxil was showing good results. PNP said as of 09/04/25, he had not sent the facility his notes on his assessment with Resident #2. Resident #1Record review of Resident #1's Face Sheet current as of 09/03/25 revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Resident #1's diagnosis included dementia mild with mood disturbances (emotional or behavioral changes, such as anxiety, apathy, depression or irritability), and anxiety disorder (intense, excessive, and persistent worry and fear about everyday situations). Record review of Resident #1's admission Comprehensive MDS, dated [DATE] revealed the following: *Section C, Brief Interview for Mental Status (BIMS) score revealed a score of 00, which indicated the resident's cognition was severely impaired. *Section E-Behavior, Physical behavioral symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) occurred 1 to 3 days. *Wandering-Presence & Frequency: Has the resident wandered? This was coded with a 0 to indicate this behavior was not exhibited. *Functional Abilities-Mobility, walk 10 feet, once standing, the ability to walk at least 10 feet in a room, corridor, or similar space. This was coded a 6, which meant she could complete this activity by herself with no assistance from a helper. Record review of Resident #1's Care Plan dated 08/12/25 included: *Problem: updated on 08/23/25 to include due to impaired cognition, Resident #1 is at risk for unwanted sexual advances from other residents. This would be addressed by ensuring client safety. *Problem, on 08/12/25 the plan included that she had physically aggressive behavior towards others. The plan included cueing resident to maintain space between self and others and assisting resident in moving self away while interacting with others. Record review of Resident #1's Observation Detail List Report noted by LVN N on 08/23/25 at 11:18 am indicated Resident #2 was witnessed with her hand down Resident #1's pants, in Resident #1's room. The nursing staff immediately entered the room and separated Resident #1 and #2. Resident #2 was placed on 1:1 observation due to this allegation. Resident #1, was assessed and she had no signs of trauma. Record review of Resident #1's Progress Notes indicated the following: *The ADON noted that on 08/26/25 Resident #1's Interdisciplinary Team met and discontinued her 1:1 observation. *The DON noted that on 08/23/25 Resident #1 (who was on 1:1 observation) was involved in an incident in which resident (Resident #2) was witnessed with her hand down resident #1's pants in Resident #1's room. Nursing staff entered the room, separated Resident #1 and #2, and removed Resident #2 from Resident #1's room. Resident #1 was assessed and there were no signs of trauma. *The DON noted on 08/22/25 that Resident #1 (who was the aggressor) was involved in an altercation with Resident #9, by slapping her on her back. Resident #9 responded by slapping Resident #1 in the face near her eye. The residents were separated and Resident #1 was placed on 1:1 observation until she could be cleared by psychiatric services. During an observation on 09/03/25 at 10:45 am revealed Resident #2 entered Resident # 7's room, and there were no CNAs present in the area. LVN L, who was at the end of the hallway, was notified that Resident #2 was in Resident #7's room. LVN L went to Resident #2, who was in Resident #7's room, and redirected and escorted her to leave the room and go to the dining/lobby area. During an interview on 09/03/25 at 11:15 AM, Resident #1 indicated nobody hurt her and she could not recall being touched on her body by Resident #2. During an interview on 09/05/25 at 11:23 AM, FM S indicated he was informed that Resident #1 was touched on the buttock by a resident but never informed that she was fondled in her private area by a resident. During an interview on 09/04/25 at 3:04 PM, CNA A indicated she started her shift on 08/22/25 at 6 PM and worked until 6 am on 08/23/25. During this shift, CNA A said she was assigned as Resident #1's 1:1 observation, which meant she had to watch her closely and keep her out of residents' room. CNA A said before she left the faciity on [DATE] at 6 am, she informed a CNA, whose name she could not recall, that she was leaving and transferring her observation to the next shift. CNA A said Resident #1 was asleep in her bed when she left. During an interview on 09/03/25 at 10:46 am, CNA C indicated on 08/23/25 she was working with CNA P; however, CNA O, who was assigned as Resident #1's 1:1 observation had not started her shift at 6 am, instead she started at 7 am. CNA C said her and CNA P provided ADL care to the residents to get them ready for breakfast. CNA C said she saw Resident #1 in the dining/lobby area and saw Resident #2 going into Resident #1's room, where she sat and fell asleep on Resident #1's recliner. CNA C said she did not redirect Resident #2 to leave Resident #1's room because she has a history of becoming upset, and because Resident #1 was not in her room. CNA C said she did not see Resident #1 return to her room, while Resident #2 slept on her recliner. CNA C said she was unaware that Resident #2 had to be watched closer due to inappropriate sexual behavior, and she knew Resident #1 had behaviors of aggression and was supposed to be watched closer per FM's request. During an interview on 09/04/25 at 10:48 AM, CNA P indicated she worked on 08/23/25 and was directed by DON to keep an eye on Resident #1 due to inappropriate touching; however, she was not assigned as her 1:1 observation. CNA P said she worked with CNA C and they assisted residents with their ADLs to get them ready for breakfast. CNA P said CNA O was supposed to start her shift at 6 am and carry out Resident #1's 1:1 observation; however, she did not arrive until 7 AM. CNA P said she assisted Resident #1 with her ADLs and took her to the dining table because Resident #2 had entered Resident #1's room. CNA P said it was easier to take Resident #1 out of her room than Resident #2, which was why she allowed Resident #2 to stay in the room. CNA P said she informed LVN F, who was administering medications, that she was leaving Resident #2 in Resident #1's room. CNA P said at approximately 7 AM CNA O entered the memory unit and asked for the whereabouts of Resident #1 and replied that Resident #1 was supposed to be in the dining area. And that's when, LVN F yelled out for staff to get Resident #2 because she was foundling Resident #1 in her room and asked who was Resident #1's 1:1 observation. CNA P said she entered Resident #1's room and saw Resident #1 standing with her pants unbuckled and in front of Resident #2, who was sitting on the recliner and holding Resident #1 by her wrist. CNA P said earlier in the morning, she dressed Resident #1 and left her pants unbuckled because they did not fit her. CNA P said upon the start of her shift on 08/23/25 at 6 am, she knew Resident #1 was on 1:1 observation; however, she was not assigned to her and continued to care for the residents. CNA P said she was unaware that Resident #2 had a history of sexual behaviors. At 1:34 PM CNA P stated she had never implemented 1:1 observation for anyone. She stated she was working on 08/23/25 and does not recall anyone informing her that they were leaving, and that they had been the 1:1 observation for Resident # 1. She stated on 08/23/25 she was the person who assisted Resident #1 with dressing and then sat her at the dining room table. During an interview on 9/04/25 at 1:40 PM CNA E stated that she has never been any resident's 1:1 staff. She stated they are typically informed by the DON or the previous shift staff may tell them if a resident is on 1:1 supervision. She stated the DON would tell them if a resident was off 1:1 supervision. She stated she had been trained by the facility staff that they stay until relief comes. She stated she did not know when, but the training had occurred since she had been at the facility. During an interview on 09/05/25 at 10:35 AM, LVN F indicated on 08/23/25 she was in the hallway parallel to Resident #1's doorway as she prepared the next medication administration, when she witnessed Resident #1 standing in front of her recliner rocking back and forth, and Resident #2's hand inside her pantie. Resident #2, who was inside Resident #1's room, was sitting on Resident #1's recliner as she fondled Resident #1. LVN F said she said she yelled out to the CNAs come get them and questioned who was assigned as Resident #1's 1:1 observation. LVN F indicated she had not been given the responsibility of assigning 1:1 staff to residents in need of closer supervision, which had been the responsibility of DON and ADON. LVN F stated on 08/22/25 Resident #2 was a new admission to the facility. LVN F said she entered Resident #2's room and saw her masturbating. LVN F said she called the previous facility and spoke to LVN DD, who informed her Resident #2 had a history of being sexually inappropriate with the male residents, because she would go into their rooms and touch their private parts, and that's why she was transferred out of the facility. LVN F said she informed the DON that Resident #2 was masturbating; therefore, she could not conduct her heat-to-toe assessment, and that's when the DON entered her room and Resident #2 grabbed his pants. LVN F said Resident #2 was not assigned special supervision; however, Resident #1 had been on 1:1 observation since 08/21/25 due to an incident of aggression. During an interview on 09/04/21 at 1:41 PM, The DON said on 08/22/24 Resident #2 was admitted to the facility, and when he assessed her in the room by himself, she went for his belt buckle and he had to move her hand away. The DON said he asked LVN F to supervise Resident #2's assessment and nothing else happened during this assessment. The DON said he was unaware Resident #2 had a history of inappropriate sexual behaviors prior to her admission to the facility; however, he was informed that Resident #2 had to move from her previous facility due to being the victim of unwanted sexual advances by the male residents. The DON indicated if a resident has an incident of aggression the charge nurse will notify him, and then he will direct them to keep them separated and to place the aggression on 1:1 observation and would not be removed unit the resident's assessed by psych services. The DON said the facility's central office reviewed Resident #2's file and directed the facility to accept her as a new admission. The DON confirmed on 08/23/25 Resident #1 was on 1:1 observation due to hitting a resident on 08/22/25. The DON said a CNA should have been within arm's reach of Resident #1, which would have prevented Resident #1 from being inappropriately touched by Resident #2. The DON said he and his staff were unaware that Resident #2 had a history of inappropriate sexual behaviors. The DON said on 08/23/25 he was informed by LVN F Resident #2 had her hand inside Resident #2's pants, and Resident #1 did not have a 1:1 observation at the time of this incident. During an interview on 09/04/25 at 10:48 AM, CNA E indicated she was unaware Resident #2 had a history of inappropriate sexual behavior. During an interview on 09/04/25 at 11:41 PM, the admission Coordinator indicated Resident #2 was approved as a transfer to the facility by their Central Intake Team. This approval was sent to her via an email on 08/21/25, and Resident #2 was admitted to the facility on [DATE]. admission Coordinator said she did not review Resident #2's notes in the admission packet and confirmed Resident #2's admission transfer notes included 3 incidents of inappropriate sexual behavior (08/03/25 x 2 and 07/16/25). During an interview on 09/04/25 at 12:05 PM, the SW indicated she was unaware Resident #2 had a history of inappropriate sexual behavior; however, after Resident #2 touched Resident #1 inappropriately, she was placed on 1:1 observation. During an interview on 09/04/25 at 12:35 PM, the MDS Coordinator indicated she was unaware Resident #2 had a history of inappropriate sexual behavior; however, after Resident #2 touched Resident #1 inappropriately, she was placed on 1:1 observation. The MDS Coordinator said she does not assign residents 1:1 observation, nor does she include 1:1 or watch closely in a resident's care plan. The MDS Coordinator said she did not include Resident #1's inappropriate sexual behavior in her care plan, because she was not informed during her admission. During an interview on 09/04/25 at 1:19 PM, FNP U indicated on 08/21/25 she was informed Resident #1 had an incident of aggression, and that's when she was placed on 1:1 observation, until psych services could evaluate her. After this incident, FNP U said she was informed Resident #1 was inappropriately touched by Resident #2, who put her hand in her pants. FNP U said on 08/23/25 Resident #1 was supposed to be on 1:1 observation, and Resident #2 should not have had the opportunity to put her hand in her pants. The facility must ensure each resident receives adequate supervision and assistance to prevent this type of accident from happening. During an interview on 09/04/25 at 2:18 PM, the Administrator indicated he received an email that at the previous facility that the male residents were after Resident #2 sexually; therefore, she was approved by his central office to admit Resident #2. The administrator said he did not review Resident #2's file upon her admission to the facility. The Administrator indicated that the facility's investigation indicated LVN F witnessed Resident #2 with her hand inside Resident #1's panties. The Administrator said CNA A, who was assigned as Resident #1's 1:1 observation, should not have left her shift until she was replaced by a staff. During an interview on 09/04/25 at 3:47 PM, PNP indicated Resident #2 had a history of inappropriate sexual behavior, because on 08/22//25 LVN F found her masturbating, and she touched the DON on his pants during her assessment. PNP said he ordered Paxil that had to go through the facility's physician because she had not been approved for psych services. On 08/26/25 PNP said he received the approval for Resident #2's psych services. PNP said he was informed by the DON that Resident #2 had not displayed inappropriate sexual activity; therefore, PNP dc the need for 1:1 observation because the Paxil was showing good results. PNP said as of 09/04/25, he had not sent the facility his notes on his assessment with Resident #2. During an interview on 09/05/25 at 10:35 AM, FNP T indicated Resident #2, who had a history of inappropriate sexual behaviors, should have been assigned a 1:1 observation or watched closely for 3 to 5 days , and should have had her inappropriate sexual behaviors care planned for her safety and the safety of others. FNP T said the observations should have been noted every 15 minutes for 72 hours, because they did not know if the resident will could be violent or hypersexual. FNP T said if Resident #1 was on 1:1 observation, then Resident #2 should never have had the opportunity to put her hand inside Resident #1's pants and panties. During an interview on 9/05/25 at 12:59 PM the DON stated that on 08/23/25 Resident #2 was placed on 1:1 supervision but they did not have documentation of that action. He stated because of the IJ they will now keep documentation of all residents who were placed on 1:1 supervision. He stated because of the IJ all residents in the secure unit were assessed by him and the SDON with no negative findings. He stated the ADON conducted safe surveys with no negative findings. He stated when the IJ was called on 09/04/25 the IDT team that included the department heads (the ADM, DON, BOM, Admissions Coordinator, HR, the DM, HK Supervisor, MDS Coordinator, and the ADM) trained all the staff on the ANE policy, 1:1 supervision (to include what it meant, the transfer process, how close they needed to be, when they could leave and documentation), and the Resident-to Resident Policy. He stated that residents who are placed on 1:1 supervision will need to ensure that they are close enough to intervene. He stated if the resident is sleeping the staff can be outside of the door and check every 15 minutes and use a flashlight so that the resident is not disturbed. He stated the 1:1 would be randomly checked to ensure that the documentation is up to date, staff are within the right distance and interventions are being followed. He stated during the week he and the ADON would do the random audits for 1:1 supervision but on the weekend, he had a RN supervisor. He stated he gave staff the opportunity to ask questions if they needed to. He stated Admissions was trained on reviewing the paperwork prior to accepting a resident in the facility. He stated before any resident is admitted to the facility their admission paperwork will be reviewed by the appropriate people in the IDT. He stated they did participate in a QAPI meeting that addressed all the components of the IJ. Record review of the facility's Abuse, Neglect and Exploitation revised on 08/05/25 indicated it is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, . Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercation. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitate or enabled through the use of technology. Criminal sexual abuse is serious bodily injury/harm shall be considered to have occurred if the conduct causing the injury is conducted described in section 2241 (relating to aggravated sexual abuse) or section 2242 (relating to sexual abuse of Title 18, United States Cod, or any similar offense under State law. In other works , serious bodily injury includes sexual intercourse with a resident by force or incapacitation or through threats of harm to the resident or others or any sexual act involving a child. Serious bodily injury also includes sexual intercourse with a resident who is incapable of declining to participate in the sexual act or lac the ability to understand the nature of the sexual act. Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that ae necessary to avoid physical harm, pain , mental anguish, or emotional distress. Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury of harm. The Administrator and DON were notified on 09/04/25 at 6:18 PM that an IJ situation was identified due to the above failures and the IJ template was provided. The following Plan of Removal was accepted on 09/05/2025 at 10:46AM: Plan of Removal 09/05/2025 Per the information provided in the IJ template given to the facility Administrator and DON on 09/04/25 at 6:18 PMThe facility failed to ensure a safe environment free from sexual abuse when Resident #2, who had a history of inappropriate sexual behaviors, placed her hand inside Resident #1's panties. The facility's DON failed to implement interventions upon Resident #2's admission on [DATE], when LVN F informed him Resident #2 was masturbating, and after Resident #2 inappropriately touched him on his pants. Residents residing in the memory unit received a skin assessment and/or a safe survey on 8/23/2025 with no additional negative findings.Person(s) Responsible: Charge Nurse, social services, and/or designee Date: 8/26/2025 Education provided to Administrator and Director of Nursing on the Abuse & Neglect Policy, 1:1 (employees should remain on 1:1, when placed on 1:1, without fail, until 1:1 is discontinued), Resident-to-Resident Policy, reviewing admission paperwork and care planning/educating staff, when needed, on sexual behaviors and interventions.Person(s) Responsible: Regional [NAME] President of Operations and/or Regional Nurse ConsultantDate: 8/23/2025 All staff educated on the Abuse & Neglect Policy, 1:1 (employees should remain on 1:1, when placed on 1:1, without fail, until 1:1 is discontinued), and Resident-to-Resident Policy.Schedules will be reviewed and the Administrator, Director of Nursing, and/or a Designated staff member will be responsible to ensure all staff will be educated prior to working their next shift.Person(s) Responsible: Administrator, Director of Nursing, and/or Designee.Date: 9/4/2025Referrals/admissions will be reviewed prior to admission to ensure high risk history, such as sexual or physical aggression, and care plans/interventions will be put into place and staff will be communicated with prior to/at admission. Care plans can be found in Matrix in the plan of care.Person(s) Responsible: admission Coordinator, Administrator, Director of Nursing, Assistant Director of Nursing, and/or Designee Date: 9/4/2025When residents are placed on 1:1, Administrator, Director of Nursing, Assistant Director of Nursing, and/or Designee will spot check, daily, Monday-Friday and a designee such as a charge nurse and/or weekend supervisor will spot check, daily, Saturday and Sunday, to ensure staff are following policy and education provided.Person(s) Responsible: Administrator, Director of Nursing, Assistant Director of Nursing, and/or DesigneeDate: 9/4/2025 QAPI-Action: Ad hoc QAPI performed with Medical Director, notified of the Immediate Jeopardy template and the facility's plan to remove it. No additional recommendations at this time. Person(s) Responsible: AdministratorDate: 9/4/2025On 09/05/25 the state surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: During an interview on 09/05/25 at 11:09 AM, the DON said the in-services indicated observation levels will be implemented by CNAs, nurses, ADONs, DON, SW, and other staff (activity director, housekeepers, and office staff as needed. During an interview on 09/05/25 the admission Coordinator was in-serviced to ensure referrals for new admissions are reviewed prior to admission. If a resident is identified with a history of sexual or physical aggression, this will be care planned to include interventions for staff to follow. During an interview on 9/05/25 at 12:59 PM the DON stated that on 08/23/25 Resident #2 was placed on 1:1 supervision but they did not have documentation of that action. He stated because of the IJ they will now keep documentation of all residents who were placed on 1:1 supervision. He stated because of the IJ all residents in the memory unit were assessed by him and the SDON with no negative findings. He stated the ADON conducted safe surveys with no negative findings. He stated when the IJ was called on 09/04/25 the IDT team that included the department heads (the ADM, DON, BOM, Admissions Coordinator, HR, the DM, HK Supervisor, MDS Coordinator, and the ADM) trained all the staff on the ANE policy, 1:1 supervision (to include what it meant, the transfer process, how close they needed to be, when they could leave and documentation), and the Resident-to Resident Policy. He stated that residents who are placed on 1:1 supervision will need to ensure that they are close enough to intervene. He stated if the resident is sleeping the staff can be outside of the door and check every 15 minutes and use a flashlight so that the resident is not disturbed. He stated the 1:1 would be randomly checked to ensure that the documentation is up to date, staff are within the right distance and interventions are being followed. He stated during the week he and ADON would do the random audits for 1:1 supervision but on the weekend, he had an RN supervisor. He stated he gave staff the opportunity to ask questions if they needed to. He stated Admissions was trained in reviewing the paperwork prior to accepting a resident in the facility. He stated before any resident is admitted to the facility their admission paperwork will be reviewed by the appropriate people in the IDT. He stated they did participate in a QAPI meeting that addressed all the components of the IJ. During an interview on 9/05/25 at 2:07 PM the DON stated they di

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents received adequate supervision to prevent accidents and/or hazards as possible for 2 of 5 residents (Resident #1, Resident #2) reviewed for supervision. The facility failed to ensure Resident #1, and Resident #2 received supervision to prevent Resident #2, who had a history of sexual behaviors, from sexually abusing Resident #1, when she put her hand in her panties. Resident #1 was on one to one (1:1) supervision due to a previous incident of aggression with a different resident; however, she was allowed to alone in her room with Resident #2. The Immediate Jeopardy (IJ) was identified on 09/04/25 at 6:18 PM. The IJ template was provided to the facility's Administrator and DON on 09/04/25 at 6:18 PM. While the immediacy was removed on 09/05/25 at 6:07 PM, the facility remained out of compliance at a scope of pattern and severity level of no actual harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems, and because all their staff had not been trained on 09/05/25. These failures could affect all residents by placing them at risk of abuse, physical harm, pain, mental anguish, emotional distress, and serious harm, due to lack of supervision.Findings include: Resident #2 Record review of Resident #2's face sheet current as of 09/03/25, revealed a [AGE] year-old-female who was admitted to the facility on [DATE]. Resident #2 diagnoses included unspecified dementia severe with agitation (a behavioral and emotional state of dementia characterized by behaviors like restlessness, pacing, shouting, aggression, and repetitive actions), mood disorder due to known physiological condition (a mental disorder characterized by persistent changes in mood), and schizoaffective disorder bipolar type (mental health condition episodes that combines mania and depression). *Record review of Resident #2's admission Comprehensive MDS, dated [DATE] revealed the following: Section C Brief Interview for Mental Status (BIMS) score revealed a score of 1 which indicated the resident's cognition was severely impaired. Section E-Behavior: Physical behavioral symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) occurred 1 to 3 days. Other behavioral symptoms not directed towards others (e.g., physical symptoms such as hitting or scratching self, packing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) occurred 1 to 3 days. Functional Abilities-Mobility: Walking 10 feet, once standing, the ability to walk at least 10 feet in a room, corridor, or similar space. This was coded an 88, which meant she had not attempted due to medical condition or safety concerns. *Record review of Resident #2's Care Plan, dated 08/24/25 revealed her inappropriate sexual activity was included in her plan after she was found with her hand in Resident #1's panties on 08/23/25. Problem: will not exhibit socially inappropriate/disruptive behavior pattern, specifically impulsive sexual behavior. This would be addressed by approaching Resident #2 and removing her from resident's room and unsafe situations. Maintain a calm environment and calm approach to the resident. Assess whether the behavior endangers the resident and/or others and intervene if necessary. Problem: has a history of touching other residents inappropriately: This would be addressed through staff and by redirection. *Record review of Resident #2's Event Report dated 08/23/25 indicated Resident #2 was involved in an incident alleging she had her hand down the pants of Resident #1. This incident was witnessed by LVN F, the residents were separated by CNA C and CNA DD, and Resident #2 was placed on one-to-one observation with the nursing staff (1:1, defined as a staff member constantly with the resident and documents at 15-minute intervals). Resident #2, who was in Resident #1's room when this incident occurred was removed from Resident #1's room. This report indicated Resident #2 was assessed and there were no signs of trauma. On 09/02/25 at 9:40 am FNP T gave LVN F orders for Resident #2 to have labs, Senior Psych referral and Aricept 5 mg. q hs. On 09/02/25 at 10:37 am PNP gave LVN F order for Resident #2's Remeron to be change to HS, and to change Paxil to am, and have nursing to monitor for over sedation. PNP added the diagnosis of Alzheimer's late onset to Resident #2's diagnosis. Resident #1: Record review of Resident #1's Face Sheet current as 0f 09/03/25 revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Resident #1's diagnosis included dementia mild with mood disturbances (emotional or behavioral changes, such as anxiety, apathy, depression or irritability), anxiety disorder (intense, excessive, and persistent worry and fear about everyday situations), insomnia (trouble sleeping). *Record review of Resident #1's admission Comprehensive Minimum Data Set, dated [DATE] revealed: Section C, Brief Interview for Mental Status (BIMS) score revealed a score of 00, which indicated the resident's cognition was severely impaired. Section E-Behavior, Physical behavioral symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) occurred 1 to 3 days. Wandering-Presence & Frequency: Has the resident wandered? This was coded with a 0 to indicate this behavior was not exhibited. Functional Abilities-Mobility, walking 10 feet, once standing, the ability to walk at least 10 feet in a room, corridor, or similar space. This was coded a 6, which meant she could complete this activity by herself with no assistance from a helper. *Record review of Resident #1's Care Plan dated 08/12/25 included: Problem: updated on 08/23/25 to include due to impaired cognition, Resident #1 is at risk for unwanted sexual advances from other residents. This would be addressed by ensuring client safety. Problem, on 08/12/25 the plan included that she had been physically aggressive towards others. The plan included cueing resident to maintain space between self and others and assisting resident in moving self away while interacting with others. *Record review of Resident #1's Observation Detail List Report noted by LVN N on 08/23/25 at 11:18 am indicated Resident #2 was witnessed with her hand down Resident #1's pants, in Resident #1's room. The nursing staff immediately entered the room and separated Resident #1 and #2. Resident #2 was placed on 1:1 observation due to this allegation. Resident #1 was assessed and she had no signs of trauma. *Record review of Resident #1's Progress Notes indicated the following: On 08/26/25 Resident #1's Interdisciplinary Team met and discontinued her 1:1 observation. 08/23/35 Resident #1 (who was on 1:1 observation) was involved in an incident in which resident (Resident #2) was witnessed with her hand down resident #1's pants in Resident #1's room. Nursing staff entered the room, separated Resident #1 and #2, and removed Resident #2 from Resident #1's room. Resident #1 was assessed and there were no signs of trauma. During an interview on 09/03/25 at 10:40 am, Resident #2 was asked a series of questions; however, her verbal responses were not understood. Instead, Resident #2 smiled each time she was asked a question, including if she had touched Resident #1 on her private area. During an interview on 09/03/25 at 10:46 am, CNA C indicated on 08/23/25 she was working with CNA P; however, CNA O, who was assigned as Resident #1's 1:1 observation had not started her shift at 6 am, instead she started at 7 am. CNA C said her and CNA P provided ADL care to the residents to get them ready for breakfast. CNA C said she saw Resident #1 in the living/dining area and saw Resident #2 go into Resident #1's room, where she sat and fell asleep on Resident #1's recliner. CNA C said she did not redirect Resident #2 to leave Resident #1's room because she has a history of becoming upset, and because Resident #1 was not in her room. CNA C said she did not see Resident #1 return to her room, while Resident #2 slept on her recliner. CNA C said she was unaware that Resident #2 had to be watched closer due to inappropriate sexual behavior, and she knew Resident #1 had behaviors of aggression and was supposed to be watched closer per FM's request. During an interview on 9/04/25 at 1:34 PM CNA P stated that prior to 08/23/25, she had never done 1:1 observation. She stated she was working on 08/23/25. She stated she did not recall anyone specifically telling her that they were leaving, and they were the 1:1 staff for Resident # 1. She stated on 08/23/25 she was the person to get Resident #1 dressed and she sat her at the dining room table. During an interview on 09/03/25 at 11:15 AM, Resident #1 indicated nobody had hurt her and she could not recall being touched on her body by Resident #2. During an interview on 09/04/25 at 10:48 AM, CNA E indicated she was unaware Resident #1 had a history of inappropriate sexual behavior. During an interview on 09/04/25 at 10:48 AM, CNA P indicated she worked on 08/23/25 and was directed by DON to keep an eye on Resident #1 due to inappropriate touching; however, she was not assigned as her 1:1 observation. CNA P said she worked with CNA C and they assisted residents with their ADLs to get them ready for breakfast. CNA P said CNA O was supposed to start her shift at 6 am and carry out Resident #1's 1:1 observation; however, she did not arrive until 7 AM. CNA P said she assisted Resident #1 with her ADLs and took her to the dining table because Resident #2 had entered Resident #1's room. CNA P said it was easier to take Resident #1 out of her room than Resident #2, which was why she allowed Resident #2 to stay in the room. CNA P said she informed LVN F, who was administering medications, that she was leaving Resident #2 in Resident #1's room. CNA P said at approximately 7 AM CNA O entered the memory unit and asked for the whereabouts of Resident #1 and CNP replied that Resident #1 was supposed to be in the dining area. And that's when, LVN F yelled out for staff to get Resident #2 because she was foundling Resident #1 in her room and asked who was Resident #1's 1:1 observation. CNA P said she entered Resident #1's room and saw Resident #1 standing with her pants unbuckled and in front of Resident #2, who was sitting on the recliner and holding Resident #1 by her wrist. CNA P said earlier in the morning, she dressed Resident #1 and left her pants unbuckled because they did not fit her. CNA P said upon the start of her shift on 08/23/25 at 6 am, she knew Resident #1 was on 1:1 observation; however, she was not assigned to her and continued to care for the residents. CNA P said she was unaware that Resident #2 had a history of sexual behaviors. At 1:34 PM CNA P stated she had never implemented 1:1 observation for anyone. She stated she was working on 08/23/25 and does not recall a night CNA informing her that she was leaving, and that they had been the 1:1 observation for Resident # 1. She stated on 08/23/25 she was the person who assisted Resident #1 with dressing and then sat her at the dining room table. During an interview on 09/04/25 at 11:41 PM, the admission Coordinator indicated Resident #2 was approved as a transfer to the facility by their Central Intake Team. This approval was sent to her via email on 08/21/25, and Resident #2 was admitted to the facility on [DATE]. The admission Coordinator said she did not review Resident #2's notes in the admission packet; and then confirmed Resident #2's admission transfer notes did include 3 incidents of inappropriate sexual behavior 08/03/25 - two incidents, and one incident on 07/16/25. During an interview on 09/04/25 at 12:05 PM, the SW indicated she was unaware Resident #2 had a history of inappropriate sexual behavior; however, after Resident #2 touched Resident #1 inappropriately, she was placed on 1:1 observation. During an interview on 09/04/25 at 12:35 PM, the MDS Coordinator indicated she was unaware Resident #2 had a history of inappropriate sexual behavior; however, after Resident #2 touched Resident #1 inappropriately, she was placed on 1:1 observation. The MDS Coordinator said she does not assign residents 1:1 observation, nor does she include 1:1 or watch closely in a resident's care plan. The MDS Coordinator said she did not include Resident #1's inappropriate sexual behavior in her care plan, because she was not informed during her admission. During an interview on 09/04/25 at 1:19 PM, the FNP U indicated on 08/21/25 she was informed Resident #1 had an incident of aggression, and that's when she was placed on 1:1 observation, until psych services could evaluate her. After this incident, FNP U said she was informed Resident #1 was inappropriately touched by Resident #2, who put her hand in her pants. FNP U said on 08/23/25 Resident #1 was supposed to be on 1:1 observation, and Resident #2 should not have had the opportunity to put her hand in her pants. The facility must ensure each resident receives adequate supervision and assistance to prevent this type of accident from happening. During an interview on 09/04/21 at 1:41 PM, the DON indicated if a resident has an incident of aggression the charge nurse will notify him, and then he will direct them to keep them separated and to place the aggressor on 1:1 observation and would not be removed unit the resident's assessed by psych services. The DON said the facility's central office reviewed Resident #2's file and directed the facility to accept her as a new admission. The DON said on 08/22/24 Resident #2 was admitted to the facility, and when he assessed her in the room by himself, she went for his belt buckle, and he had to move her hand away. The DON said he asked LVN F to supervise his assessment of Resident #2's and nothing else happened. The DON said he was unaware Resident #2 had a history of inappropriate sexual behaviors prior to her admission to the facility; however, he was informed that Resident #2 had to move from her previous facility due to being the victim of unwanted sexual advances by the male residents. The DON indicated on 08/23/25 Resident #1 was on 1:1 observation due to hitting a resident on 08/22/25. The DON said a CNA should have been within arm's reach of Resident #1, which would have prevented Resident #1 from being inappropriately touched by Resident #2. The DON said he and his staff were unaware that Resident #2 had a history of inappropriate sexual behaviors. The DON said on 08/23/25 he was informed by LVN F Resident #2 had her hand inside Resident #1's pants, and that Resident #1 did not have a 1:1 observation at the time of this incident. During an interview on 9/04/25 at 1:40 PM CNA E stated that she has never been any resident's 1:1 staff. She stated they are typically informed by the DON or the previous shift staff may tell them if a resident is on 1:1 supervision. She stated the DON would tell them if a resident was off 1:1 supervision. She stated she had been trained by the facility staff that they stay until relief comes. She stated she did not know when, but the training had occurred since she had been at the facility. During an interview on 09/04/25 at 2:18 PM, the Administrator indicated that the facility's investigation included that LVN F witnessed said she witnessed Resident #2 with her hand inside Resident #1's panties. The Administrator said CNA A, who was assigned as Resident #1's 1:1 observation, should not have left her shift until she was replaced by a staff. During an interview on 09/04/25 at 3:04 PM, CNA A indicated she started her shift on 08/22/25 at 6 PM and worked until 6 AM on 08/23/25. During this shift, CNA A said she was assigned as Resident #1's 1:1 observation, which meant she had to watch her closely and keep her out of residents' room. CNA A said before she left the faciity on [DATE] at 6 am, she informed a CNA, whose name she could not recall, that she was leaving and transferring her observation to the next shift. CNA A said Resident #1 was asleep in her bed when she left. During an interview on 09/04/25 at 3:47 PM, PNP indicated Resident #2 had a history of inappropriate sexual behavior, because on 08/22//25 LVN F found her masturbating, and she touched the DON on his pants during her assessment. PNP said he ordered Paxil that had to go through the facility's physician because she had not been approved for psych services. On 08/26/25 PNP said he received the approval for Resident #2's psych services. PNP said he was informed by the DON that Resident #2 had not displayed inappropriate sexual activity; therefore, PNP dc the need for 1:1 observation because the Paxil was showing good results. PNP said as of 09/04/25, he had not sent the facility his notes on his assessment with Resident #2. During an interview on 09/05/25 at 10:35 PM, FNP T indicated Resident #2, who had a history of inappropriate sexual behaviors, should have been assigned a 1:1 observation or watched closely for 3 to 5 days, and should have had her inappropriate sexual behaviors care planned for her safety and the safety of others. FNP T said the observations should have been noted every 15 minutes for 72 hours, because you don't know if the resident will could be violent or hypersexual. FNP T said if Resident #1 was on 1:1 observation, then Resident #2 should never have had the opportunity to put her hand inside Resident #1's pants and panties. During an interview on 09/05/25 at 10:35 AM, LVN F indicated on 08/23/25, Resident #2 was not assigned special observation; however, Resident #1 was on 1:1 observation due to an incident of aggression on 08/21/25. On 08/23/25 LVN F said she was in the hallway parallel to Resident #1's doorway as she prepared the next medication administration, when she witnessed Resident #1 standing in front of her recliner rocking back and forth and Resident #2's hand inside her pantie. Resident #2, who was inside Resident #1's room, was sitting on Resident #1's recliner as she fondled Resident #1. LVN F said she said she yelled out to the CNAs “come get them” and questioned who was assigned as Resident #1's 1:1 observation. LVN F indicated she was not informed CNA O was not starting her shift at 6 AM, had not been given the responsibility of assigning 1:1 staff to residents in need of closer supervision, which had been the responsibility of DON and ADON. The facility's policy and procedure, Observation Levels, dated 04/2024 indicated “It is the policy of the facility that staff monitoring is instituted to maintain the safety of each resident and provided by a system of progressive intensity of resident observation and oversight. The use of the level that provide each resident with optimal level of safety in the least restrictive manner will be utilized. Resident will be routinely observed in compliance with physician orders and/or clinical protocols.” The level of supervision included: Standard observation (assess and document at no less than every two hours). Minimum level of observation for all residents. Line of sight (assess and document at 15-minute intervals). A level of observation wherein the resident remains in staff view. A specific staff member may be assigned, and the line-of-sight observation is maintained by staff in person and not through video monitoring. One to one (staff member constantly with the resident and documents at 15-minute intervals). Consist of One-to-one with a resident never farther away than 10 or less feet. The residents must remain within this parameter. A licensed nurse my place a resident ton line-of-sight or one-on-one and increase the level of observation at any time as clinically necessary. In all cases the least restrictive clinically appropriate intervention will be implemented. The license nurse my not decrease the level of observation until conferring with the director of nursing/designee and/or physician. The procedure includes three levels of resident observation are used. The levels are designated to provide increasing intensity of observation, precaution, and oversight commensurate with physician and staff. The appropriate observation level is implemented: After evaluation and assessment, a level of observation may be instituted by the attending physician or registered nurse. If a registered nurse institutes an observation level, the attending physician is notified as soon as possible. The physician's order shall include the Observation Level and the reason for the monitoring. The charge nurse will assign staff to perform the standard observation level on a designated set of residents. Resident online of sight or one on one will be assigned specific staff. The charge nurse will assign staff to perform the standard observation level on a specific designated set of residents. Resident online of sight or one on one will be assigned specific staff. The nurse will arrange for staff to be relieved for breaks and meals. Assigned staff will complete the resident observations as rounds are made and document on the rounds from. Staff will observe the resident's location and note the residents' behavior. Rounds are not to be documented in advance. In addition to recording the whereabouts of resident at ordered intervals, the purpose of observation is to provide a system of progressive intensity of resident observation, precaution and oversight based on resident acuity, severity and type of symptoms, and overall needs. The order of observation level is communicated to all staff. Staff must hand-off responsibility for maintaining observation of assigned resident of any break or potential interruption in completing assigned rounds. The Administrator and DON were notified on 09/04/25 at 6:18 PM that an IJ situation was identified due to the above failures and the IJ template was provided. The following Plan of Removal was accepted on 09/05/2025 at 10:46AM: “Plan of Removal 09/05/2025 The facility failed to provide the “planned” or “scheduled” 1:1 supervision for resident #1 that resulted in exposing her to a hazard of being inappropriately / sexually touched by resident #2. 1. On 08/23/25 Resident #2, who was the aggressor that put her hand inside Resident #1's panties, was placed on 1:1 observation. Resident #1, who was supposed to be on 1:1 observation when Resident #2 put her hand in her panties, was returned to 1:1 observation. On 08/26/25, Resident #2 was taken off of 1:1 observation after IDT's review.Person(s) Responsible: Administrator, Director of Nursing, and/or DesigneeDate: 8/26/2025 2. Residents residing in the memory unit received a skin assessment and/or a safe survey on 8/23/2025 with no additional negative findings.Person(s) Responsible: Charge Nurse, social services, and/or designeeDate: 8/23/2025 3. Education was provided to the Administrator and the Director of Nursing on the Abuse & Neglect Policy, 1:1 (employees should remain on 1:1, when placed on 1:1, without fail, until 1:1 is discontinued), and the Resident-to-Resident Policy.Person(s) Responsible: Regional [NAME] President of Operations and/or Regional Nurse ConsultantDate: 9/4/2025 4. All staff educated on the Abuse & Neglect Policy, 1:1 (employees should remain on 1:1, when placed on 1:1, without fail, until 1:1 is discontinued), and Resident-to-Resident Policy.Schedules will be reviewed and the Administrator, Director of Nursing, and/or a Designated staff member will be responsible to ensure all staff will be educated prior to working their next shift.Person(s) Responsible: Administrator, Director of Nursing, and/or Designee Date: 9/4/2025 5. When residents are placed on 1:1, Administrator, Director of Nursing, Assistant Director of Nursing, and/or Designee will spot check, daily, Monday-Friday and a designee such as a charge nurse and/or weekend supervisor will spot check, daily, Saturday and Sunday, to ensure staff are following policy and education provided.Person(s) Responsible: Administrator, Director of Nursing, Assistant Director of Nursing, and/or DesigneeDate: 9/4/2025 6. QAPI— Action: Ad hoc QAPI performed with Medical Director, notified of the Immediate Jeopardy template and the facility's plan to remove it. No additional recommendations at this time.Person(s) Responsible: AdministratorDate: 9/4/2025 7. During an interview on 9/05/25 at 12:59 PM the DON stated that on 08/23/25 Resident #2 was placed on 1:1 supervision but they did not have documentation of that action. He stated because of the IJ they will now keep documentation of all residents who were placed on 1:1 supervision. He stated because of the IJ all residents in the secure unit were assessed by him and the SDON with no negative findings. He stated the ADON conducted safe surveys with no negative findings. He stated when the IJ was called on 09/04/25 the IDT team that included the department heads (the ADM, DON, BOM, Admissions Coordinator, HR, the DM, HK Supervisor, MDS Coordinator, and the ADM) trained all the staff on the ANE policy, 1:1 supervision (to include what it meant, the transfer process, how close they needed to be, when they could leave and documentation), and the Resident-to Resident Policy. He stated that residents who are placed on 1:1 supervision will need to ensure that they are close enough to intervene. He stated if the resident is sleeping the staff can be outside of the door and check every 15 minutes and use a flashlight so that the resident is not disturbed. He stated the 1:1 would be randomly checked to ensure that the documentation is up to date, staff are within the right distance and interventions are being followed. He stated during the week he and the ADON would do the random audits for 1:1 supervision but on the weekend, he had a RN supervisor. He stated he gave staff the opportunity to ask questions if they needed to. He stated Admissions was trained on reviewing the paperwork prior to accepting a resident in the facility. He stated before any resident is admitted to the facility their admission paperwork will be reviewed by the appropriate people in the IDT. He stated they did participate in a QAPI meeting that addressed all the components of the IJ. On 09/05/25 the state surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: Observation on 09/05/25 at 7:55 AM revealed CNAs B, C and DON were working on the memory unit. The DON, who was monitoring, said he was filling in because CNA M was not able to work her shift, and ADON, would also fill in as needed. The DON said there was not a resident in this unit, who was on 1:1 observation or a special level of observation. The staff were expected to monitor and prevent Resident #2 from entering a resident's room. The memory unit had a 3-foot-tall wall that is approximately 12 feet wide and separates the living/dining area from the hallway, which allowed staff to see the residents in the living/dining area and the hallway. Resident #2 did not enter a resident's room. Observation on 09/05/25 at 8:05 AM, revealed Resident #2 was observed walking around the living/dining area and the CNAs were in the hallway and living/dining area observing approximately 9 Residents, including Residents #1 and #2. Resident #2 did not enter a resident's room. Observation on 09/05/25 at 10:06 AM, CNAs, B, C, and DON, who was monitoring, were on duty, and Resident #2 was walking from the hallway to the living/dining area. Resident #2 did not enter a resident's room. Observation on 09/05/25 at 11:21 AM, CNAs, B, C, and DON, who was monitoring, were on duty, and Resident #2 was walking from the hallway to the living/dining area. Resident #2 did not enter a resident's room. Observation on 09/05/25 at 11:23 AM, CNAs, B, C, and DON, who was monitoring, were on duty, and Resident #2 was standing near the CNAs. Resident #2 did not enter a resident's room. Observation on 09/05/25 at 2:10 PM, CNAs, B, C, and LVN F, who was monitoring, were on duty, and Resident #2 was walking in the living/dining area. Resident #2 did not enter a resident's room. Observation on 09/05/25 at 4:55 PM, CNAs B and C, and MA G, who was monitoring, were in the memory care unit, and Resident #2 was walking in the hallway. Resident #2 did not enter a resident's room. Interview on 09/05/25 at 12:57 PM, the DON indicated Resident #2 was the only one identified with sexual behaviors; however, since 08/23/25 she had not made any attempts to touch a resident or staff inappropriately. *Record Review of Resident #2's Event Report dated 09/03/25 indicated: On 08/24/25 at 10:54 AM. Resident #2 was being monitored on the memory unit on, and she was wandering among the common areas with 1:1 assigned staff member. She exhibits no signs of agitation or pain. She has minimal verbal exchanges and has been minimal in complete thoughts and sentences. On 08/24 at 4:22 PM Resident #2 only makes visual contact nonverbal, in good spirit, affect appropriate, and can't assist with questions to complete any SW admission assessments. On 08/26/25 at 10:56 AM revealed Resident #2's Interdisciplinary Team met and discontinued her 1:1 observation. On 09/02/05 LVN F received orders from FNP T, who was in the facility, to complete Resident #2 a CBC, CMP, TSH, A1C, senior psych referral, and Aricept 5mg q hs. This report included that on On 09/02/25 at 10:37 AM LVN F received orders from PNP to change Remeron to HS, change Paxil to AM, monitor for over sedation, and add history of Alzheimer's late onset. *Review Resident #2's FNP T's Progress Note dated 09/02/25 indicated Resident #2 was taking Aricept 5 mg at bedtime orally once a day. This assessment indicated Resident #2 required memory care unit, Aricept, and psych consult. During interview conducted with staff on duty on 09/05/25 from 10:06 PM until 5:01 PM that worked on the 6 AM to 6 PM shift (FNP T at 10:06 PM, LVN F at 10:35 AM , DON at 11:09 PM, ADON at 11:32 PM, CNA H at 1:06 pm, LVN I at 1:36 PM, CNA HH at 1:56 PM, LVN F at 1:49 PM, SW at 2:12 PM, CNA P at 2:32 PM, Activity Director at 2:50 PM, MA J at 2:58 PM, CNA II, at 3:23 PM, Admissions Coordinator at 3:29 PM, HK Supervisor at 4:45 PM, MA G at 5:42 PM), and 6 pm to 6 am shifts (RN Z at 5:51 PM, and CNA and CNA D at 1:28 PM). These staff were in-serviced on preventing Abuse, Neglect, and Exploitation, Levels of Observation, and Resident to Resident Altercat

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the rights of the residents to be free from abuse and neglect for 3 of 6 residents (Resident #1, #2, and #3) reviewed for abuse A. The facility failed to keep Resident #2 safe from abuse when Resident #1 pulled her out of bed after already exhibiting increased aggressive behavior on 11/14/24. B. The facility failed to keep Resident #3 safe from abuse when Resident #1 grabbed her in the face after already exhibiting increased aggressive behavior on 11/14/24. C. The facility failed to keep Resident #1 safe from an unknown nighttime staff when allegations of abuse was made on 11/23/24 by Resident #1 and Family Member M to CNA A, C, the Assistant Activity Director, LVN B and a confidential individual. An Immediate Jeopardy (IJ) was identified on 11/27/24 at 12:49 PM. The IJ template was provided to the facility on [DATE] at 12:49 PM. While the IJ was removed on 11/27/24 at 1:28 PM, the facility remained out of compliance at a severity level of actual harm and a scope of pattern because all staff had not been trained on 11/27/24. This failure could place residents at risk for serious psychosocial harm from abuse, humiliation, intimidation, fear, shame, agitation, and decreased quality of life. Findings included: Resident #1 Record Review of Resident #1's face sheet, dated 11/22/24, revealed an [AGE] year-old male that was admitted to the facility on [DATE], with a diagnosis of dementia (memory loss). Record Review of Resident #1's Comprehensive MDS assessment dated [DATE], revealed under Section C, Cognitive Patterns, a BIMS score of 00, indicating the resident was severely cognitively impaired. Section E revealed Resident #1 exhibited physical behavior (hitting, kicking, pushing, scratching, grabbing, and abusing) during the review [E0200]. The identified symptoms placed the resident at significant risk for physical illness or injury [E0500]. The identified symptoms placed others at risk for physical injury, significantly intruded on the privacy or activity of others, and significantly disrupted care or living environment. Record review of Resident #1's progress notes dated from 09/22/24- 11/22/24 revealed the following: The Social Worker documented on 11/14/24 at 6:35 PM that she received a message from staff (unidentified) that a staff (unidentified) was punched in the face. LVN N documented on 11/14/24 at 8:30 PM that Resident #1 hit the day certified nursing aide (unidentified) in the face and opened a skin tear on both arms. LVN N documented on 11/14/24 at 8:40 PM that Resident #1 was becoming agitated again, hit a certified nursing aide (unidentified) in the chest. Resident #1 was pacing and yelling in intervals. Record review of Resident #1's care plan, dated 11/22/24, revealed a focused area, initiated on 11/22/24, Resident #1 had a history of aggressive behavior towards others. The goal initiated on 11/22/24, was Resident #1 would have fewer than 3 episodes of aggressive behavior before the next review date. The interventions initiated 11/22/24 included keeping the environment calm, relaxed, convey acceptance of the resident during periods of inappropriate behavior, remove from public area when behavior was unacceptable, and to ask for help when his behavior becomes unacceptable. Record review of the facility event summary report, dated 08/26/24-11/26/24, revealed the following: Resident #1 had aggressive/combative resident-to-resident aggression on 11/16/24 and 2 unwitnessed falls on 11/23/24. Record review of the facility event summary report dated 08/26/24-11/26/24, did not reveal any documentation regarding his resident-to-resident altercation that occurred on 11/14/24 with Resident # 2 and Resident #3. Record review of Resident #1's hospice progress notes did not reveal any information about Resident #1's and Family Member B's allegation of ANE. There was no information regarding Resident #1's resident-to-resident altercation with Resident #2 (pulling her out if bed). There was no information regarding Resident #1's resident-to-resident altercation with Resident # (grabbing her in her face). The notes did reveal the following: On 11/23/24 at 5:39 AM a call was placed by LVN N to hospice requesting a nurse visit. The progress note indicated that LVN N stated Resident #1 rolled out of bed and had an abrasion to his right eyebrow, a cut on his lip and a skin tear to the bridge of his nose. On 11/23/24 Hospice Nurse T assessed Resident #1. Hospice Nurse T observed Resident #1's nose and lower swollen. She observed steri strips to the face and nose. State surveyor attempted to interview LVN N on 11/27/24 at 8:34 AM and the attempt was unsuccessful. State surveyor left a message. During an interview on 11/26/24 at 9:30 AM, the Regional Nursing Consultant stated during the entrance conference that an injury of unknown origin or bruising should be investigated and reported to HHSC. She said if the bruising could be explained, a progress note would be entered by the nurse who identified the bruising and explain where the bruising came from. She said all efforts would be documented in the resident's electronic medical record. During an interview on 11/26/24 at 10:00 AM, Family Member M stated she was told by facility staff that Resident #1 had told them a nighttime staff had hit him the weekend off 11/23/24 and that she was notified that Resident #1 had a fall. She said she did not know the full name of the staff who reported this information to her nor did she know the name of the staff that allegedly hit Resident #1. She said Resident #1 told her that a woman had hit him. She said the same staff reported that another female resident had hit Resident #1. She said she did not tell anyone specifically about what the facility staff and Resident #1 told her, but that staff knew because she (Family Member M) was vocal about it. A confidential interview revealed that Resident #1 had a fall the weekend of 11/23/24. They said they could not remember if it was a Friday or a Saturday. They said when they came to work, Resident #1 was quiet and not as active as he once was. They said that Resident #1 gestured with his hand that staff had hit him on top of the head. They asked Resident #1 if it was an overnight staff that had hit him, and Resident #1 stopped answering questions when they started asking for details. They stated Family Member M had expressed in the past that she did not feel that the overnight staff were taking care of Resident #1. They said the weekend that they came in for their shift, and Resident #3 allegedly fell he (Resident #1) did have a cut on his eye and his lip. They said when they attempted to get Resident #1 up for breakfast, Resident #1 was sleepy, and she had to get a wheelchair to roll him to the table. They said they did not know if this was from the fall. They stated that the morning Resident #1 fell, a hospice nurse (unknown) and LVN B were assessing Resident #1. They said the hospice nurse (unknown) said the injuries that Resident #1 sustained were not consistent with a fall. They said that the hospice nurse (unknown) did not say what specifically the injuries looked like they came from. They stated that the same day, Resident #1 did not eat. They said when Resident #1 told them that he had been hit by staff, they told CNA A. They said CNA A told them the injuries looked like injuries from a fall, and CNA compared Resident #1 to another resident with a similar fall. They said that Family Member M told them that Resident #1 had expressed to her that he had been hit by night staff. They said that they did not report the allegations that Resident #1 reported to them nor the concerns that Family Member M reported to them because their phone was not working. They stated they did not use the facility phone because the on-call staff never answered the phone when they called from the facility phone. They said the previous day, they had tried to call the on-call phone from the facility for a staffing concern, and the staff did not answer. They said they had been trained to call the ADM, who was the abuse coordinator if they witnessed or suspected ANE. They said they had been taught to contact the abuse coordinator immediately. They said that they did not contact the ADM, who was the abuse coordinator, because it was the weekend. They said they could not remember if they reported the allegations of ANE to LVN B, but the nurse typically does not stay in the locked unit. They said they did mention the accusations of ANE regarding Resident #1 to the Assistant Activity Director. They said no one had asked them anything about the nature of the fall. During an interview on 11/26/24 at 3:06 PM, CNA A stated that she did not know much about the fall that occurred on 11/23/24 involving Resident #1. They said CNA O told her that Resident #1 had an unwitnessed fall when she came on shift. She said CNA O told her that LVN N was helping her do rounds and change residents. She said CNA O said that she and LVN N had come out of Resident #1's room, and he had fallen. CNA A said she did not remember a staff member telling her that Family Member M had concerns about the injuries, but that Family Member M did express to her that she had concerns about the injuries that Resident #1 sustained. CNA A said that when Family Member M said that she did not think the injuries were consistent with a fall, she encouraged Family Member M to talk to LVN B because as a certified nurse aide she had been trained to refer family concerns to her nurse. CNA A said Resident #1's face was beat up. She said Resident #1 had steri-strips (reinforces skin closure) all over his face. She said he had a busted lip and a cut by his eye. CNA A said she was unaware of Resident #1 having any physical altercations with female residents where he was not the aggressor. CNA A said Resident #1 was aggressive, and all staff knew about it, which had been reported to management. CNA A said Resident #1 had punched her in the face. She said she could not remember the exact date but that it was documented in Resident #1's progress notes. She said they did not receive any instructions on handling Resident #1. She said she felt if his behaviors had been addressed, his behaviors wouldn't have continued to escalate. She said no one had interviewed her regarding Resident #1's behaviors or Family Member M's allegations. CNA said that she had been trained to report ANE as soon as possible to the ADM. During an interview on 11/26/24 at 3:55 PM, the Assistant Activity Director stated that she had experience with Resident #1 and his aggressive behavior. She said when Resident #1 had his resident-to-resident altercation on 11/16/24, she was assisting taking him out of the memory unit to calm down. She said Resident #1 saw an exit door and attempted to exit. She said she tried to redirect him, but he grabbed her hair and pulled it. She said they ultimately got him back to the unit. She said that Resident #1 punched another staff member in the face before that incident. She said she had not received any training specific to Resident #1 on responding to his aggressive behaviors. She said on Saturday, 11/23/24, she went into the memory unit and noticed Resident #1 was at the dining room table with his head down. She thought this was odd because Resident #1 was usually up and pacing around. She said CNA P told her that Resident #1 had fallen. She said she had asked if Family Member M had been notified and was told that attempts had been made, but they were unsuccessful because Family Member M's phone was off. The Assistant Activity Director said that later in the day (11/23/24), Family Member M came to the facility and said to her that Resident #1 reported to her (Family Member M) that someone came into his room at night and hit him. She said it was around lunchtime when she (Family Member M) told her that Resident #1 made the allegation. The Assistant Activity Director stated she told the aides (she did not disclose who) that were working the memory unit and that the aides said that it looked like someone hit Resident #1. She said she told the aides to get a nurse to explain Resident #1's injuries to Family Member M. She said the nurse (LVN B) told Family Member M it was a fall, and it was documented. The Assistant Activity Director told LVN B that Family Member M thought someone had beaten Resident #1 up. She was told that the documentation reflected that Resident #1 had a fall. The Assistant Activity Director said the abuse coordinator was the SW. She said she did not report the allegations of abuse to the SW because the SW was not at the facility. She said she had been trained on what to do if they suspect or witnessed abuse. She said that she had been taught to call the ADM. She said that she did not report the allegations of ANE to the ADM because she was not there when the incident allegedly happened. She said no one had interviewed her to ask her about her knowledge of the incident regarding allegations of abuse. She said she was unaware of any physical altercations that involved Resident #1. During an interview on 11/26/24 at 8:20 PM, LVN B stated the abuse coordinator was the ADM. She stated she had ANE training. She said she had been trained that if she witnessed or suspected abuse, she needed to report the allegation to the ADM as soon as possible. She said that on the day (11/23/24), Resident #1 fell on the overnight shift. He had also fallen on her shift (a day shift). She said CNA A said that she had found Resident #1 on the floor. She said she assessed Resident #1 and called Hospice out for assistance. She said she notified Family Member M. Family Member M was upset because Resident #1 had fallen on the overnight shift. LVN B said it was around 1:00 PM when Resident #1 had fallen on her shift. LVN B said she did not have details about Resident #1's first fall. She said Family Member M was upset. She said that she could tell by her body language but that she was speaking in Spanish to CNA A. LVN B said it was relayed to her from CNA A that Family Member M did not believe the lacerations, cuts, and gashes had come from a fall and that he looked like he had been punched. She said Resident #1 had a history of falls. LVN B said she did not report the allegations that CNA A had translated from Family Member B to the ADM because Family Member B was concerned with the overnight fall. She (LVN B) was sure that Resident #1 did not get punched on her shift, and that Family Member M said she would take Resident #1 home. She said that she was told that Resident #1 had a history of falls, according to the hospice nurse who came out and was not sure why Resident #1's falling was an issue. LVN B said she was unaware that Resident #1 had any physical altercations with female residents in the locked unit. She said Resident #1 never said he had been hit by staff when she interacted with him. She said she was unaware of any incidents that involved Resident #1 and other female residents. She said that since his admission, she had never received any training on how to deal with Resident #1's aggressive behavior. She said she had never been interviewed regarding Resident #1's behaviors or the allegations of ANE. She said the potential negative outcome of not reporting allegations of ANE to the abuse coordinator was that the abuse could continue. She said Resident #1 had told her that he fell. She said she documented what happened during her shift but did not document the information regarding Family Member M because she knew no one punched Resident #1 on her shift. She said that although it may sound silly, she felt that Family Member M wanted to take Resident #1. During an interview on 11/26/24 at 8:25 AM, Hospice Nurse S did not provide any information that supports the facility's deficient practice. She reported that she did not have any concerns with staff treatment, nor did she suspect or witness ANE. She was unaware of any allegations that Family Member M made. She said that she was the nurse who came out when he had behaviors on 11/14/24. She said there were discussions to send him to a behavioral center, but it was decided and, in her opinion, not beneficial for Resident #1 because of his diagnosis of dementia. She said she never said that his injuries were inconsistent with a fall. During an interview on 11/26/24 at 8:38 AM, Hospice Nurse T did not provide any information that supports the facility's deficient practice. She reported that she did not have any concerns with staff treatment, nor did she suspect or witness ANE. She was unaware of any allegations that Family Member M made. She said she came out on 11/23/24 when Resident #1 had his 2nd fall; this was her first time meeting Resident #1. She said that she never expressed that she felt that Resident #1's injuries were inconsistent with any of his falls. During an interview on 11/27/24 at 9:30 AM, CNA C stated that she did not know any details about Resident #1's fall on 11/23/24. She said she heard about Resident #1 punching CNA A but knew nothing about that incident. She said she knew that Resident #1 had been aggressive since he came to the facility. She said she heard that Resident #1 had a broken nose and that someone had been hitting him on top of the head. She said she heard it was a nighttime staff that was hitting him. She said she was told this on 11/26/24 by CNA A. She said she did not report what CNA A told her to the abuse coordinator because she was told that it had already been reported to the state. She said she had no proof that the allegation of ANE had been reported but was told that was why the state was in the facility. She said she had been trained that all allegations of abuse should be reported to the abuse coordinator as soon as possible. She said she received abuse training within the last year when she took her CNA classes. She said the potential negative outcome of not reporting allegations of abuse could allow abuse to continue. During an interview on 11/27/24 at 9:23 AM, the ADM stated he was unaware of Family Member M's allegations of abuse. He said none of the incidents were investigated because he was unaware of the incidents. Preventive measures were not put in place to protect Resident #1 after the allegations of abuse because he was unaware of the incident. He was unaware that Resident #1 had aggressive behaviors before admission. He said that there were discussions about sending Resident #1 to a behavior facility, but after consulting with Hospice, it was recommended by Hospice that pharmaceutical attempts should be taken first. Regarding the injury of unknown origin, he said he was unaware of the injury and that the staff did not know where it came from. He said this was not reported to him. Resident #2 Record Review of Resident #2's face sheet, dated 11/27/24, revealed an [AGE] year-old female that was initially admitted to the facility on [DATE] and readmitted on [DATE], with the following diagnoses: dementia (memory loss), anxiety (increased worry), and cognitive communication (difficulty communicating). Record Review of Resident #2's Comprehensive MDS assessment dated [DATE], revealed under Section C, Cognitive Patterns, a BIMS score was blank. Section E did not reveal any documented behaviors for Resident #2. Record Review of Resident #2's Brief Interview for Mental Status (BIMS) dated 11/27/24 revealed the summary score was 99, indicating the resident was severely cognitively impaired. Record Review of Resident #2's Quarterly MDS assessment dated [DATE], revealed under Section E did not reveal any documented behaviors for Resident #2. Record review of Resident #2's care plan, dated 08/22/24, revealed a focused area, initiated on 10/01/24, that indicated Resident #2 had socially inappropriate/disruptive behaviors as evidenced by abusing the staff. The goal initiated on 10/31/24, Resident #2 will not harm self or others. The interventions initiated 10/01/24 included assessing the resident for placement, assess whether the behavior endangers the resident and others, avoid over stimulation, praise for acceptable behavior, and maintain a calm environment. Record review of Resident #2's progress notes dated from 08/27/24- 11/27/24 did not reveal any information regarding her resident-to-resident altercation on 11/14/24 with Resident #1. Record review of the facility event summary report dated 08/26/24-11/26/24, did not reveal any documentation regarding his resident-to-resident altercation that occurred on 11/14/24 with Resident #2 and Resident #1. Record review of Resident #2 EMR did not reveal any assessments conducted on 11/4/24. During an interview on 11/26/24 at 9:07 AM Family Member R stated they did not have any concerns with the treatment of Resident #2. She said she did not get to visit often. She said that she has not received any notifications of ANE. She said she only received notification when Resident #2 had fallen or if they had sent Resident #2 out to the hospital. She said no incidents involving Resident #2 and any of her peers had been reported to her. During an interview on 11/26/24 at 3:06 PM, CNA A stated she had been trained on what to do if she suspected or witnessed abuse. She stated she had been instructed to report all allegations of ANE to the ADM, who was the abuse coordinator, as soon as she suspected or witnessed abuse CNA A said she was unaware of Resident #1 having any physical altercations with female residents where he was not the aggressor. CNA A said Resident #1 was aggressive, and all staff knew about it, which had been reported to management. CNA A said Resident #1 had punched her in the face. She said she could not remember the exact date but that it was documented in Resident #1's progress notes. She said on the same day he punched her in the face, Resident #1 had increased behaviors. She said she heard Resident #2 yelling. When she walked into Resident #2's room, she observed Resident #1 attempting to pull Resident #2 out of bed. She said Resident #2's bed was lowered to the floor with a bedside mat next to it. She said she observed Resident #1 standing on the mat next to Resident #2's bed, and he had her by her (Resident #2's) legs. CNA said that Resident #2 was screaming, and Resident #1 was accusing them (staff) of restraining Resident #2 and that he would call the police. CNA A said she attempted to redirect Resident #1, but he tried to hit her. She said she blocked the first hit from Resident #1. She said he then tried to grab the fire extinguisher and said he would hit her. She said Resident #1 grabbed a chair, and because other residents were close, she went to grab the chair from him. She said that when she got the chair from him, and she was putting it down, Resident #1 hit her hard in the face, and she started crying. She said that on the same date that Resident #1 hit her he also tried to pull Resident #2 out of bed. She said the Former DON wanted to send Resident #1 to a behavior center but was told by the ADM that they wanted to try other things. She said she told the ADM that Resident #1 and the other residents in the locked unit were not safe. She said she did tell the ADM about Resident #1 hitting her and pulling Resident #2 out of bed. CNA A said she was unsure if a nurse physically assessed any of the residents because she was told to go home and leave. She said they did not receive any instructions on handling Resident #1. She said she felt if his behaviors had been addressed, his behaviors wouldn't have continued to escalate. She said no one had interviewed her regarding Resident #1's behaviors or his interactions with Resident #2. She said she was alone in the memory unit during the time the incident occurred. During an interview on 11/26/24 at 4:30 PM, the SW stated she was not present when Resident #1 grabbed Resident #3 in the face. She said that she was notified by staff but did not remember the staff who reported the information. She stated she had never observed Resident #1 grab anyone but had observed Resident #1 being redirected. During an interview on 11/27/24 at 9:30 AM, CNA C stated that she said she knew that Resident #1 had been aggressive since he came to the facility. She said she did not see the incident but had heard about Resident #1 trying to pull Resident #2 out of bed because he thought she (Resident #2) shouldn't have been in bed. She was unsure of the date of the incident. CNA C said she was unaware if Resident #1 actually made contact with Resident #2. She said no one ever interviewed or asked about the resident-to-resident altercation between Resident #1 and Resident #2. During an interview on 11/27/24 at 9:23 AM, the ADM stated he was unaware of an incident where Resident #1 tried to pull Resident #2 out of bed. He said none of the incidents were investigated because he was unaware of the incidents. He said no preventative measures were put in place to safeguard Resident #2 from Resident #1. During an interview on 11/27/24 at 1:05 PM, Resident #2 was unable to answer any questions about the alleged incident between her and Resident #1. She turned her head and refused to speak. Resident #3 Record Review of Resident #3's face sheet, dated 11/27/24, revealed an [AGE] year-old female that was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses of dementia (memory loss), anxiety (increased worry), and cognitive communication deficit (difficulty communicating). Record Review of Resident #3's Comprehensive MDS assessment dated [DATE], revealed under Section C, Cognitive Patterns, a BIMS score of 03, indicating the resident was severely cognitively impaired. Section E did not reveal any documented behaviors for Resident #3. Record Review of Resident #3's Quarterly MDS assessment dated [DATE], revealed under Section E did not reveal any documented behaviors for Resident #3. Record review of Resident #3's progress notes dated from 08/27/24- 11/27/24 did not reveal any information regarding her resident-to-resident altercation on 11/14/24 with Resident #1. Record review of Resident #3's care plan, dated 06/12/24, revealed a focused area, initiated on 10/01/24, Resident #3 had physically abusive behavior symptoms. The goal initiated on 11/06/24, was Resident #3 would not physically abuse other residents, visitors, and staff. The interventions initiated 10/01/24 included assess whether the resident's behavior endangers the resident or others, convey an attitude of acceptance towards the resident, maintain a calm environment, and allow extra time to process information. Record review of the facility event summary report dated 08/26/24-11/26/24, did not reveal any documentation regarding his resident-to-resident altercation that occurred on 11/14/24 with Resident #1. Record review of Resident #3 EMR did not reveal that any assessments were conducted on 11/14/24. During an interview on 11/26/24 at 3:06 PM, CNA A stated Resident #1 had punched her in the face. She said she could not remember the exact date but that it was documented in Resident #1's progress notes. She said on the same day he punched her in the face, Resident #1 had increased behaviors. She said that on the same date that Resident #1 hit her in the face, he grabbed Resident #3 in the face. She said the ADM and the SW were present when Resident #1 grabbed Resident #3 in the face. She said Resident #1 did it so fast that she could not intervene. She said Resident #3 exclaimed, Why did he do that? She said the Former DON wanted to send Resident #1 to a behavior center but was told by the ADM that they wanted to try other things. She said she told the ADM that Resident #1 and the other residents in the locked unit were not safe. She said she did not tell the ADM about Resident #1 grabbing Resident #3 in the face because he was present when Resident #1 grabbed Resident #3 in the face. CNA A said she was unsure if a nurse physically assessed any of the residents because she was told to go home and leave. She said they did not receive any instructions on handling Resident #1. She said she felt if his behaviors had been addressed, his behaviors wouldn't have continued to escalate. She said no one had interviewed her regarding Resident #1's behaviors or his interaction with Resident #3. CNA A said that she was the only staff in the memory unit when the incidents occurred. During an interview on 11/27/24 at 9:23 AM, the ADM stated he said he was unaware of an incident where Resident #1 grabbed Resident #3 in the face. He said none of the incidents were investigated because he was unaware of the incidents. He said no preventative measures were put in place to safeguard Resident #3 from Resident #1. During an interview on 11/27/24 at 1:17 PM, Resident #3 stated she could not remember the date or the name of the male resident who grabbed her in the face. She said it hurt. She said that the male resident was no longer in the facility, and she was glad because him grabbing her scared her. She said she did not know why he grabbed her, but he was mean. During an interview on 11/27/24 at 9:23 AM, the ADM stated that regarding resident-to-resident altercations, he expected staff to separate them and ensure the residents were calm and safe. He said they should immediately notify the abuse coordinator. He said the potential negative outcome is that if steps were missed or done out of order, something could happen to the residents or escalate the incidents. He said not reporting resident-to-resident altercations or handling them appropriately could cause an inability for barriers and interventions to be put in place to protect residents. He said if an incident occurs on the weekend, the staff should respond the same. He said there was an on-call system that staff have been trained to use, but unfortunately, the phone was with a staff that no longer worked at the facility. He said the on-call telephone had just been returned to the facility on [DATE]. He said his phone number was posted everywhere, so staff still should be able to reach him, and he would answer phone calls from the facility. He said staff have been trained to send a text and to keep calling if they do not get an answer. He said he had no documentation to reflect the staff training to keep calling if they do not get an answer. He said he verbalized this in ANE training. He said if there was an allegation of ANE, notifications should be made to the physician, abuse coordinator, and the police if actual abuse occurred. He said the potential negative outcome of not following the abuse policy could be that interventions could not be put in place to protect the residents and prevent abuse. He said residents should be assessed by a nurse for mental concerns and physical injuries. He said if residents were not assessed, there could be an untreated mental concern or untreated issue. He said that an investigation should be conducted if there were abuse allegations. He said the failure to conduct investigations of ANE could prevent them from knowing how something occurred and what occurred and hurt the ability to prevent abuse from happening again. He said prevention measures should be put in place. He said that the aggressor should be monitored depending on the situation and that no additional aggressive behavior should be allowed. He said he was the abuse coordinator, and all things (allegations of ANE and resident-to-resident altercations) should be reported to him within an hour or as soon as possible. He said allegations of abuse, resident-to-resident altercations, assessments, and notifications to the family should be documented. He said the nurse working on the incident would be responsible for documentation, assessments, and notifications. He said he, as the abuse coordinator, was responsible for investigating and reporting to HHSC. On 11/27/24 at 12:49 PM an IJ situation was identified due to the above failures and the IJ template was provided. The following Plan of Removal submitted by the facili[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to implement written policies and procedures that prohibit and prevent abuse and neglect for 3 of 6 residents (Resident #1, #2, and #3) reviewed for abuse. A. The ADM failed to follow the facility's abuse policy by not reporting the allegation of abuse to HHSC and documenting his investigation/prevention measures regarding Resident #1 by an unknown nighttime staff on 11/23/24 . CNA A, C, the Assistant Activity Director, LVN B, and a confidential individual failed to follow the facility's abuse policy by not reporting the allegation of abuse involving Resident #1, reported by Resident #1 and Family Member M on 11/23/24 to the abuse preventionist between the dates of 11/23/24-11/27/24. B. The ADM failed to follow the facility's abuse policy by not reporting the incident to HHSC and investigating an injury of an unknown origin involving Resident #1 that occurred and that was documented on 11/11/24. C. The ADM failed to follow the facility's abuse policy by not reporting the resident-to-resident altercation (Resident #1 attempted to pull Resident #2 out of bed) that occurred on 11/14/24 between Resident #1 and Resident #2 to HHSC and documenting his investigation/prevention measures regarding Resident #2. D. The ADM failed to follow the facility's abuse policy by not notifying Family Member R of the resident-to-resident altercation (Resident #1 attempted to pull Resident #2 out of bed) that occurred on 11/14/24 between Resident #1 and Resident #2. E. The ADM failed to follow the facility's abuse policy by not assessing Resident #2 for mental and physical effect after the resident-to-resident altercation (Resident #1 attempted to pull Resident #2 out of bed) that occurred on 11/14/24 between Resident #1 and Resident #2. F. The ADM failed to follow the facility's abuse policy by not reporting the resident-to-resident altercation (Resident #1 grabbed Resident #3 in the face) that occurred on 11/14/24 between Resident #1 and Resident #3 to HHSC and documenting his investigation/prevention measures regarding Resident #3. G. The ADM failed to follow the facility's abuse policy by not assessing Resident #3 for mental and physical effect after the resident-to-resident altercation (Resident #1 grabbed Resident #3 in the face) that occurred on 11/14/24 between Resident #1 and Resident #3. An Immediate Jeopardy (IJ) was identified on 11/27/24 at 12:49 PM. The IJ template was provided to the facility on [DATE] at 12:49 PM. While the IJ was removed on 11/27/24 at 1:28 PM, the facility remained out of compliance at a severity level of actual harm and a scope of pattern because all staff had not been trained on 11/27/24. These failures could place residents as risk for abuse and neglect. Findings included: Record review of the facility policy, Abuse Investigation and Reporting, revised October 2023 revealed: Policy Statement The facility will provide protection for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, and exploitation and misappropriation of resident property. Policy Interpretation and Implementation The facility will develop and implement written policies and procedures that: o Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property; and o Establish policies and procedures to investigate any such allegations; and The facility will designate an Abuse Prevention Coordinator in the facility who is responsible for reporting allegations or suspected abuse, neglect, or exploitation to the state survey agency and other officials in accordance with state law. The facility will provide ongoing oversight and supervision of staff to ensure that its policies are implemented as written. Abuse Prohibition Plan Components II. Prevention of Abuse, Neglect and Exploitation The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves: 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; C. Ensuring an assessment of the resources needed to provide care and services to all residents is included in the facility assessment; G. Addressing features of the physical environment that may make abuse, neglect, exploitation, and misappropriation of resident property more likely to occur; and H. Assigning responsibility for the supervision of staff on all shifts for identifying inappropriate staff behaviors. III. Identification of Abuse, Neglect and Exploitation The facility will have written procedures to assist staff in identifying the different types of abuse - mental/verbal abuse, sexual abuse, physical abuse, and the deprivation by an individual of goods and services. This includes staff to resident abuse and certain resident to resident altercations. Possible indicators of abuse include, but are not limited to: 1. Resident, staff, or family report of abuse; 2. Physical marks such as bruises or patterned appearances such as a handprint, belt, or ring mark on a resident's body; 3. Physical injury of a resident, of unknown source; IV. Investigation of Alleged Abuse, Neglect and Exploitation An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. Written procedures for investigations include: o Identifying staff responsible for the investigation; o Exercising caution in handling evidence that could be used in a criminal investigation (e.g., not tampering or destroying evidence); o Investigating different types of alleged violations; o Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations; o Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and o Providing complete and thorough documentation of the investigation. V. Protection of Resident The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to: Responding immediately to protect the alleged victim and integrity of the investigation; Examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed; Increased supervision of the alleged victim and residents; Room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator; Protection from retaliation; VI. Reporting/Response The facility will have written procedures that include: o Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. 5. Taking all necessary actions as a result if the investigation, which may include, but are not limited to, the following: Analyzing the occurrence(s) to determine why abuse, neglect, misappropriation of resident property or exploitation occurred, and what changes are needed to prevent further occurrences; Defining how care provision will be changed and/or improved to protect residents receiving services; Training of staff on changes made and demonstration of staff competency after training is implemented; Identification of staff responsible for implementation of corrective actions; The expected date for implementation; and Identification of staff responsible for monitoring the implementation of the plan. B. The Administrator will follow up with government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within 5 working days of the incident, as required by state agencies. Management 1. The resident and family/representatives will be informed of the resident's condition as well as the potential risks and benefits or proposed interventions. 2. Interventions will be individualized and part of an overall care environment that supports physical, functional and psychosocial needs, and strives to understand, prevent or relieve the resident's distress or loss of abilities. 3. Interventions and approaches will be based on a detailed assessment of physical, psychological and behavioral symptoms and their underlying causes, as well as the potential situational and environmental reasons for the behavior. The care plan will include, as a minimum: a. A description of the behavioral symptoms, including: (1) Frequency; (2) Intensity; (3) Duration; (4) Outcomes; (5) Location; (6) Environment; and (7) Precipitating factors or situations. 4. Non-pharmacologic approaches will be utilized to the extent possible to avoid or reduce the use of antipsychotic medications to manage behavioral symptoms. 5. The Director of Nursing, or designee, will evaluate whether the staffing needs have changed based on acuity of the residents and their plans of care. Additional staff and/or staff training will be provided if it determined that the needs of the residents cannot be met with the current level of staff or staff training. Record review of the facility policy, Behavioral Assessment, Intervention and Monitoring, revised December 2021 revealed: Policy Statement 1. The center will provide and residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care. Policy Interpretation and Implementation Assessment 1. As part of the comprehensive assessment, staff will evaluate, based on input from the resident, family and caregivers, review of medical record and general observations: a. The resident's usual patterns of cognition, mood and behavior; b. The resident's typical or past responses to stress, fatigue, fear, anxiety, frustration and other triggers; and 2. New onset or changes in behavior will be documented regardless of the degree of risk to the resident or others. Record review of the facility policy, Resident-to Resident Altercations, revised October 2023 revealed: Policy Statement All altercations, including those that may represent resident-to-resident abuse, shall be investigated, and reported to the Nursing Supervisor, the Director of Nursing Services and to the Administrator. Policy Interpretation and Implementation Facility staff will monitor residents for aggressive/inappropriate behavior towards other residents, family members, visitors, or to the staff. Occurrences of such incidents shall be promptly reported to the Nurse Supervisor, Director of Nursing Services, and to the Administrator. If two residents are involved in an altercation, the nursing staff will: a. Separate the residents, and institute measures to calm the situation up to and/or including 1:1 supervision of the offending resident; Identify what happened, including what might have led to aggressive conduct on the part of one or more of the individuals involved in the altercation; Review the events with the Nursing Supervisor and Director of Nursing, and possible measures to try to prevent additional incidents; Make any necessary changes in the care plan approaches to any or all of the involved individuals; Document in each resident's clinical record all interventions and their effectiveness; o Residents may only be released from 1:1 supervision once deemed safe by one or a combination of the following: Complete a Report of Incident/Accident form and document the incident, findings, and any corrective measures taken in the resident's medical/clinical record; If, after carefully evaluating the situation, it is determined that care cannot be readily given within the facility, transfer the resident; and Report incidents, findings, and corrective measures to HHSC or other appropriate agencies if indicated as outlined in our facility's abuse reporting policy. Inquiries concerning resident-to-resident altercations should be referred to the Director of Nursing Services or to the Administrator. There were no provider investigation reports available for review that involved any of the residents listed in the sample as of 11/26/24. Resident #1 Record Review of Resident #1's face sheet, dated 11/22/24, revealed an [AGE] year-old male that was admitted to the facility on [DATE], with a diagnosis of dementia (memory loss). Record Review of Resident #1's Comprehensive MDS assessment dated [DATE], revealed under Section C, Cognitive Patterns, a BIMS score of 00, indicating the resident was severely cognitively impaired. Section E revealed Resident #1 exhibited physical behavior (hitting, kicking, pushing, scratching, grabbing, and abusing) during the review [E0200]. The identified symptoms placed the resident at significant risk for physical illness or injury [E0500]. The identified symptoms placed others at risk for physical injury, significantly intruded on the privacy or activity of others, and significantly disrupted care or living environment. Record review of Resident #1's progress notes dated from 09/22/24- 11/22/24 revealed the following: LVN N documented on 11/10/24 at 11:47 PM that Resident #1 was urinating on the floor and when he was redirected, he hit the certified nurse's aide in the face and began to tear up the air mattress machine in his room. LVN N documented on 11/11/24 at 4:49 PM that Resident #1 continued to go into other residents' rooms hitting on walls and moving closet doors. LVN N documented on 11/11/24 at 5:53 AM that a certified nursing aide (unidentified) and she observed 2 small abrasions approx., 2 cm in size. One was located by his left eye and the other was above his left eye. LVN N documented that it was unknown how Resident #1 received the abrasions. She documented that Resident #1 continued to go into other residents' rooms and when he was redirected, he would lift his hands/arm up as if he was going to hit staff . The Social Worker documented on 11/14/24 at 6:35 PM that she received a message from staff (unidentified) that a staff (unidentified) was punched in the face. LVN N documented on 11/14/24 at 8:30 PM that Resident #1 hit the day certified nursing aide (unidentified) in the face and opened a skin tear on both arms. LVN N documented on 11/14/24 at 8:40 PM that Resident #1 was becoming agitated again, hit a certified nursing aide (unidentified) in the chest. Resident #1 was pacing and yelling in intervals. LVN Q documented on 11/16/24 at 5:45 PM that Resident #1 initiated aggression towards another resident (unidentified) and the resident returned a hit back. She documented that Resident #1 was taken out of the memory unit to calm down. Resident #1 attempted to exit the facility and when staff tried to redirect/intervene he became aggressive. Record review of Resident #1's care plan, dated 11/22/24, revealed a focused area, initiated on 11/22/24, Resident #1 had a history of aggressive behavior towards others. The goal initiated on 11/22/24, was Resident #1 would have fewer than 3 episodes of aggressive behavior before the next review date. The interventions initiated 11/22/24 included keeping the environment calm, relaxed, convey acceptance of the resident during periods of inappropriate behavior, remove from public area when behavior was unacceptable, and to ask for help when his behavior becomes unacceptable. Record review of the facility event summary report, dated 08/26/24-11/26/24, revealed the following: Resident #1 had aggressive/combative resident-to-resident aggression on 11/16/24 and 2 unwitnessed falls on 11/23/24. Record review of the facility event summary report dated 08/26/24-11/26/24, did not reveal any documentation regarding his resident-to-resident altercation that occurred on 11/14/24 with Resident # 2 and Resident #3 . Record review of Resident #1's hospice progress notes did not reveal any information about Resident #1's and Family Member B's allegation of ANE. There was no information regarding Resident #1's resident-to-resident altercation with Resident #2 (pulling her out if bed). There was no information regarding Resident #1's resident-to-resident altercation with Resident # (grabbing her in her face). The notes did reveal the following: On 11/23/24 at 5:39 AM a call was placed by LVN N to hospice requesting a nurse visit. The progress note indicated that LVN N stated Resident #1 rolled out of bed and had an abrasion to his right eyebrow, a cut on his lip and a skin tear to the bridge of his nose. On 11/23/24 Hospice Nurse T assessed Resident #1. Hospice Nurse T observed Resident #1's nose and lower swollen. She observed steri strips to the face and nose. State surveyor attempted to interview LVN N on 11/27/24 at 8:34 AM and the attempt was unsuccessful. State surveyor left a message. During an interview on 11/26/24 at 9:30 AM, the Regional Nursing Consultant stated during the entrance conference that an injury of unknown origin or bruising should be investigated and reported to HHSC. She said if the bruising could be explained, a progress note would be entered by the nurse who identified the bruising and explain where the bruising came from. She said all efforts would be documented in the resident's electronic medical record . During an interview on 11/26/24 at 10:00 AM, Family Member M stated she was told by facility staff that Resident #1 had told them a nighttime staff had hit him the weekend off 11/23/24 and that she was notified that Resident #1 had a fall. She said she did not know the full name of the staff who reported this information to her nor did she know the name of the staff that allegedly hit Resident #1. She said Resident #1 told her that a woman had hit him. She said the same staff reported that another female resident had hit Resident #1. She said she did not tell anyone specifically about what the facility staff and Resident #1 told her, but that staff knew because she (Family Member M) was vocal about it . A confidential interview revealed that Resident #1 had a fall the weekend of 11/23/24. They said they could not remember if it was a Friday or a Saturday. They said when they came to work, Resident #1 was quiet and not as active as he once was. They said that Resident #1 gestured with his hand that staff had hit him on top of the head. They asked Resident #1 if it was an overnight staff that had hit him, and Resident #1 stopped answering questions when they started asking for details. They stated Family Member M had expressed in the past that she did not feel that the overnight staff were taking care of Resident #1. They said the weekend that they came in for their shift, and Resident #3 allegedly fell he (Resident #1) did have a cut on his eye and his lip. They said when they attempted to get Resident #1 up for breakfast, Resident #1 was sleepy, and she had to get a wheelchair to roll him to the table. They said they did not know if this was from the fall. They stated that the morning Resident #1 fell, a hospice nurse (unknown) and LVN B were assessing Resident #1. They said the hospice nurse (unknown) said the injuries that Resident #1 sustained were not consistent with a fall. They said that the hospice nurse (unknown) did not say what specifically the injuries looked like they came from. They stated that the same day, Resident #1 did not eat. They said when Resident #1 told them that he had been hit by staff, they told CNA A. They said CNA A told them the injuries looked like injuries from a fall, and CNA compared Resident #1 to another resident with a similar fall. They said that Family Member M told them that Resident #1 had expressed to her that he had been hit by night staff. They said that they did not report the allegations that Resident #1 reported to them nor the concerns that Family Member M reported to them because their phone was not working. They stated they did not use the facility phone because the on-call staff never answered the phone when they called from the facility phone. They said the previous day, they had tried to call the on-call phone from the facility for a staffing concern, and the staff did not answer. They said they had been trained to call the ADM, who was the abuse coordinator if they witnessed or suspected ANE. They said they had been taught to contact the abuse coordinator immediately. They said that they did not contact the ADM, who was the abuse coordinator, because it was the weekend. They said they could not remember if they reported the allegations of ANE to LVN B, but the nurse typically does not stay in the locked unit. They said they did mention the accusations of ANE regarding Resident #1 to the Assistant Activity Director. They said no one had asked them anything about the nature of the fall . During an interview on 11/26/24 at 3:06 PM, CNA A stated that she did not know much about the fall that occurred on 11/23/24 involving Resident #1. They said CNA O told her that Resident #1 had an unwitnessed fall when she came on shift. She said CNA O told her that LVN N was helping her do rounds and change residents. She said CNA O said that she and LVN N had come out of Resident #1's room, and he had fallen. CNA A said she did not remember a staff member telling her that Family Member M had concerns about the injuries, but that Family Member M did express to her that she had concerns about the injuries that Resident #1 sustained. CNA A said that when Family Member M said that she did not think the injuries were consistent with a fall, she encouraged Family Member M to talk to LVN B because as a certified nurse aide she had been trained to refer family concerns to her nurse. CNA A said Resident #1's face was beat up. She said Resident #1 had steri-strips (reinforces skin closure) all over his face. She said he had a busted lip and a cut by his eye. CNA A said she was unaware of Resident #1 having any physical altercations with female residents where he was not the aggressor. CNA A said Resident #1 was aggressive, and all staff knew about it, which had been reported to management. CNA A said Resident #1 had punched her in the face. She said she could not remember the exact date but that it was documented in Resident #1's progress notes. She said they did not receive any instructions on handling Resident #1. She said she felt if his behaviors had been addressed, his behaviors wouldn't have continued to escalate. She said no one had interviewed her regarding Resident #1's behaviors or Family Member M's allegations. CNA said that she had been trained to report ANE as soon as possible to the ADM. During an interview on 11/26/24 at 3:55 PM, the Assistant Activity Director stated that she had experience with Resident #1 and his aggressive behavior. She said when Resident #1 had his resident-to-resident altercation on 11/16/24, she was assisting taking him out of the memory unit to calm down. She said Resident #1 saw an exit door and attempted to exit. She said she tried to redirect him, but he grabbed her hair and pulled it. She said they ultimately got him back to the unit. She said that Resident #1 punched another staff member in the face before that incident. She said she had not received any training specific to Resident #1 on responding to his aggressive behaviors. She said on Saturday, 11/23/24, she went into the memory unit and noticed Resident #1 was at the dining room table with his head down. She thought this was odd because Resident #1 was usually up and pacing around. She said CNA P told her that Resident #1 had fallen. She said she had asked if Family Member M had been notified and was told that attempts had been made, but they were unsuccessful because Family Member M's phone was off. The Assistant Activity Director said that later in the day (11/23/24), Family Member M came to the facility and said to her that Resident #1 reported to her (Family Member M) that someone came into his room at night and hit him. She said it was around lunchtime when she (Family Member M) told her that Resident #1 made the allegation. The Assistant Activity Director stated she told the aides (she did not disclose who) that were working the memory unit and that the aides said that it looked like someone hit Resident #1. She said she told the aides to get a nurse to explain Resident #1's injuries to Family Member M. She said the nurse (LVN B) told Family Member M it was a fall, and it was documented. The Assistant Activity Director told LVN B that Family Member M thought someone had beaten Resident #1 up. She was told that the documentation reflected that Resident #1 had a fall. The Assistant Activity Director said the abuse coordinator was the SW. She said she did not report the allegations of abuse to the SW because the SW was not at the facility. She said she had been trained on what to do if they suspect or witnessed abuse. She said that she had been taught to call the ADM. She said that she did not report the allegations of ANE to the ADM because she was not there when the incident allegedly happened. She said no one had interviewed her to ask her about her knowledge of the incident regarding allegations of abuse. She said she was unaware of any physical altercations that involved Resident #1. During an interview on 11/26/24 at 8:20 PM , LVN B stated the abuse coordinator was the ADM. She stated she had ANE training. She said she had been trained that if she witnessed or suspected abuse, she needed to report the allegation to the ADM as soon as possible. She said that on the day (11/23/24), Resident #1 fell on the overnight shift. He had also fallen on her shift (a day shift). She said CNA A said that she had found Resident #1 on the floor. She said she assessed Resident #1 and called Hospice out for assistance. She said she notified Family Member M. Family Member M was upset because Resident #1 had fallen on the overnight shift. LVN B said it was around 1:00 PM when Resident #1 had fallen on her shift. LVN B said she did not have details about Resident #1's first fall. She said Family Member M was upset. She said that she could tell by her body language but that she was speaking in Spanish to CNA A. LVN B said it was relayed to her from CNA A that Family Member M did not believe the lacerations, cuts, and gashes had come from a fall and that he looked like he had been punched. She said Resident #1 had a history of falls. LVN B said she did not report the allegations that CNA A had translated from Family Member B to the ADM because Family Member B was concerned with the overnight fall. She (LVN B) was sure that Resident #1 did not get punched on her shift, and that Family Member M said she would take Resident #1 home. She said that she was told that Resident #1 had a history of falls, according to the hospice nurse who came out and was not sure why Resident #1's falling was an issue. LVN B said she was unaware that Resident #1 had any physical altercations with female residents in the locked unit. She said Resident #1 never said he had been hit by staff when she interacted with him. She said she was unaware of any incidents that involved Resident #1 and other female residents. She said that since his admission, she had never received any training on how to deal with Resident #1's aggressive behavior. She said she had never been interviewed regarding Resident #1's behaviors or the allegations of ANE. She said the potential negative outcome of not reporting allegations of ANE to the abuse coordinator was that the abuse could continue. She said Resident #1 had told her that he fell. She said she documented what happened during her shift but did not document the information regarding Family Member M because she knew no one punched Resident #1 on her shift. She said that although it may sound silly, she felt that Family Member M wanted to take Resident #1. During an interview on 11/26/24 at 8:25 [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and/or record review the facility failed to provide the necessary treatment and services, based on the comprehensive assessment and consistent with professional standards of practice, to prevent development of new pressure ulcers/injuries for 2 of 3 residents (Resident #1 and Resident #2) reviewed for pressure injuries, in that: 1. LVN A failed to implement proper wound care techniques and implement adequate infection control practices to promote wound healing during observation of wound care on 11/29/2023. 2. LVN A failed to follow orders for wounds for providing wound care for Resident #1 and Resident #2, leaving wounds open to air and exposed to bacteria and possible infection. 3. Facility staff failed to treat and cover wounds for Resident #1 and Resident #2 4. Facility failed to follow doctors' orders of providing a wound culture (is a test to find germs such as bacteria, a virus, or a fungus that can cause an infection) for Resident #1 This failure could cause resident wounds to worsen, spread of infection, loss of limb, and possible sepsis leading to death. This failure was determined to be an Immediate Jeopardy situation that was identified on 12/01//2023 at 12:00 p.m. While the IJ was removed on 12/01/2023 at 8:15 pm, the facility remained out of compliance at a severity level of actual harm and a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. The findings included: Record Review of Resident #1's face sheet documented he was a [AGE] year-old male who was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident #1 was admitted with a diagnosis which includes: acute respiratory failure - difficult to breath on your own, quadriplegia - paralysis of all four limbs, tracheostomy - an opening in the windpipe from outside of the neck to help oxygen reach the lungs, contracture to left ankle - inability to move foot to a neutral position, contracture to right knee - can no longer move is stiff, contracture to right ankle - inability to move foot to a neutral position, abnormalities of gait and mobility -unable to walk in typical way, obstructive and reflux uropathy - urine cannot drain through the urinary tract, rash and other nonspecific skin eruption - skin reaction to an irritant, urinary calculus - solid particles in the urinary system, pain - mild to severe discomfort, pressure ulcer of other site (unstageable) - sore on a specific area of skin from pressure resulting in the lack of blood flow and oxygen to tissue, muscle weakness - lack of muscle strength, unspecified disorder of eye and adnexa - eye and surrounding structure disorder, acid reflux - stomach acid or bile irritating the stomach lining , muscle spasms - involuntary movement, cardiac arrhythmias - improper beating of the heart, vitamin Deficiency - too little of one or more vitamin, hypokalemia - low blood level, dysphagia - difficulty speaking, hypoxemia - low level of oxygen in the blood, persistent vegetative state - a person shows no sign of awareness, cognitive communication deficit - difficulty with thinking, chronic respiratory failure shortness of breath, diffuse traumatic brain injury with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving - brain dysfunction trauma to the brain. Record review of Resident #1's Annual Minimum Data Set (MDS) dated [DATE] documented that Resident #1's BIMS (Brief Interview for Mental Status) was left blank and incomplete. Record Review of Resident #1 Annual MDS dated [DATE] revealed: On the section for risk of pressure ulcers/injuries indicated Resident #1 is at risk for pressure ulcers. On the section under skin conditions: Current number of unhealed pressure ulcers/ Injuries at each stage was left blank and not complete. Record Review of Resident #1 Care Plan dated 11/22/2018 revealed Resident #1 had a pressure ulcer and states Resident #1 was not as mobile as he used to be, his skin is fragile and he is at risk for skin tears, bruising, pressure wounds with interventions of monitor for signs and symptoms of skin breakdown or bruising, notify doctor of any skin breakdown or bruising, may wear boots for preventions per family request, Resident #1 has contractures and was unable to float heels, wound care as ordered. Resident #1 needs assist bars for psychological comfort and to establish bed boundaries. Resident #1 needs help from staff with turning and uses his assist bars for some repositioning with interventions of: assist bar will be reviewed at least quarterly to ensure they are still needed, check on and reposition when giving care and prn, staff to ensure that assist bars are up X 2/4 and secured when in bed, treat with respect and dignity. Resident #1 had urinary incontinence with interventions of: motor and report red areas noted, provide cheerful dialogue while cleansing to encourage and maintain self-esteem, provide incontinent care every 2 hours and as toileting pattern indicates. Resident #1 had ADLs functional status/rehabilitation potential with the interventions of: consistent approach amongst caregivers, monitor for presence of pain/intolerance during self-care, provide adequate rest periods between activities, report a further deterioration in status to physician. Resident #1 had a self-care deficit with traumatic brain injury. Resident #1 requires total assistance with ADLs with interventions of may utilize Geri chair (a large padded chair that is designed to help seniors with limited mobility) to get out of bed, provide assistance x2 with bathing/showering three times a week, incontinent of bowel and requires x 2 assist with peri-care, requires x1 assist with dressing, requires x1 assist with eating, Resident #1 has enteral feedings, requires x2 assist with bathing. Requires x2 toileting, requires x2 assist with transfers, requires x2 assist with transfers with lift, requires x2 assist with bed mobility, turn, and reposition x2 assist every 2 hours. Resident #1 had interventions in place for weekly head to toe skin check. Resident #1 had a pressure ulcer to right buttocks with immobilization with interventions of; apply dressings as doctor ordered: clean, apply Santyl and calcium alginate and foam dressing, assess pressure ulcer for staged, size, (length, width, and depth), presence/absence of granulation tissue and epithelialization,(development of new epidermis and granulation tissue. Granulation tissue is new connective tissue with new, fragile, thin-walled capillaries) and condition of surrounding skin daily, conduct a systematic skin inspection weekly, report any signs of any further skin breakdown, keep clean and dry as possible, minimize skin exposure to moisture. Resident #1 had a pressure ulcer on left upper back with immobilization with interventions of: apply dressing per doctor orders, clean, apply Santyl and calcium alginate and foam dressing daily to left upper back, assess the pressure ulcer for stage, size (length, width, and depth), presence/absence of granulation tissue and epithelization, and condition of surrounding skin every day. Keep clean and dry as possible, minimize skin exposure to moisture, keep linens clean, dry as possible, minimize skin exposure to moisture, keep linens clean, dry, and wrinkle free, keep resident off left upper back. Record Review of Resident #2's face sheet documented he was a [AGE] year-old male who was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #2 was admitted with a diagnosis which includes: post-traumatic seizures - occurs after head trauma, quadriplegia - paralysis of all four limbs, unspecified injury of right foot - injury or damage to body part, tachycardia - rapid or irregular heartbeat, elevation of liver transaminase levels - abdominal pain or swelling , hyperosmolality and hypernatremia - electrolyte problems, granulomatous disorder of the skin and subcutaneous tissue - raised bumps under skin, non-pressure chronic ulcer of skin of other sites with fat layer exposed - open area of skin, seborrheic dermatitis - scaly red patches of skin, muscle spasms - involuntary movement, pain - mild to severe discomfort, hypokalemia - low blood level, contracture right hip - shortening or hardening of muscles, contracture left hip - shortening or hardening of muscles, contracture right knee - shortening or hardening of muscles, contracture left knee - shortening or hardening of muscles, contracture right and left ankle - shortening or hardening of muscles, muscle wasting and atrophy - wasting of muscle, generalized muscle weakness - decreased in strength, acid reflux - stomach acid or bile irritating the stomach lining, contracture of right wrist - shortening or hardening of muscles, concussion with loss of consciousness - injury caused by head trauma, persistent vegetative state - no sign of awareness, personal history of traumatic brain injury - brain trauma , tracheostomy - an opening in the windpipe from outside of the neck to help oxygen reach the lungs, gastrostomy - an opening into the stomach from the abdominal wall, made surgically for the introduction of food. Record review of Resident #2's Annual Minimum Data Set (MDS) dated [DATE] documented that Resident #2's BIMS (Brief Interview for Mental Status) was left blank and incomplete. Record Review of Resident #2 Annual MDS (Minimum Data Set) dated 11/06/2023 revealed that Resident #2 was listed as a risk of pressure ulcers. On the section under unhealed pressure ulcer/injuries is listed as Resident #2 does not have any pressure ulcers when he does have pressure injuries. Record Review of Resident #2 Care Plan dated 11/15/2023 revealed Resident #2 had a risk for pressure ulcers due to impaired sensory perception. Resident #2 is at risk for skin breakdown as evidenced by contractures, moisture/excessive perspiration, nutritional concerns, limited mobility, incontinence with interventions of; consider specialty mattress or bed, elevate heels, and use protectors as able, skin assessment and inspection every shift with close attention to heels, use pillows between knees and bony prominences to avoid direct contact. Resident #2 had a risk for pressure ulcer due to moisture, has MASD to left groin with interventions of assess for other moisture problem areas such as in skin folds, avoid hot water, use mild soap and soft cloths or packaged cleanser wipes, check incontinence pads frequently (every 2-3 hours) and change as needed, moisture dry unbroken skin, skin assessment and inspection every shift with close attention to heels, use moisture barrier ointments (protective skin barriers), wound care as ordered. Resident #2 had a risk for pressure ulcer due to bedfast/mobility with interventions of Braden scale as needed and quarterly, consider specialty bed, elevate heels off bed or use heel protectors, notify doctor and resident representatives of any skin issues, position prone if appropriate or elevate head of bed no more than 30 degrees, position with pillows to elevate pressure points off the bed, pressure reducing mattress, skin assessment weekly, skin inspection each incontinent episode and during bath, report changes to charge nurse, turn and reposition every 2 to 3 hours and as needed. Resident #2 had a risk for pressure ulcer due to friction and shear with interventions of: minimum of 2 people plus draw sheet to lift resident while in bed, skin assessment and inspection every shift with close attention to heels. Resident #2 needed assistance for psychological comfort and to establish bed boundaries. Resident #2 required assistance from staff for repositioning with interventions of: assist bar will be reviewed at least quarterly, to ensure they are still needed, check on and reposition when giving care and as needed, staff to ensure that assist bars are up X1/4 and secured when in bed, treat with respect and dignity. Resident #2 had urinary incontinence with interventions of: monitor and report red areas noted, provide cheerful dialogue while cleansing to encourage maintained self-esteem, provide incontinent care every two hours and as voiding pattern indicates. Resident #2 required assistance with ADLs and is unable to perform any on his own with interventions of: may use Geri chair (a large padded chair that is designed to help seniors with limited mobility) to enable getting out of bed, provide assistance x2 with bathing/showering three times a week, incontinent of bowel and bladder and requires x 2 assist with peri-care, requires x1 assist with dressing, requires x 1 with eating and has enteral feedings, requires x 2 assist with bathing, requires x 2 assist with toileting, requires x 2 assist with transfers, requires x 2 assist with bed mobility, turn and reposition x 2 every 2 hours. Resident #2 had interventions in place for weekly head to toe skin check (Licensed Nurse). Resident #2 had non-healing surgical wound with previous gastrostomy with interventions of: assess condition of surrounding skin, report emergencies of skin excoriation, dressing changes per physician order, observe and report signs of localized infection, pain, redness, swelling, tenderness, loss of function, heat at the infected area. Observe and report signs of sepsis (fever, lassitude, or malaise, change in mental status, tachycardia, hypotension, anorexia, nausea, vomiting, diarrhea, headache, lymph node), record the amount, type, consistency, color, and odor of drainage from the wound. Record the location (size, length, width, and depth), color, and presence/absence of granulation tissue and epithelization of surgical wound. Use principles of infection control and universal/standard precautions. Resident #2 had chronic wound to left groin with interventions of need protectors/float heels, pain medication as needed for comfort, re-evaluation for improvement in 14 days, supplements as ordered, treatments and medication as ordered. Resident #2 had pressure ulcer left four toes with interventions of apply dressing per doctor order: clean, calcium alginate, cover with foam dressing. Assess resident for pain related to pressure ulcer or its treatment. Prevent or treat pain by keeping foot in boot. Conduct a systematic skin inspection daily, report any signs of any further skin worsening. Keep clean and dry as possible. Minimize skin exposure to moisture, keep resident off toes. Reduce friction injuries by using protective boots. Use protective boot to relieve pressure on the heels. Resident #2 had infection of the foot with interventions of assess and record if resident's feet are desensitized to pain and/or pressure. During an Observation of Resident #2 on 11/29/2023 at 11:15 AM. Observed Resident #2 lying in bed on back with head of bed elevated. Resident #2 was in a brief only, no shirt or pants. Resident #2 has top sheet lying on left side of body. Resident #2 is nonverbal but able to answer yes and no questions by nodding head or blinking eyes. Resident #2's left foot moving up and down on bed. Observed Resident #2 with four toes bloody with no skin on ends of toes. Observed Resident #2's pinkie toe with dime size scab to top and side of toe. Resident #2 had the sheet under foot had blood. There was blood on right lower leg and heel. Observed Resident #2's call light on the floor at head of bed. Resident #2's hands are contracted, and resident cannot use hands. During an observation and interview with CNA B on 11/29/2023 beginning at 11:25 AM. CNA B stated she went in room to change Resident #2, the roommate to Resident #1. CNA B went to check on Resident #2 and noticed blood on sheet and Resident #2's' toes. CNA B stated she last worked on Sunday and Resident #2's toes were not like that. CNA B stated she had never seen his toes like that. CNA B stated she does not know what happened or when it happened. CNA B stated she came on shift at 06:30 AM and took a break at 10:00 AM and does not remember seeing his foot like that. CNA B stated the wound nurse made rounds that morning (12/01/2023). CNA B stated Resident #2 was not able to use a regular call light. CNA B stated Resident #2 might be able to use a pressure pad call light, but he probably would not use that either. CNA B stated Resident #2 has wound to his Left groin. During incontinent care surveyor attempted to observe wound to left groin but Resident #2 refused to relax his leg. Left groin with thick bloody drainage. Surveyors were unable to see wound. CNA B stated she was told it was from the use of briefs rubbing leg due to Resident #2 constantly moving leg. CNA B stated there was an ABD pad in groin and she removed ABD pad. Observed minimal bloody drainage on ABD pad. Resident #2 had old pressure wound to buttocks that had been healed. Resident #2's crack to buttocks was red no open areas noted. Resident #2 had open area to right hip the size and shape of a black-eyed pea. Resident #2 wound not covered, no drainage wound bed pink. Resident #2 had a dried gauze to lower abdomen with an unknown substance on it. The gauze was tinted yellow and pink. CNA B stated she was not sure where that came from. Resident #2 had strong body odor smell. CNA B gathered all dirty linen and left resident lying flat in bed with only brief on. Resident was uncovered with curtain at end of bed. CNA B left the room with the sack of dirty linen. CNA B pushed door to room all the way open on her way out of the room. CNA B returned to room and pulled curtain ½ way on left side of bed. CNA B repositioned Resident #2 and raised head of bed and covered resident with a sheet. CNA B went to Resident #1 to change resident. Observed Resident #1 lying on back in bed with only a sheet covering his lower body and curtain was end of bed. Resident #1 right foot was hanging off the left side of the bed. CNA B and LVN A performed incontinent care for Resident #1. Resident #1 had pressure ulcer to right buttock open to air, bloody drainage noted to bed pad. Resident had wound to coccyx covered with foam dressing with date 11-28-23. LVN A stated she had not done wound care for resident today. She stated his wound care was daily. Resident #1 turned to right side. Observed Resident #1 had large area to left bottom shoulder blade. LVN A stated 2 weeks ago resident had a scratch there from his lift and now he had that. LVN A stated, I just don't see how a scratch turned to this. LVN A stated Resident #1 had been on an air mattress since she went to work there. Resident #1 with a wound to left lower shoulder blade upper circle covered in black eschar, yellowish green below the black and large red beefy area below that. Bloody drainage noted on bed pad, left open and not covered. When resident was turned to right there was a strong foul odor coming from the wound. The wound was open to air. CNA B placed gloved hand on open wound several times during incontinent care. Resident #1 has small black eyed pea size wound to left hip. Open to air. No drainage noted. Wound bed is pink. CNA B and LVN A repositioned Resident #1 and covered with a sheet. During an interview with LVN A on 11/29/2023 at 12:24 PM. LVN A stated she did not have any orders for dressing for Resident #2. LVN A stated she text (wound nurse) again to check on orders. During an observation of Resident #2. Observed Resident #2 on 11/29/2023 at 1:40 PM left foot wrapped with foam gauze and secured with tegaderm due to resident constant movement of foot. During an observation for wound care for Resident #1 on 11/29/2023 at 1:55 PM provided by LVN A assisted by CNA B. LVN A stated she did do the wound care for Resident #1. LVN A stated she placed alginate to wound bed, covered with foam dressing and covered with tegaderm due to Resident #1's constant foot movement. LVN A stated she did not measure wounds. LVN A gathered wound supplies and placed on bedside table. No observation of BST being sanitized and no barrier. LVN A changed gloves. No observation of hand washing or ABHR. LVN A donned gloves and placed saline in 3 cups. LVN A then placed gauze in all 3 cups. LVN A placed Santyl in medicine cup. LVN A placed all supplies on foot of resident's bed on used bed pad. LVN A removed old dressing to coccyx using a q-tip. LVN A placed old dressing on bed pad behind resident she cleaned wound with normal saline and gauze. LVN A cleaned out to inner wound. LVN A then opened calcium alginate packed and placed on bed pad beside dirty gauze and old dressing. LVN A tore off small piece and placed inside of wound. She covered wound with foam dressing. Resident #1 wounds were measured as listed: right buttocks: 3.5 width x 3.5 and superficial. Wound shows to have grown from what is documented. Resident #1 back shoulder is measuring: 5 x 5.5 from length to width and the depth is 1.25. As per documentation it shows that the wound on the shoulder has also grown in a week. Resident #1's coccyx wound is measuring to be: 1.5 cm in length, 2.5 cm in width, and 1.0 in depth, which indicate the wound has grown since last week. LVN A cleaned bottom cheek wound from [NAME] to enter. LVN A placed used gauze on bed pad behind Resident #1. LVN A applied Santyl to wound bed with q-tip. LVN A used calcium alginate from package laying in pile of used gauze and covered wound. LVN A covered with foams dressing. LVN A dated and initialed dressing and removed gloves. LVN A removed gloves. LVN A turned Resident #1 on right side. Observed Resident #1 left shoulder wound uncovered with brownish discharge on bed pad and foul odor from wound. Resident #1 shoulder wound measured 5cmX5 ½ cm X 1 ¼ cm. LVN A cleaned wound from outer to inner wound. LVN A applied Santyl to wound bed and covered with calcium alginate and foam dressing. LVN A gathered trash and removed gloves and repositioned Resident #1. LVN A grabbed suction and dropped it on the floor and then picked up the tubing and placed it in the trash. Observed no additional tubing in the drawer. LVN A removed gloves and exited the room to go get more supplies. No observation of hand washing. LVN A returned to the room. LVN A donned gloves and suctioned Resident #1's trach and change residents inner canula. LVN A repositioned Resident #1 and doffed gloves. LVN A cleaned BST placing unused supplies in box on BST. LVN A washed hands. LVN A stated Resident #1 was not able to rub dressing off his shoulder. LVN A stated the only movement Resident #1 does was when he coughs, and he moves his legs. LVN A stated the only way it could be rubbed off was when staff turn Resident #1. LVN A stated the pressure ulcer to left hip had no orders. LVN A was told to leave it open to air and monitor it. Observed pressure ulcer to left hip was black eyed pea size and shape and the wound bed was superficial and pink. No observation of hand washing or ABHR during glove changes during wound care. No observation of glove changed when going from dirty to clean. During an Interview with CNA B on 11/29/2023 at 2:10 PM. CNA B stated if the dressing comes off a wound, she would notify the nurse. CNA B stated when Resident #1's family visited the other day, CNA B had showered Resident #1 and his family member had noticed the wounds on Resident #1's shoulder and bottom. CNA B stated she covered wound with a dressing and notified the charge nurse. CNA B stated the family member went to DON to complain about the wounds. CNA B stated the DON told her she was not allowed to cover any wounds. During an interview with the DON on 11/29/2023 at 4:19 PM. DON stated she did a skin sweep last Friday and passed out shower sheets for staff to use. DON stated the staff have not been completing the shower sheets. DON stated she does not have any shower sheets to provide for evidence of shower sheets being completed. During an Interview with LVN A for infection control practices on 11/30/2023 at12:50 PM. LVN A stated that she had been trained in infection control practices. LVN A stated that she has had in-services for infection control practices. LVN A stated that the facility will do verbal refreshers with the staff randomly by just walking up to them and asking random infection control questions. LVN A stated that the facility does provide in-services and they are approximately monthly. LVN A stated that they will also go over infection control in the monthly meeting and that was covered by the Administrator and the DON. LVN A stated that they just had skills check for hand washing at the beginning of the month. LVN A stated that the Nurse Educator was the one who oversaw the skills check. LVN A stated that she did not learn to use a dirty paper towel to turn off the faucet at this particular facility, but she did learn to do that when she worked at another facility. LVN A stated that it was a mistake that she should not have made. LVN A stated that the negative potential outcome for not using proper infection control practices is cross contamination, potential infection, exposure to bacteria. LVN A stated that when she was cleaning the wound for Resident #1, she did not drag, she used a half-moon one swipe method and she started from furthest away from the wound working her way to the wound so that she would not bring anything from outside of the wound to the inside of the wound. LVN A stated that her thought process is to get everything outside of the wound cleaned so that she did not contaminate the wound itself. LVN A stated that she has never been trained in wound care by the facility, she just tried to use her best judgement. LVN A stated that the Nurse Educator will train in wound care if needed but just has not gotten to it yet. LVN A stated that the negative potential outcome for improperly cleaning a wound could be cross contamination, sepsis, further wound damage, or worse infection. During an interview on 11/30/2023 at 1:36 PM, NP M stated she saw Resident #2 on 11/29/2023, around 7:15 AM and saw the wounds on his toes. She stated the wounds on his toes looked fresh and she notified LVN A. She stated, LVN A had walked off when she was doing the assessment on Resident #2. She stated she can do the wound care but cannot cover the wounds. She stated she told LVN A that it would be okay until she could get it covered with a bandage, because she did not have a bandage available at the time, she was doing the assessment. NP M stated she would have expected the wounds to be covered before 12:26 PM. During an interview on 11/30/2023 at 1:36 PM, NP M stated this is her second week for seeing Resident #1. She stated Resident #1's wounds developed over a period of a few days is how she understood it. She stated some of them were significant wounds, she debrided his shoulder wound and stated, that was the worst one. She stated, I ordered a culture of Resident #1's shoulder, and it came back positive, and Resident #1 was started on Levaquin (an antibiotic that is used to treat bacterial infections), this medication was used to treat a respiratory infection and wound. NP M stated the wound did have an odor when she saw it on 11/29/23. She stated she has taken care of Resident #1 one time before with his heel and that was the only pressure injury he had had. NP M stated those are true pressure injuries on bony points. She states she does not know if they could have been prevented. During an interview with DON on 11/30/2023 at 3:56 PM. DON stated there was no wound culture done for left shoulder wound on Resident #1. DON stated the only culture done was a sputum culture (test to detect and identify bacteria or fungi that infects the lungs or breathing passages) from Resident #1 trach on 11/22/2023. During an Interview with NP M on 11/30/2023 at 4:24 PM. FNP stated she spoke with LVN A, and she stated the culture did come back and Resident #1 was started on Levaquin(an antibiotic that is used to treat bacterial infections). NP M stated it was good that Levaquin covered both cultures. Record Review of facility provided policy labeled, Wound Care, date revised in June 2022, revealed. Purpose: The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Preparation: 1. Verify that there is a physician's order for the procedure. 2. Review the resident's care plan to assess for any special needs for the resident. A). For example, the resident may have PRN orders for pain medication to be administered prior to wound care. 3. Assemble the equipment and supplies as needed. Date and initialed all bottles and jars upon opening. Equipment and Supplies: The following equipment and supplies will be necessary when performing this procedure. 1. Dressing material, as indicated. 2. Disposable cloths, as indicated. 3. Antiseptic (as ordered). 4. Personal Protective Equipment Steps in the Procedure: 1. Use disposable cloth (paper towel is adequate) to establish clean field on resident's overbed table. Place all items to be used during procedure on the clean field. Arrange the supplies so they can be easily reached. 2. Perform hand hygiene. 3. Position Resident. Place disposable cloth next to resident (under the wound) to serve as a barrier to protect the bed linen and other body sites. 4. Put on clean gloves. Loosens tape and remove dressing. 5. Pull glove over dressing and discard into appropriate receptacle. Perform hand hygiene. 6. Put on clean gloves. Gowns will only be necessary if soiling of your skin or clothing with blood, urine, feces, or other body fluids is likely. Masks and eyewear will only be necessary if splashing of blood or other body fluids into your eyes or mouth is likely. 7. Use no-touch technique. Use sterile tongue blades and applicators to remove ointments and creams from their containers. 8. Pour liquid solutions directly or gauze sponges on their papers. 9. Wash wound in a circular motion from the inside out with ordered wound cleanse. Use additional gauze and repeat as needed with fresh gauze each time. 10. Apply treatments and dress wound as ordered by physician. 11. [NAME] tape with initials, time, and date and apply to dressing. 12. Remove the disposable cloth next to the resident and discard into the designated container. 13. Discard disposable items into the designated container. Discard all soiled laundry, linen, towels, and washcloths into the soiled laundry container. Remove disposable gloves and discard into designated container. Perform hand hygiene. 14. Reposition the bed covers. Make the resident comfortable. Use supportive devices as instructed. 15. Place the call light within easy reach of the resident. 16. Sanitize overbed table. 17. Return the overbed table to its proper position. 18. Sanitize scissors. 19. Perform hand hyge3eine. 20. If the resident desires, return the door and curtains to the open position and if visitors are waiting, tell them that they may now enter the room. Documentation: The following information should be recorded in the resident's medical record. 1. The type of wound care given. 2. The date and time the wound care was given. 3. The name and title of the individual performing the wound care. 4. Any change in the resident's condition. 5. All assessment data (wound bed color, size, drainage, etc.) obtained when inspecting the wound. 6. Assess the resident for pain and medicate as ordered. 7. Any problems or complaints made by the resident related to the procedure. 8. If the resident refused the treatment and the reasons why. 9. The signature and site of the person recording the data. Reporting: 1. Notify the supervisor if the resident refuses the wound care. 2. Report other information in accordance with center policy and professional standards of practice. Record Review of facility provided wound log for Resident #1, labeled, Facility Wound Summary Report, dated 11/22/2023, revealed: It [NAME][TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that residents had the right to be free from neglect for 4 of 5 residents who required blood sugar monitoring and administration of insulin (Residents #1, 2, 3, 4); in that: 1) The facility failed to effectively monitor Resident #1's blood sugars and take appropriate actions related to blood sugar results, which resulted in the hospitalization of Resident #1 with a diagnosis of metabolic acidosis. Staff failed to notify nursing supervisory staff and physician of Resident #1's refusals of blood sugar testing and insulin in order to receive further instructions on what to do. This failure resulted in the identification of an IJ on 4/15/23 at 5:25 PM. While the IJ was removed, the facility remained out of compliance at a severity level of actual harm that is not Immediate Jeopardy and a scope of isolated. The facility failed to provide adequate documentation related to Medication Administration Records for Residents #1, 2, 3 and 4, who required blood sugar monitoring and insulin administration. These failures could place residents at risk for elevated levels of glucose which could result in harm, impairment, or death. The findings include: Resident #1 Record review of the Physician Order Report for male Resident #1 dated 4/10/2023 - 4/10/2023 revealed the resident was admitted to the facility on [DATE] and was [AGE] years old. Diagnoses listed were type 2 diabetes mellitus with ketoacidosis without coma (blood sugar disorder), hyperlipidemia, unspecified (elevated cholesterol), unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (mental disorder), essential (primary) hypertension (high blood pressure), acute kidney failure, unspecified, personal history of transient ischemic attack (TIA) and cerebral infarction without residual deficits (stroke), and vascular dementia, severe, and other behavioral disturbance (mental disorder). Further record review of this Physician Order Report for Resident #1 revealed that the resident had the following orders documented as Order type - Prescription. Start date 4/6/2023 - End date Open-ended. Description. Humalog U-100Insulin (insulin lispro) solution; 100 unit/mL; amt: Per Sliding Scale; If Blood Sugar is less than 60, call MD. If Blood Sugar is 61 to 150, give 0 Units. If Blood Sugar is 151 to 250, give 3 Units. If Blood Sugar is 251 to 350, give 5 Units. If Blood Sugar is 351 to 450, give 7 Units. If Blood Sugar is 451 to 500, give 10 Units. If Blood Sugar is greater than 500, call NP/PA. Subcutaneous Before Meals and At Bedtime 06:30 AM, 11:30 AM, 04:30 PM, 08:00 PM. Ordered by Physician A. Order type - Prescription. Start date 4/6/2023 - End date Open-ended. Description. Lantus Solostar U-100 insulin (insulin glargine) insulin pen; 100 unit/mL (3ml); amt: 25; Subcutaneous [DX: type 2 diabetes mellitus with ketoacidosis without coma] Once a morning; Morning 7:00 AM-10:00 AM. Ordered by Physician A . Record review of the MDS documentation for Resident #1 revealed the resident's admission MDS was not due. Record review of the current care plan for Resident #1 dated 4/14/23 revealed a Problem start date: 4/6/23. Category: diagnosis diabetes. Created: 4/14/23. Created by DON. The goal listed was, No complications. Created: 4/14/23. Created by: DON. Approaches listed were as follows, Approach start date: 4/6/23 FSBS checked per physician's order. Created: 4/14/23. Created by: DON. Approach start date: 4/6/23. Meds as ordered. Created: 4/14/23. Created by: DON. Approach start date: 4/6/23. Observe for S/S of hypo/hyper glycemia (high and low blood sugar). Created: 4/14/23. Created by: DON. The care plan documented, Last review/revised: 4/14/23 at 3:11 PM by DON. Record review of the MAR for Resident #1 dated 4/1/23 - 4/14/23 documented the following regarding the resident's ordered Lantus and sliding scale Humalog insulin: Record review of 4/6/23 at 8:00 PM revealed there was no documentation on the MAR of any blood sugar testing conducted or insulin administered. The area was blank. Record review of the Progress Notes for Resident #1 dated 4/6/23 on admission at 5:22 PM documented that the resident's blood sugar was tested, and it was 203 and 3 units of insulin was administered prior to dinner - admission Observation by LVN C. Further record review of the MAR revealed the following: On 4/7/23 at 6:30 AM his blood sugar was checked, and it was 142 and no insulin was given or required. At 11:30 AM his blood sugar was 163 and he was given three units of Humalog with LVN A. At 4:30P, His blood sugar was 264 and five units of Humalog was given by LVN A. At 8:00 PM. The blood sugar was 361 and the resident was given seven units of Humalog. It was given by LVN B. On 4/8/23 the resident refused his Lantus and refused blood sugar checks at 6:30 AM and was combative with LVN A. At 11:30 AM he refused his blood sugar and was combative with LVN A. At 4:30 PM his blood sugar was 201 and he received three units of Humalog insulin. At 8 PM his blood sugar was 400 and he was given seven units of insulin by LVN B. On 4/9/23 the resident refused his Lantus and refused blood sugar testing at 6:30 AM from LVN A. There was no documentation at 11:30 AM regarding blood sugar checks or insulin administered. At 4:30 PM the resident's blood sugar was 120 and required no sliding scale insulin by LVN F. At 8:00 PM the resident's blood sugar was 500 and receive 10 units of Humalog from LVN B. Record review of the Resident Progress Notes for Resident #1 dated 4/10/23 documented the following: 04/10/2023 5:40AM. called to the room by CNA, resident was reported to be having seizure like activity, he had jerking movements to his arms, he did not respond to verbal stimuli, this seizure like activity lasted around 1 min. Notified DON, called (Physician A) office, left message with answering service, on call to return call LVN B. 04/10/2023 6:02AM. NP A, returned call, rec (received) orders to send to ER, (hospital). BS reading hi. called (Ambulance service) amb (ambulance), awaiting amb. LVN B Record review of the hospital records for Resident #1, dated 4/10/23 revealed that a reason for the ER/hospital visit, chief complaint was altered mental status. Visit Diagnosis was diabetic, ketoacidosis with coma associated with type one diabetes mellitus, primary and dementia, unspecified, dementia, severity, unspecified, dementia, type, unspecified, whether behavioral, psychotic or mood, disturbance or anxiety. It further documented that the resident had the following diagnosis/hospital problems: acute metabolic encephalopathy, primary 4/10/23 and present on admission. AKI (acute kidney injury) date noted 4/10/23 and present on admission. DKA (diabetic ketoacidosis) date noted 2/23/23 and present on admission . Further record review revealed the following history, Visit date/time: 4/10/23 at 6:45 AM. Mode of arrival: ambulance . History. CC: altered mental status. HPI: (Resident #1) is an [AGE] year-old male who has a history of seizure from nursing home history is obtain strictly from EMS, the patient is comatose, cannot contribute to his care, is a chronic resident of a nursing home, he has a known dementia, and probably a seizure disorder is as speculated from his Depakote prescription. At any rate he is also diabetic. He noted this morning that he was not himself and had a minute seizure not witnessed by EMS, happened prior to arrival by EMS. EMS arrived at the scene and found him to be comatose. They gave him Narcan and he was transferred here for further care. He is D stick by EMS (obtain blood glucose reading) and in ER is high. no precipitating factor for this event is known. No further history available for this immediate illness. Reviewed his previous records and recent hospitalization Physical exam. Neuro: . does not open his eyes. Does not respond to pain. Does not respond to his verbalization. Does not speak. Labs. Comprehensive metabolic panel. Abnormal. Collected: 4/10/23 at 7:06 AM. Specimen: blood. Potassium 6.1 on a normal scale of 3.5-5.1 mmol/L . carbon dioxide 8 on a normal scale of 21-32 mmol/L. Glucose 1,030 on a normal scale of 74-106 mg/dL. Urinalysis with Microscopic if indicated. Abnormal . Collected: 4/10/23 at 7:06 AM. Specimen: urine. Blood, urine moderate. Glucose, urine 100 mg/dL. Ketones, urine 40 mg/dL. Disposition. Clinical impression: Final Diagnosis: diabetic ketoacidosis with coma associated with type one diabetes mellitus. Dementia, unspecified, dementia, severity, unspecified, dementia type, and specified, whether behavioral, psychotic, or mood disturbance or anxiety. Comment. Clinical impression: diabetic ketoacidosis with coma associated with type one diabetes mellitus. Clinical impression: dementia, unspecified, dementia, severity, unspecified, dementia type, unspecified, whether behavioral, psychotic, or mood disturbance or anxiety. Expected patient class: in patient. Level of service: ICU. Discharge summary note. Discharge summary. Service: palliative care. Death summary. date of death : 4/15/2023. Time of death: 1929 (7:29 PM) Cause of death: renal failure, metabolic acidosis, lactic acidosis. Other contributing factors: Principal problem: acute metabolic encephalopathy. Active problems: . diabetes myelitis. DKA (diabetic keto acidosis) . Hospital Course: (Resident #1) is a [AGE] year old male who was admitted on [DATE]. Patient is currently living at (Nursing Facility), he has a significant past medical history of poorly controlled diabetes mellitus, hypertension . severe vascular dementia He presented to the ER via EMS with altered mental status, and possible seizure .4/12 (2023) patients functional and Neuro status continue to decline. patient transferred to palliative care unit for comfort care, symptom management and discharge planning. Patient continued to decline, and death pronounced on 4/15/23 . Record review of facility clinical records for Resident #1 revealed there was prior documentation of a history of hospitalization for ketoacidosis. The documentation was as follows: Record review of Hospital, History and Physical for Resident #1 dated 2/23/23 revealed the following documentation, Date of admission: [DATE]. Reason for admission: DKA. Chief complaint: multiple episodes of nausea/vomiting. History of present illness. He was recently placed in a nursing home for this past Friday (2/17/23) who presented to (Hospital ER) via EMS from nursing home for elevated blood glucose. Upon arrival to (Hospital ER) blood glucose was recorded at 581. and found to be in metabolic acidosis. He will be admitted to MICU (intensive care) under the care of the intensivists for continued DKA management and insulin. Record review of the face sheet for Resident #1 from his previous discharging facility, Nursing Facility B, revealed that he was admitted to the facility on [DATE] from the hospital. His primary admission diagnosis was type 2 diabetes mellitus with ketoacidosis without coma. Record review of a NP B visit to Resident #1 at Nursing Facility B dated 3/14/23 revealed the following documentation, .confused, refuses meds/Accu checks, hitting staff. Assessment/Plan. 1. Ketoacidosis. 2. diabetes mellitus Lantus and SSI refused. Record review of the Resident Progress Notes at Nursing Facility B for Resident #1 dated 4/5/23 revealed that the resident was referred to his current facility. On 4/14/23 at 5:18 PM an interview was conducted with charge nurse LVN C. Regarding Resident #1 she stated, she conducted his admission. She added that he was oriented to self and family. He had a diagnosis of diabetes mellitus and a history of diabetic ketoacidosis. He could be combative. He refused medications, insulin, and food. She stated she only had one hour with him and conducted a blood sugar check and administered three units of insulin. LVN C also stated she was present at the time Resident #1 was sent to the ER on [DATE]. Regarding Resident #1 on 4/10/23, she stated, the night nurse said that he had a seizure. Staff checked his blood sugar two times, and it was high on the glucometer scale. Staff did contact On-call, NP A and were told send him to the ER. She stated the resident had no other seizure activity before he left. LVN C stated that she went back and reviewed the notes for the resident and saw he had refused blood sugar checks. Regarding the protocol if a resident refused blood sugar checks, she stated, she would attempt multiple times, and could usually get the resident to consent to blood sugar testing. She added that if the blood sugar was high, she would contact the family to help persuade the resident to take the insulin. If she still could not accomplish that, she would contact the Provider, then follow their instructions. She stated she would call the doctor at a blood sugar of 500. On 4/14/23 at 7:19 PM an interview was conducted with the Director of Nurses regarding Resident #1 incident. She stated the resident was admitted on the sixth (4/06/23). On Saturday and Sunday (4/08/23 and 4/09/23) he refused his morning blood sugar checks and insulin. LVNs attempted blood sugar checks at lunch, dinner and bedtime and he took his sliding scale insulin. She stated that at approximately 5:40 AM on 4/10/23, staff noted seizure activity. Resident #1 was sent to the ER and had high blood sugar. She added that the resident was administered insulin at bedtime to cover spikes in blood sugar levels. Regarding insulin refusal procedures, she stated, staff would try to re-approach and give it again. She added at bedtime the resident's blood sugar was elevated, and he was administered sliding scale insulin in order to prevent spikes in his blood sugar levels. She stated he was AC and HS blood sugar test. On 4/14/23 at 7:56 PM an observation was made of Resident #1 at the hospital. Visitors were present and the resident was sleep and not responsive to touch or sound, had IV medications, oxygen and a catheter. On 4/14/23 at 8:02 PM an interview was conducted with hospital charge nurse, RN A regarding seizures. She stated that Resident #1 was on PRN medication for seizures. She stated, he had a seizure dosage and anxiety dosage. She stated that the resident had been placed on palliative care. On 4/15/23 at 10:20 AM an interview was conducted with the Director of Nurses regarding staff that were present on 4/10/23, during Resident #1's incident. She stated staff were LVN B, CNA A and CNA B. On 4/15/23 at 11:58 AM an interview was conducted with LVN B regarding Resident #1's incident on 4/10/23. She stated, staff called her back to the dementia unit, and said the resident was having a seizure. LVN C checked his blood sugar and said it displayed high on the glucometer, with no specific number as to what the specific blood sugar was. She stated she had not heard that he refused blood sugar checks. She added that on a couple of occasions he would not take his pills for her. Regarding the 8:00PM blood sugar result of 500 on 4/09/23, she stated she followed the sliding scale insulin order because the blood sugar was not over 500. She added that the resident took his medications the first nights in the facility. She stated the last night he was in the facility; he still spit out his pills in the presence of his wife. Regarding procedures on refusals, she stated, residents had the right to refuse. She added she would call the doctor if blood sugar checks were high, and the resident did not take the insulin. She stated the night Resident #1's blood sugar was high (4/09/23 at 8:00PM), she expected it to come down later (after receiving the insulin). She further stated she was not aware of any seizure activity with Resident #1 earlier in the shift on 4/09/23. On 4/15/23 at 12:14 PM an interview was conducted with CNA A. She stated on the morning of 4/10/23 staff were making rounds on the dementia unit, and she saw Resident #1 jerking. She added the other CNA went to get the nurse. This occurred at the end of the shift. She stated the resident was normally up and walking. She further stated at the beginning of the night/evening shift on 4/9/23, the resident was discovered in another resident's bed and was sluggish. She added that this observation was reported to the nurse (LVN B), and she took the resident's blood sugar at that time. Regarding Resident #1's demeanor she stated, the resident had behaviors and was physically combative. On 4/15/23 at 12:24 PM an interview was conducted with the Nurse Practitioner for Physician A, NP A. Regarding what she expected from staff related to Resident #1 refusing insulin and blood sugar testing. She stated, staff should have called her. She added patients could refuse medications and they would tell staff to offer it again. Regarding a resident missing their Lantus insulin, she stated, staff needed to have contacted the NP/Physician. She added she had checked 3 nurses on her phone contact app and could not say that she had been contacted regarding Resident #1's refusals. She stated diabetic coma, increased blood sugars, or nothing could happen if a resident did not receive their insulin. On 4/15/23 at 12:38 PM an interview was conducted with LVN A regarding Resident #1. Regarding the blank blood sugar result area in the MAR for 4/9/23 at 11:30 AM, she stated the resident, in general, was combative with her and would tell her to stop and get away. She stated she tried a couple of times to administer the insulin and take blood sugar checks but did not remember why the area was blank on the MAR. She added that weekend (4/8/23 and 4/9/23) the facility was short staffed, and she had to take on CNA duties. Regarding Resident #1 refusing his Lantus, she stated she typically tried to convince residents, but he was not letting her get close. Regarding anyone contacted about Resident #1 refusing Lantus and his blood sugar checks. She stated she honestly did not think she (LVN A) did contact anyone, only the wife. Regarding the facility procedure if long-acting insulin is not given, she stated, notify the physician and the family. She added she should have contacted the physician and the family but did not contact them. She stated residents could end up in the hospital with hypoglycemia as a result of not receiving their insulin. Regarding any facility training she received regarding insulin and when or who to report to regarding refusals. She stated she had not received any training or in-services regarding those subjects. She stated that she had worked in the facility since August 2022. On 4/15/23 at 1:17 PM an interview was conducted with the Director of Nurses, and she stated she had conducted in-services on insulin and notifications but could not find the folder they were in. On 4/15/23 at 1:46 PM an interview was conducted with the Director of Nursing regarding glucose monitoring. She stated, if it were her, she would have called someone about the refusals of blood sugar checks and insulin. She added that in a previous in-service, she instructed staff to notify on refusals. She added if it was a couple of times, staff should contacted someone. Regarding what she expected staff to have done in that situation regarding the missed insulin and refusals for Resident #1, she stated, she expected staff to notify someone. She added if it were her, she would contact the nurse practitioner, the on-call NP/Physician and the family. She added it was basic nursing knowledge to know who and when to notify. Regarding whom was responsible to ensure that staff notify the appropriate people regarding refusals and the lack of administration of insulin, she stated, the DON and the nurses. She stated increased blood sugars could result from residents not receiving their insulin and blood sugar checks not conducted. On 4/15/23 at 2:44 PM an interview was conducted with the Director of Nurses regarding LVN A informing her or a supervisor about Resident #1 refusing blood sugar checks and Lantus. She stated, LVN A did not inform her of the refused Lantus. She stated she did not know until 5:40 AM (4/10/23) when the resident was sent out to the ER, and she started looking at the charting. She added if a resident's blood sugar check was over 500, the glucometer display reads high. On 4/16/23 at 12:48 PM an interview was conducted with LVN A and she stated she remembered she told the Director of Nurses on Saturday 4/8/23 of Resident #1's refusal of blood sugar checks and insulin and the ADON was present. She added the Director of Nurses told her the resident had a right to refuse and did not mention anything about calling the nurse practitioner or physician. She further stated she had not received any in-services on insulin refusals or physician notifications guidelines. She stated her supervisor was the Director of Nurses. She further stated it was correct that she did not call the doctor or nurse practitioner regarding Resident #1's refusals of blood sugar testing and insulin. Regarding her orientation at the time she was hired, she stated it was more like being introduced to the system and not an orientation or training. She added there was no competency reviews conducted and she was trained on the floor one day with a senior nurse. She further stated her second day she was on the floor on her own. On 4/16/23 at 1:30 PM, an interview was conducted with the Director of Nurses and she stated there was a chart audit of blood sugar checks and insulin conducted on 4/15/23 and additional issues were discovered. She stated physicians were notified of those issues. Regarding if NP A and Physician A were aware or had any knowledge of the refusals of insulin by Resident #1, she stated neither had any prior knowledge of the refusals of insulin. On 4/16/23 at 2:00 PM an interview was conducted with the Director of Nurses, and she stated she was in the facility last Saturday, 4/8/23 and denied being told about Resident #1's refusal of insulin on 4/08/23. She stated she was not aware of the refusals until Monday (4/10/23). Regarding orientation of new nurses, she stated, the training was conducted by the ADONs. Nursing administration gear the training to the nurse to determine when they were ready. Regarding competency reviews of nurses, she stated, they were conducted by nurse management if something specific or issue occurs. She added, she had the conducting of annual nurse competencies on her list to do but had not been able to do them. She further stated the facility had no overall system in place to monitor staff actions related to blood sugar checks and refusals (blood sugar checks/insulin). Regarding why the issue happened with Resident #1, she stated, the nurses did not notify anyone in order to seek guidance as to what to do next. She stated she defined supervisor as the DON and ADON and at times it could be situational. She stated, she had not found anyone LVN A reported Resident #1's refusals to; staff or physician. Resident #2 Record review of the Physician Order Report: 4/16/23-4/16/23 for female Resident #2 revealed the resident was admitted to the facility on [DATE] and was [AGE] years old. Further record review revealed that the resident had diagnoses of end-stage renal disease (kidney disease) and diabetes mellitus due to underlying condition with diabetic chronic kidney disease. Record review of the Physician Order Report revealed that the resident had the following orders, Order type - Prescription. Start date 3/9/23. End date - Open ended. Description. Humalog U-100 insulin (insulin lispro) Solution; 100 unit/mL; amt: per sliding scale; If blood sugar is less than 60, call MD. If blood sugar is 150 to 200 give two units. If blood sugar is 201 to 250 give four units. If blood sugar is 251 to 300, give six units. If blood sugar is 301 to 350, give eight units. If blood sugar is 351 to 400, give 10 units. If blood sugar is 401 to 450, give 12 units. If blood sugar is greater than 450, give zero units. If blood sugar is greater than 450, call MD. Subcutaneous. [DX: diabetes mellitus due to underlying condition with diabetic chronic kidney disease] Before meals and at bedtime; 7:30 AM, 12:30 PM, 4:30 PM, 8:00 PM Record review of the most recent quarterly MDS assessment for Resident #2, dated 3/23/23 documented that the resident had a BIMS score of 15 indicating that she was cognitively intact. Further record review of the MDS revealed that the resident had an active diagnosis of diabetes mellitus. Documentation under the area Medications revealed that the resident received insulin injections seven times in the last seven days. Record review of the care plan for Resident #2, Last Reviewed/Revised: 3/29/23.revealed a Problem, documented as, Problems start date: 3/10/23. Category: diagnosis diabetes. Edited: 3/29/23. The listed Approaches included, Approach start date: 3/10/23 FSBS checked as ordered. Created: 3/13/23. Approach start date: 3/10/23. Meds as ordered. Created: 3/13/23 and Approach start date: 3/10/23. Observe for S/S of hypo/hyper glycemia. Created: 3/13/23 . Record review of the MAR for Resident #2 dated 4/1/23-4/14/23 revealed that under the Humalog administration, there was a refusal of blood sugar checks on 4/9/23 at 12:30 PM by LVN A. There were also refusals of blood sugar testing documented on the following days and times, 4:30 PM on 4/3/23, 4/4/23, and 4/12/23 by LVN A. The reason for the refusals was documented that the resident would not wake up from her nap. There were also blank spaces with no documentation regarding blood sugar checks or insulin on the following days and times: 8:00 PM on 4/4/23, 4/8/23, and 4/12/23. Record review of the Resident Progress Notes for Resident #2 dated 3/16/23 to 4/14/23 had no documentation regarding the blank areas on the MAR. Resident #3 Record review of the Physician Order Report: 4/16/23-4/16/23 for female Resident #3 revealed that the resident was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnoses of other cerebral infarction (heart attack), and major depressive disorder. Further record review of the Physician Order Report revealed the resident had the following orders: Order Type - Prescription. Start date - 5/12/22. End date - Open ended. Trulicity (dulaglutide) pen injector; 0.75 mg/0.5 ml; amt: 0.5 ml; sub cutaneous. [DX: type two diabetes mellitus without complications] once a day on Wednesday; 7:00 AM - 10:00 AM. Order type - Prescription. Start date - 7/26/22. End date - Open ended. Description. Humalog U - 100 insulin (insulin lispro) solution; 100 unit/ml; amt: per sliding scale; If blood sugar is less than 60, call MD. If blood sugar is 150 to 200, give two units. If blood sugar is 201 to 250, get four units. If blood sugar is 251 to 300, gives six units. If blood sugar is 301 to 350, give eight units. If blood sugar is 351 to 400, give 10 units. If blood sugar is greater than 400, call NP/PA. Subcutaneous [DX: type two diabetes mellitus without complications] Twice a day; morning, 7:00 AM to 10:00 AM, bedtime 7:00 PM to 10:00 PM. Record review of the MAR for Resident #3 dated 4/1/20 23-4/14/2023 revealed the following documentation: Humalog administration revealed there was no documentation for the bedtime 7 PM - 10 PM blood sugar testing or insulin administration (Blank) on 4/4/23, 4/7/23, 4/8/23, 4/12/23, and 4/13/23. There was no documentation as to why these areas were blank. Record review of the most recent quarterly MDS for Resident #3 dated 3/2/23 documented that the resident had a BIM's score of 14 indicating that she was cognitively intact. An active diagnosis was documented as diabetes mellitus. Further record review of the MDS revealed that the resident received five insulin injections within the last seven days. Record review of the care plan for Resident #3 Last Reviewed/Revised: 3/8/23. Revealed a Problem as follows: Problem, start date: 5/18/20. Category: diagnosis. Resident has diabetes type 2 edited: 3/8/23. The Approaches listed included, Approach start date: 5/18/20. FSBS checked as ordered. Created: 5/18/20. Approach start date: 5/18/20. Meds as ordered. Created: 5/18/20. Approach start date: 5/18/20. Observe for S/S of hypo/hyperglycemia. Created: 5/18/20 . Record review of the Resident Progress Notes for Resident #3 dated 3/16/23 to 4/14/23 had no documentation regarding the blank areas on the MAR. Resident #4 Record review of the Physician Order Report dated 4/16/23-4/16/23 for female Resident #4 revealed she was admitted to the facility on [DATE] and was [AGE] years old. Documented diagnoses were end-stage renal disease and type two diabetes mellitus with other skin ulcer. Further record review of the Physician Order Report revealed the following orders: Order type - Prescription. Start date - 5/18/22. End date - Open ended. Description. Insulin lispro Insulin pen; 100 unit/ML; AMT: per sliding scale; If blood sugar is less than 70, call NP/PA. If blood sugar is 70 to 150, give 0 units. If blood sugar is 151 to 200, give two units. If blood sugar is 201 to 250, give four units. If blood sugar is 251 to 300, give six units. If blood sugar is 300 to 350, give eight units. If blood sugar is 351 to 400, give 10 units. If blood sugar is 401 to 450, gives 12 units. If blood sugar is 450 to 500, give 14 units. If blood sugar is greater than 501, called NP/PA. Subcutaneous. [DX: type two diabetes myelitis without complications] Before meals, and at bedtime; 7:30 AM, 11:30 AM, 4:30 PM, 8:00 PM Order type - Prescription. Start date - 4/11/23. End date - Open ended. Description. Lantus U-100 insulin (insulin glargine) solution; 100 units/ML; amount AMT: 20 units; subcutaneous. [DX: type two diabetes mellitus without complications] Twice a day; morning, 7:00 AM - 10:00 AM, bedtime, 7:00 PM - 10:00 PM Record review of the most recent quarterly, MDS Resident #4 revealed that the resident had a BIMS score of 14 indicating she was cognitively intact. Further record review of the MDS revealed that the resident had an active diagnosis of diabetes mellitus. Record review revealed that the resident received insulin injections six times in the last seven days. Record review of the care plan for Resident #4 revealed that it was Last Reviewed/Revised: 3/7/23. There was a documented Problem stating, Problem Start Date: 06/08/2022. Category: Endocrine Disorders. Resident has an impaired endocrine system r/t diabetes. Edited: 03/07/2023. The approaches listed for this problem were geared toward resident education of diabetes. Record review of the MAR documentation for Resident #4 revealed the following documentation for insulin lispro: there were documented refusals of blood sugar testing on 4/4/23 at 11:30 AM and 4:30 PM by the ADON and 4/8/23 at 11:30 AM by LVN D. There was no documentation of blood sugar testing or insulin administration (blank) on 4/6/23 at 8:00 PM and 4/12/23 at 7:30 AM and 11:30 AM. Record review of the MAR for Lantus U - 100 revealed the resident refused her Lantus on 4/6/23 at 7:00 AM to 10:00 AM. There was no documentation of blood sugar testing or administration of Lantus (blank) on 4/6/23 at 7 PM to 10 PM bedtime. Record review of the Resident Progress Notes for Resident #4 dated 3/16/23 to 4/14/23 had no documentation regarding the blank areas on the MAR. On 4/16/23 at 3:02 PM the DON stated that she was not aware of refusals and missing documentation for the residents listed on the MAR chart audit until the facility conducted a chart [NAME][TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 4 of 5 residents who required blood sugar monitoring and administration of insulin (Residents #1, 2, 3, 4); in that: The facility failed to effectively monitor Resident #1's blood sugars and take appropriate actions related to blood sugar results, which resulted in the hospitalization of Resident #1 with a diagnosis of metabolic acidosis. Staff failed to notify nursing supervisory staff and physician of Resident #1's refusals of blood sugar testing and insulin in order to receive further instructions on what to do. This failure resulted in the identification of an IJ on 4/15/23 at 5:25 PM. While the IJ was removed, the facility remained out of compliance at a severity level of actual harm that is not Immediate Jeopardy and a scope of isolated. The facility failed to provide adequate documentation related to Medication Administration Records for Residents #1, 2, 3 and 4, who required blood sugar monitoring and insulin administration. These failures could place residents at risk for elevated levels of glucose which could result in harm, impairment, or death. The findings include: Resident #1 Record review of the Physician Order Report for male Resident #1 dated 4/10/2023 - 4/10/2023 revealed the resident was admitted to the facility on [DATE] and was [AGE] years old. Diagnoses listed were type 2 diabetes mellitus with ketoacidosis without coma (blood sugar disorder), hyperlipidemia, unspecified (elevated cholesterol), unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (mental disorder), essential (primary) hypertension (high blood pressure), acute kidney failure, unspecified, personal history of transient ischemic attack (TIA) and cerebral infarction without residual deficits (stroke), and vascular dementia, severe, and other behavioral disturbance (mental disorder). Further record review of this Physician Order Report for Resident #1 revealed that the resident had the following orders documented as Order type - Prescription. Start date 4/6/2023 - End date Open-ended. Description. Humalog U-100Insulin (insulin lispro) solution; 100 unit/mL; amt: Per Sliding Scale; If Blood Sugar is less than 60, call MD. If Blood Sugar is 61 to 150, give 0 Units. If Blood Sugar is 151 to 250, give 3 Units. If Blood Sugar is 251 to 350, give 5 Units. If Blood Sugar is 351 to 450, give 7 Units. If Blood Sugar is 451 to 500, give 10 Units. If Blood Sugar is greater than 500, call NP/PA. Subcutaneous Before Meals and At Bedtime 06:30 AM, 11:30 AM, 04:30 PM, 08:00 PM. Ordered by Physician A. Order type - Prescription. Start date 4/6/2023 - End date Open-ended. Description. Lantus Solostar U-100 insulin (insulin glargine) insulin pen; 100 unit/mL (3ml); amt: 25; Subcutaneous [DX: type 2 diabetes mellitus with ketoacidosis without coma] Once a morning; Morning 7:00 AM-10:00 AM. Ordered by Physician A . Record review of the MDS documentation for Resident #1 revealed the resident's admission MDS was not due. Record review of the current care plan for Resident #1 dated 4/14/23 revealed a Problem start date: 4/6/23. Category: diagnosis diabetes. Created: 4/14/23. Created by DON. The goal listed was, No complications. Created: 4/14/23. Created by: DON. Approaches listed were as follows, Approach start date: 4/6/23 FSBS checked per physician's order. Created: 4/14/23. Created by: DON. Approach start date: 4/6/23. Meds as ordered. Created: 4/14/23. Created by: DON. Approach start date: 4/6/23. Observe for S/S of hypo/hyper glycemia (high and low blood sugar). Created: 4/14/23. Created by: DON. The care plan documented, Last review/revised: 4/14/23 at 3:11 PM by DON. Record review of the MAR for Resident #1 dated 4/1/23 - 4/14/23 documented the following regarding the resident's ordered Lantus and sliding scale Humalog insulin: Record review of 4/6/23 at 8:00 PM revealed there was no documentation on the MAR of any blood sugar testing conducted or insulin administered. The area was blank. Record review of the Progress Notes for Resident #1 dated 4/6/23 on admission at 5:22 PM documented that the resident's blood sugar was tested, and it was 203 and 3 units of insulin was administered prior to dinner - admission Observation by LVN C. Further record review of the MAR revealed the following: On 4/7/23 at 6:30 AM his blood sugar was checked, and it was 142 and no insulin was given or required. At 11:30 AM his blood sugar was 163 and he was given three units of Humalog with LVN A. At 4:30P, His blood sugar was 264 and five units of Humalog was given by LVN A. At 8:00 PM. The blood sugar was 361 and the resident was given seven units of Humalog. It was given by LVN B. On 4/8/23 the resident refused his Lantus and refused blood sugar checks at 6:30 AM and was combative with LVN A. At 11:30 AM he refused his blood sugar and was combative with LVN A. At 4:30 PM his blood sugar was 201 and he received three units of Humalog insulin. At 8 PM his blood sugar was 400 and he was given seven units of insulin by LVN B. On 4/9/23 the resident refused his Lantus and refused blood sugar testing at 6:30 AM from LVN A. There was no documentation at 11:30 AM regarding blood sugar checks or insulin administered. At 4:30 PM the resident's blood sugar was 120 and required no sliding scale insulin by LVN F. At 8:00 PM the resident's blood sugar was 500 and receive 10 units of Humalog from LVN B. Record review of the Resident Progress Notes for Resident #1 dated 4/10/23 documented the following: 04/10/2023 5:40AM. called to the room by CNA, resident was reported to be having seizure like activity, he had jerking movements to his arms, he did not respond to verbal stimuli, this seizure like activity lasted around 1 min. Notified DON, called (Physician A) office, left message with answering service, on call to return call LVN B. 04/10/2023 6:02AM. NP A, returned call, rec (received) orders to send to ER, (hospital). BS reading hi. called (Ambulance service) amb (ambulance), awaiting amb. LVN B Record review of the hospital records for Resident #1, dated 4/10/23 revealed that a reason for the ER/hospital visit, chief complaint was altered mental status. Visit Diagnosis was diabetic, ketoacidosis with coma associated with type one diabetes mellitus, primary and dementia, unspecified, dementia, severity, unspecified, dementia, type, unspecified, whether behavioral, psychotic or mood, disturbance or anxiety. It further documented that the resident had the following diagnosis/hospital problems: acute metabolic encephalopathy, primary 4/10/23 and present on admission. AKI (acute kidney injury) date noted 4/10/23 and present on admission. DKA (diabetic ketoacidosis) date noted 2/23/23 and present on admission . Further record review revealed the following history, Visit date/time: 4/10/23 at 6:45 AM. Mode of arrival: ambulance . History. CC: altered mental status. HPI: (Resident #1) is an [AGE] year-old male who has a history of seizure from nursing home history is obtain strictly from EMS, the patient is comatose, cannot contribute to his care, is a chronic resident of a nursing home, he has a known dementia, and probably a seizure disorder is as speculated from his Depakote prescription. At any rate he is also diabetic. He noted this morning that he was not himself and had a minute seizure not witnessed by EMS, happened prior to arrival by EMS. EMS arrived at the scene and found him to be comatose. They gave him Narcan and he was transferred here for further care. He is D stick by EMS (obtain blood glucose reading) and in ER is high. no precipitating factor for this event is known. No further history available for this immediate illness. Reviewed his previous records and recent hospitalization Physical exam. Neuro: . does not open his eyes. Does not respond to pain. Does not respond to his verbalization. Does not speak. Labs. Comprehensive metabolic panel. Abnormal. Collected: 4/10/23 at 7:06 AM. Specimen: blood. Potassium 6.1 on a normal scale of 3.5-5.1 mmol/L . carbon dioxide 8 on a normal scale of 21-32 mmol/L. Glucose 1,030 on a normal scale of 74-106 mg/dL. Urinalysis with Microscopic if indicated. Abnormal . Collected: 4/10/23 at 7:06 AM. Specimen: urine. Blood, urine moderate. Glucose, urine 100 mg/dL. Ketones, urine 40 mg/dL. Disposition. Clinical impression: Final Diagnosis: diabetic ketoacidosis with coma associated with type one diabetes mellitus. Dementia, unspecified, dementia, severity, unspecified, dementia type, and specified, whether behavioral, psychotic, or mood disturbance or anxiety. Comment. Clinical impression: diabetic ketoacidosis with coma associated with type one diabetes mellitus. Clinical impression: dementia, unspecified, dementia, severity, unspecified, dementia type, unspecified, whether behavioral, psychotic, or mood disturbance or anxiety. Expected patient class: in patient. Level of service: ICU. Discharge summary note. Discharge summary. Service: palliative care. Death summary. date of death : 4/15/2023. Time of death: 1929 (7:29 PM) Cause of death: renal failure, metabolic acidosis, lactic acidosis. Other contributing factors: Principal problem: acute metabolic encephalopathy. Active problems: . diabetes myelitis. DKA (diabetic keto acidosis) . Hospital Course: (Resident #1) is a [AGE] year old male who was admitted on [DATE]. Patient is currently living at (Nursing Facility), he has a significant past medical history of poorly controlled diabetes mellitus, hypertension . severe vascular dementia He presented to the ER via EMS with altered mental status, and possible seizure .4/12 (2023) patients functional and Neuro status continue to decline. patient transferred to palliative care unit for comfort care, symptom management and discharge planning. Patient continued to decline, and death pronounced on 4/15/23 . Record review of facility clinical records for Resident #1 revealed there was prior documentation of a history of hospitalization for ketoacidosis. The documentation was as follows: Record review of Hospital, History and Physical for Resident #1 dated 2/23/23 revealed the following documentation, Date of admission: [DATE]. Reason for admission: DKA. Chief complaint: multiple episodes of nausea/vomiting. History of present illness. He was recently placed in a nursing home for this past Friday (2/17/23) who presented to (Hospital ER) via EMS from nursing home for elevated blood glucose. Upon arrival to (Hospital ER) blood glucose was recorded at 581. and found to be in metabolic acidosis. He will be admitted to MICU (intensive care) under the care of the intensivists for continued DKA management and insulin. Record review of the face sheet for Resident #1 from his previous discharging facility, Nursing Facility B, revealed that he was admitted to the facility on [DATE] from the hospital. His primary admission diagnosis was type 2 diabetes mellitus with ketoacidosis without coma. Record review of a NP B visit to Resident #1 at Nursing Facility B dated 3/14/23 revealed the following documentation, .confused, refuses meds/Accu checks, hitting staff. Assessment/Plan. 1. Ketoacidosis. 2. diabetes mellitus Lantus and SSI refused. Record review of the Resident Progress Notes at Nursing Facility B for Resident #1 dated 4/5/23 revealed that the resident was referred to his current facility. On 4/14/23 at 5:18 PM an interview was conducted with charge nurse LVN C. Regarding Resident #1 she stated, she conducted his admission. She added that he was oriented to self and family. He had a diagnosis of diabetes mellitus and a history of diabetic ketoacidosis. He could be combative. He refused medications, insulin, and food. She stated she only had one hour with him and conducted a blood sugar check and administered three units of insulin. LVN C also stated she was present at the time Resident #1 was sent to the ER on [DATE]. Regarding Resident #1 on 4/10/23, she stated, the night nurse said that he had a seizure. Staff checked his blood sugar two times, and it was high on the glucometer scale. Staff did contact On-call, NP A and were told send him to the ER. She stated the resident had no other seizure activity before he left. LVN C stated that she went back and reviewed the notes for the resident and saw he had refused blood sugar checks. Regarding the protocol if a resident refused blood sugar checks, she stated, she would attempt multiple times, and could usually get the resident to consent to blood sugar testing. She added that if the blood sugar was high, she would contact the family to help persuade the resident to take the insulin. If she still could not accomplish that, she would contact the Provider, then follow their instructions. She stated she would call the doctor at a blood sugar of 500. On 4/14/23 at 7:19 PM an interview was conducted with the Director of Nurses regarding Resident #1 incident. She stated the resident was admitted on the sixth (4/06/23). On Saturday and Sunday (4/08/23 and 4/09/23) he refused his morning blood sugar checks and insulin. LVNs attempted blood sugar checks at lunch, dinner and bedtime and he took his sliding scale insulin. She stated that at approximately 5:40 AM on 4/10/23, staff noted seizure activity. Resident #1 was sent to the ER and had high blood sugar. She added that the resident was administered insulin at bedtime to cover spikes in blood sugar levels. Regarding insulin refusal procedures, she stated, staff would try to re-approach and give it again. She added at bedtime the resident's blood sugar was elevated, and he was administered sliding scale insulin in order to prevent spikes in his blood sugar levels. She stated he was AC and HS blood sugar test. On 4/14/23 at 7:56 PM an observation was made of Resident #1 at the hospital. Visitors were present and the resident was sleep and not responsive to touch or sound, had IV medications, oxygen and a catheter. On 4/14/23 at 8:02 PM an interview was conducted with hospital charge nurse, RN A regarding seizures. She stated that Resident #1 was on PRN medication for seizures. She stated, he had a seizure dosage and anxiety dosage. She stated that the resident had been placed on palliative care. On 4/15/23 at 10:20 AM an interview was conducted with the Director of Nurses regarding staff that were present on 4/10/23, during Resident #1's incident. She stated staff were LVN B, CNA A and CNA B. On 4/15/23 at 11:58 AM an interview was conducted with LVN B regarding Resident #1's incident on 4/10/23. She stated, staff called her back to the dementia unit, and said the resident was having a seizure. LVN C checked his blood sugar and said it displayed high on the glucometer, with no specific number as to what the specific blood sugar was. She stated she had not heard that he refused blood sugar checks. She added that on a couple of occasions he would not take his pills for her. Regarding the 8:00PM blood sugar result of 500 on 4/09/23, she stated she followed the sliding scale insulin order because the blood sugar was not over 500. She added that the resident took his medications the first nights in the facility. She stated the last night he was in the facility; he still spit out his pills in the presence of his wife. Regarding procedures on refusals, she stated, residents had the right to refuse. She added she would call the doctor if blood sugar checks were high, and the resident did not take the insulin. She stated the night Resident #1's blood sugar was high (4/09/23 at 8:00PM), she expected it to come down later (after receiving the insulin). She further stated she was not aware of any seizure activity with Resident #1 earlier in the shift on 4/09/23. On 4/15/23 at 12:14 PM an interview was conducted with CNA A. She stated on the morning of 4/10/23 staff were making rounds on the dementia unit, and she saw Resident #1 jerking. She added the other CNA went to get the nurse. This occurred at the end of the shift. She stated the resident was normally up and walking. She further stated at the beginning of the night/evening shift on 4/9/23, the resident was discovered in another resident's bed and was sluggish. She added that this observation was reported to the nurse (LVN B), and she took the resident's blood sugar at that time. Regarding Resident #1's demeanor she stated, the resident had behaviors and was physically combative. On 4/15/23 at 12:24 PM an interview was conducted with the Nurse Practitioner for Physician A, NP A. Regarding what she expected from staff related to Resident #1 refusing insulin and blood sugar testing. She stated, staff should have called her. She added patients could refuse medications and they would tell staff to offer it again. Regarding a resident missing their Lantus insulin, she stated, staff needed to have contacted the NP/Physician. She added she had checked 3 nurses on her phone contact app and could not say that she had been contacted regarding Resident #1's refusals. She stated diabetic coma, increased blood sugars, or nothing could happen if a resident did not receive their insulin. On 4/15/23 at 12:38 PM an interview was conducted with LVN A regarding Resident #1. Regarding the blank blood sugar result area in the MAR for 4/9/23 at 11:30 AM, she stated the resident, in general, was combative with her and would tell her to stop and get away. She stated she tried a couple of times to administer the insulin and take blood sugar checks but did not remember why the area was blank on the MAR. She added that weekend (4/8/23 and 4/9/23) the facility was short staffed, and she had to take on CNA duties. Regarding Resident #1 refusing his Lantus, she stated she typically tried to convince residents, but he was not letting her get close. Regarding anyone contacted about Resident #1 refusing Lantus and his blood sugar checks. She stated she honestly did not think she (LVN A) did contact anyone, only the wife. Regarding the facility procedure if long-acting insulin is not given, she stated, notify the physician and the family. She added she should have contacted the physician and the family but did not contact them. She stated residents could end up in the hospital with hypoglycemia as a result of not receiving their insulin. Regarding any facility training she received regarding insulin and when or who to report to regarding refusals. She stated she had not received any training or in-services regarding those subjects. She stated that she had worked in the facility since August 2022. On 4/15/23 at 1:17 PM an interview was conducted with the Director of Nurses, and she stated she had conducted in-services on insulin and notifications but could not find the folder they were in. On 4/15/23 at 1:46 PM an interview was conducted with the Director of Nursing regarding glucose monitoring. She stated, if it were her, she would have called someone about the refusals of blood sugar checks and insulin. She added that in a previous in-service, she instructed staff to notify on refusals. She added if it was a couple of times, staff should contacted someone. Regarding what she expected staff to have done in that situation regarding the missed insulin and refusals for Resident #1, she stated, she expected staff to notify someone. She added if it were her, she would contact the nurse practitioner, the on-call NP/Physician and the family. She added it was basic nursing knowledge to know who and when to notify. Regarding whom was responsible to ensure that staff notify the appropriate people regarding refusals and the lack of administration of insulin, she stated, the DON and the nurses. She stated increased blood sugars could result from residents not receiving their insulin and blood sugar checks not conducted. On 4/15/23 at 2:44 PM an interview was conducted with the Director of Nurses regarding LVN A informing her or a supervisor about Resident #1 refusing blood sugar checks and Lantus. She stated, LVN A did not inform her of the refused Lantus. She stated she did not know until 5:40 AM (4/10/23) when the resident was sent out to the ER, and she started looking at the charting. She added if a resident's blood sugar check was over 500, the glucometer display reads high. On 4/16/23 at 12:48 PM an interview was conducted with LVN A and she stated she remembered she told the Director of Nurses on Saturday 4/8/23 of Resident #1's refusal of blood sugar checks and insulin and the ADON was present. She added the Director of Nurses told her the resident had a right to refuse and did not mention anything about calling the nurse practitioner or physician. She further stated she had not received any in-services on insulin refusals or physician notifications guidelines. She stated her supervisor was the Director of Nurses. She further stated it was correct that she did not call the doctor or nurse practitioner regarding Resident #1's refusals of blood sugar testing and insulin. Regarding her orientation at the time she was hired, she stated it was more like being introduced to the system and not an orientation or training. She added there was no competency reviews conducted and she was trained on the floor one day with a senior nurse. She further stated her second day she was on the floor on her own. On 4/16/23 at 1:30 PM, an interview was conducted with the Director of Nurses and she stated there was a chart audit of blood sugar checks and insulin conducted on 4/15/23 and additional issues were discovered. She stated physicians were notified of those issues. Regarding if NP A and Physician A were aware or had any knowledge of the refusals of insulin by Resident #1, she stated neither had any prior knowledge of the refusals of insulin. On 4/16/23 at 2:00 PM an interview was conducted with the Director of Nurses, and she stated she was in the facility last Saturday, 4/8/23 and denied being told about Resident #1's refusal of insulin on 4/08/23. She stated she was not aware of the refusals until Monday (4/10/23). Regarding orientation of new nurses, she stated, the training was conducted by the ADONs. Nursing administration gear the training to the nurse to determine when they were ready. Regarding competency reviews of nurses, she stated, they were conducted by nurse management if something specific or issue occurs. She added, she had the conducting of annual nurse competencies on her list to do but had not been able to do them. She further stated the facility had no overall system in place to monitor staff actions related to blood sugar checks and refusals (blood sugar checks/insulin). Regarding why the issue happened with Resident #1, she stated, the nurses did not notify anyone in order to seek guidance as to what to do next. She stated she defined supervisor as the DON and ADON and at times it could be situational. She stated, she had not found anyone LVN A reported Resident #1's refusals to; staff or physician. Resident #2 Record review of the Physician Order Report: 4/16/23-4/16/23 for female Resident #2 revealed the resident was admitted to the facility on [DATE] and was [AGE] years old. Further record review revealed that the resident had diagnoses of end-stage renal disease (kidney disease) and diabetes mellitus due to underlying condition with diabetic chronic kidney disease. Record review of the Physician Order Report revealed that the resident had the following orders, Order type - Prescription. Start date 3/9/23. End date - Open ended. Description. Humalog U-100 insulin (insulin lispro) Solution; 100 unit/mL; amt: per sliding scale; If blood sugar is less than 60, call MD. If blood sugar is 150 to 200 give two units. If blood sugar is 201 to 250 give four units. If blood sugar is 251 to 300, give six units. If blood sugar is 301 to 350, give eight units. If blood sugar is 351 to 400, give 10 units. If blood sugar is 401 to 450, give 12 units. If blood sugar is greater than 450, give zero units. If blood sugar is greater than 450, call MD. Subcutaneous. [DX: diabetes mellitus due to underlying condition with diabetic chronic kidney disease] Before meals and at bedtime; 7:30 AM, 12:30 PM, 4:30 PM, 8:00 PM Record review of the most recent quarterly MDS assessment for Resident #2, dated 3/23/23 documented that the resident had a BIMS score of 15 indicating that she was cognitively intact. Further record review of the MDS revealed that the resident had an active diagnosis of diabetes mellitus. Documentation under the area Medications revealed that the resident received insulin injections seven times in the last seven days. Record review of the care plan for Resident #2, Last Reviewed/Revised: 3/29/23.revealed a Problem, documented as, Problems start date: 3/10/23. Category: diagnosis diabetes. Edited: 3/29/23. The listed Approaches included, Approach start date: 3/10/23 FSBS checked as ordered. Created: 3/13/23. Approach start date: 3/10/23. Meds as ordered. Created: 3/13/23 and Approach start date: 3/10/23. Observe for S/S of hypo/hyper glycemia. Created: 3/13/23 . Record review of the MAR for Resident #2 dated 4/1/23-4/14/23 revealed that under the Humalog administration, there was a refusal of blood sugar checks on 4/9/23 at 12:30 PM by LVN A. There were also refusals of blood sugar testing documented on the following days and times, 4:30 PM on 4/3/23, 4/4/23, and 4/12/23 by LVN A. The reason for the refusals was documented that the resident would not wake up from her nap. There were also blank spaces with no documentation regarding blood sugar checks or insulin on the following days and times: 8:00 PM on 4/4/23, 4/8/23, and 4/12/23. Record review of the Resident Progress Notes for Resident #2 dated 3/16/23 to 4/14/23 had no documentation regarding the blank areas on the MAR. Resident #3 Record review of the Physician Order Report: 4/16/23-4/16/23 for female Resident #3 revealed that the resident was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnoses of other cerebral infarction (heart attack), and major depressive disorder. Further record review of the Physician Order Report revealed the resident had the following orders: Order Type - Prescription. Start date - 5/12/22. End date - Open ended. Trulicity (dulaglutide) pen injector; 0.75 mg/0.5 ml; amt: 0.5 ml; sub cutaneous. [DX: type two diabetes mellitus without complications] once a day on Wednesday; 7:00 AM - 10:00 AM. Order type - Prescription. Start date - 7/26/22. End date - Open ended. Description. Humalog U - 100 insulin (insulin lispro) solution; 100 unit/ml; amt: per sliding scale; If blood sugar is less than 60, call MD. If blood sugar is 150 to 200, give two units. If blood sugar is 201 to 250, get four units. If blood sugar is 251 to 300, gives six units. If blood sugar is 301 to 350, give eight units. If blood sugar is 351 to 400, give 10 units. If blood sugar is greater than 400, call NP/PA. Subcutaneous [DX: type two diabetes mellitus without complications] Twice a day; morning, 7:00 AM to 10:00 AM, bedtime 7:00 PM to 10:00 PM. Record review of the MAR for Resident #3 dated 4/1/20 23-4/14/2023 revealed the following documentation: Humalog administration revealed there was no documentation for the bedtime 7 PM - 10 PM blood sugar testing or insulin administration (Blank) on 4/4/23, 4/7/23, 4/8/23, 4/12/23, and 4/13/23. There was no documentation as to why these areas were blank. Record review of the most recent quarterly MDS for Resident #3 dated 3/2/23 documented that the resident had a BIM's score of 14 indicating that she was cognitively intact. An active diagnosis was documented as diabetes mellitus. Further record review of the MDS revealed that the resident received five insulin injections within the last seven days. Record review of the care plan for Resident #3 Last Reviewed/Revised: 3/8/23. Revealed a Problem as follows: Problem, start date: 5/18/20. Category: diagnosis. Resident has diabetes type 2 edited: 3/8/23. The Approaches listed included, Approach start date: 5/18/20. FSBS checked as ordered. Created: 5/18/20. Approach start date: 5/18/20. Meds as ordered. Created: 5/18/20. Approach start date: 5/18/20. Observe for S/S of hypo/hyperglycemia. Created: 5/18/20 . Record review of the Resident Progress Notes for Resident #3 dated 3/16/23 to 4/14/23 had no documentation regarding the blank areas on the MAR. Resident #4 Record review of the Physician Order Report dated 4/16/23-4/16/23 for female Resident #4 revealed she was admitted to the facility on [DATE] and was [AGE] years old. Documented diagnoses were end-stage renal disease and type two diabetes mellitus with other skin ulcer. Further record review of the Physician Order Report revealed the following orders: Order type - Prescription. Start date - 5/18/22. End date - Open ended. Description. Insulin lispro Insulin pen; 100 unit/ML; AMT: per sliding scale; If blood sugar is less than 70, call NP/PA. If blood sugar is 70 to 150, give 0 units. If blood sugar is 151 to 200, give two units. If blood sugar is 201 to 250, give four units. If blood sugar is 251 to 300, give six units. If blood sugar is 300 to 350, give eight units. If blood sugar is 351 to 400, give 10 units. If blood sugar is 401 to 450, gives 12 units. If blood sugar is 450 to 500, give 14 units. If blood sugar is greater than 501, called NP/PA. Subcutaneous. [DX: type two diabetes myelitis without complications] Before meals, and at bedtime; 7:30 AM, 11:30 AM, 4:30 PM, 8:00 PM Order type - Prescription. Start date - 4/11/23. End date - Open ended. Description. Lantus U-100 insulin (insulin glargine) solution; 100 units/ML; amount AMT: 20 units; subcutaneous. [DX: type two diabetes mellitus without complications] Twice a day; morning, 7:00 AM - 10:00 AM, bedtime, 7:00 PM - 10:00 PM Record review of the most recent quarterly, MDS Resident #4 revealed that the resident had a BIMS score of 14 indicating she was cognitively intact. Further record review of the MDS revealed that the resident had an active diagnosis of diabetes mellitus. Record review revealed that the resident received insulin injections six times in the last seven days. Record review of the care plan for Resident #4 revealed that it was Last Reviewed/Revised: 3/7/23. There was a documented Problem stating, Problem Start Date: 06/08/2022. Category: Endocrine Disorders. Resident has an impaired endocrine system r/t diabetes. Edited: 03/07/2023. The approaches listed for this problem were geared toward resident education of diabetes. Record review of the MAR documentation for Resident #4 revealed the following documentation for insulin lispro: there were documented refusals of blood sugar testing on 4/4/23 at 11:30 AM and 4:30 PM by the ADON and 4/8/23 at 11:30 AM by LVN D. There was no documentation of blood sugar testing or insulin administration (blank) on 4/6/23 at 8:00 PM and 4/12/23 at 7:30 AM and 11:30 AM. Record review of the MAR for Lantus U - 100 revealed the resident refused her Lantus on 4/6/23 at 7:00 AM to 10:00 AM. There was no documentation of blood sugar testing or administration of Lantus (blank) on 4/6/23 at 7 PM to 10 PM bedtime. Record review of the Resident Progress Notes for Resident #4 dated 3/16/23 to 4/14/23 had no documentation regarding the blank areas on the MAR. On 4/16/23 at 3:02 PM the DON stated that she was not aware of refusals

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the resident's right to be free from abuse for one (Resident #1) of six residents reviewed for abuse. The Administrator failed ensure Resident #1, who was named an alleged victim of abuse was safe from CNA E who was named as the alleged perpetrator. CNA E worked the remainder of his shift after being named as the alleged perpetrator. As a result of the facility's failures, Resident #1 had continued exposure to CNA E as well as the remaining 79 residents in the facility. On 12/30/22 at 5:04 PM an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 12/31/22 at 3:12 PM, the facility remained out of compliance at a severity level of actual harm and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure could place all residents who were exposed to CNA E by placing them at risk for abuse. Findings Included: Record review of Resident #1's undated face sheet revealed an [AGE] year-old-female who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include unspecified dementia (impaired ability to remember), psychotic disorder with delusions (condition to affect the mind), disorder to bone structure (condition affecting the bone structure) and pain. Record review of Resident #1's Quarterly Minimum Data Set, dated [DATE], revealed: Section C for Brief Interview for Mental Status score revealed a score of 02, which indicated the resident's cognition was severely impaired. Record review of Resident #1's Physician Order Report, dated 11/30/22-12/30/22, revealed: Order Type: Radiology Start Date: 12/26/22 End Date: 12/26/22 Description: RT Forearm; RT Wrist; Other Test: (Portable x-ray due to wheelchair bound in nursing home, of the hand wrist and forearm r/t pain) Ordered by: MD Order Type: Prescription Start Date: 1/21/11 End Date: Open Ended Description: Gabapentin 100 mg DX:pain Ordered by: MD Order Type: Prescription Start Date: 08/07/20 End Date: 12/26/22 Description: acetaminophen 500 mg 2 tabs Dx: Low back pain Ordered by: MD Record Review of Resident #1's care plan, undated, revealed the following: Problem Problem Start date: 08/04/2021 Category: Behavioral Symptoms Residents has socially inappropriate/ disruptive behavioral symptoms . Problem Problem Start Date 01/20/21 Category: Diagnosis Resident bones are osteopenic and are at increased risk of fracture Edited 10/28/21 Edited by : The DON Problem Resident #1 has behaviors. She will pull at other residents shirts. She will try to pinch other residents. Edited: 10/28/2022 Edited by: The DON Record review of the facility provider investigator report, dated 12/25/22, revealed the following documentation: Charge nurse did not complete event for the allegation of abuse, instead documented the bruises identified to wrist and hand. Upon further investigation xrays were ordered, physician and family notified of allegation and event added to EMR for abuse allegation. Record review of the Hospital records with the service dated 12/28/22 revealed the following: Per EMS, they said she was being assisted when someone pulled too hard. Though they are unclear about when this exactly happened she does have localized pain Her xray to the right forearm revealed oblique spiral fracture distal right ulnar diaphysis. Record review of the facility policy, Abuse Prevention Program, dated June 2021, revealed the following documentation: Policy Statements: (1) The Administrator is responsible for the overall coordination and implementation of our Center's abuse prevention program policies and procedures. (2) Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. (7) All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by Center management. Findings of abuse investigations will also be reported. Training and Prevention: (5) 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 in doubt, report it. a. Signs of Actual Physical Abuse: i. Welts or bruises; ii. Abrasions or lacerations; iii. Fractures, dislocations or sprains of questionable origin; Identification: Assessment and Recognition of Abuse: 1. The nurse will assess the individual and document related findings. Assessment data will include: a. Injury assessment (bleeding, bruising deformity, swelling etc.); b. Pain assessment; 2. The nurse will report findings to the physician. As needed, the physician will assess the resident/patient to verify or clarify such findings, especially if the cause or source of the problem is unclear. 3. The physician will help identify individuals with a history of having been abused or neglected, or those showing evidence of possible abuse or neglect; for example, someone admitted from home or the hospital with multiple pressure ulcers and severe under-nutrition. 6. As indicated, the physician will evaluate the resident or refer him or her for evaluation; for example, to rule out sexual assault or fracture, or to assess the possible causes of bruises. Investigation: Role of the Administrator: 1. The Administrator has the overall responsibility for the coordination and implementation of our Center's abuse prevention program policies and procedures. The Administrator is the Abuse Prevention Coordinator. In the absence of the Administrator the Director of Nursing will serve in this capacity. 2. The Administrator has the authority to delegate coordination and implementation of various components of these policies and procedures to other individuals within the Center. These may include: a. The Director of Nursing Services; b. The Director of Social Services; c. The Director of Staff Development; d. The Director of Risk Management; e. The Assistant Administrator; f. The Medical Director; g. The Quality Assessment and Assurance Committee; and h. Other staff members as determined by the Administrator. 3. If an incident or suspected incident of resident abuse, mistreatment, neglect or injury of unknown source is reported, the Administrator will assign the investigation to an appropriate individual. 6. The Administrator will suspend immediately any employee who has been accused of resident abuse, pending the outcome of the investigation. 7. The Administrator will ensure that any further potential abuse, neglect exploitation or mistreatment is prevented. Role of the Investigator: 1. The individual conducting the investigation will, at a minimum: e. Interview the resident (as medically appropriate); Reporting: All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the Center Administrator, or his/her designee, to the following persons or agencies as required: 3. Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury; or Twenty-four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury. Response: Protection of Residents During Abuse Investigations 1. During abuse investigations, residents will be protected from harm by the following measures: a. Employees accused of participating in the alleged abuse will be immediately suspended until the findings of the investigation have been reviewed by the Administrator. During an interview with the Administrator on 12/30/22 at 09:07 AM, she stated that she was notified on Christmas day of the incident concerning Resident #1 around 6:00 PM. She said she spoke with CNA B and CNA E. She stated that both staff did not provide any information. She stated she later found out after further investigation that the incident that allegedly caused the injury (fracture to Resident #1) to the resident actually occurred on 12/24/22. She said she instructed LVN A to assess Resident #1 at this time (6:00 PM) and when she did, she was told that the resident had bruising on her hands. She stated she was unsure why LVN A did not do the event (report the allegation of abuse) as instructed. She stated her expectation was for the event to include the details of the allegation. The Administrator said that she did not give instructions for an X-ray. She stated that she started interviewing everyone who worked and included it in her report provided to the surveyor. She said she suspended CNA E verbally. She stated she never interviewed the alleged victim (Resident #1). When asked why she had not interviewed the resident, she stated the resident was majority Spanish speaking. She said she would typically have her social worker conduct that interview but was unsure if the social worker interviewed Resident #1. She stated the DON worked the night of 12/26/22, and she followed up on the x-ray. She stated the x-ray was not done in a timely manner because there was confusion about who was supposed to do which duties. She stated the ADON printed the face sheet and obtained the order from the doctor. She stated the issue was no one ever called the x-ray company was never called. During an interview with Resident #1 on 12/30/22 at 10:07 AM, at the local hospital she stated that she fell. She said that someone told her she had a right arm cut. Resident #1 was able to tell the surveyor her name and the name of her daughters. She could not remember the president's name but could tell the surveyor that she was in the hospital. She stated that her arm was hurting and that she was in pain and has been hurting for a couple of days. An observation of Resident # 1 on 12/30/22 at 10:07 AM revealed that she was in bed located in the local hospital. Her right arm had a soft splint. Surveyor was unable to see any bruising or swelling at the time of the observation. During an interview with the Hospital RN on 12/30/22 at 10:15 AM, she reported that she does not know much about the incident (concerning Resident #1 and the fracture) but only what was passed to her in the report from the previous nurse. She stated Resident #1 was not oriented to time or place. She said the resident was admitted on suspected abuse. She stated it was noted in the computer system that someone pulled too hard on her arm. She stated it was hard to say what could have caused the injury. She stated anything could have caused the injury from a fall or someone twisting the resident's arm. During an interview with the Hospital Social Worker on 12/30/22 at 10:17 AM, she revealed that it was reported to her by the medical staff that Resident # 1 was okay medically to go back to the facility, but there were concerns if the return back to the facility was safe. She stated that in her electronic medical record that someone pulled on Resident #1 arm, and until they heard back about the result of the allegation, she was not going to release the resident back to the facility. During an interview with CNA B on 12/30/22 at 12:07 PM, she stated the initial incident that may have caused the injury to Resident #1 occurred on 12/24/22 around the facility dinner time. She said CNA E was coming down the hall, and he was redirecting Resident #1 to go to the table and eat. She stated that Resident #1 used her right hand and went to hit CNA E. She said she could not see if CNA E grabbed or blocked the resident from hitting him. She stated the resident did not appear to be in any pain. She stated that CNA E pushed the resident whle in her wheelchair to the table to eat. She reported the resident ate without any incident and did not complain of any pain. She stated the resident utilized her hand for the remainder of the meal. She stated that the resident speaks Spanish the majority of the time. She said she was under the impression that CNA E reported it and charted it. She reported that Resident #1 does have behaviors where she will hit staff and try to hit residents. She stated that she had been trained in reporting abuse, neglect, and exploitation. She said she did not report anything because she was under the impression that CNA E did. She reported she had not had specific training on Resident #1 behaviors. During an interview with LVN A on 12/30/22 at 12:17 PM, she stated that the incident with Resident #1 occurred on 12/25/22. She said that a certified nurse aide, whom she has difficulty pronouncing her name, which she later identified as CNA A, reported to her that the family member of Resident #1 complained about a staff member grabbing Resident #1 arm on 12/26.22. She stated that she did assess the resident at this time of the report. She stated that the resident had bruising on her hand (on both hands). She said that she noted bruising on her right arm but was unable to note the size. She reported the incident to the Administrator because she was the abuse coordinator on 12/25/22 (not sure of the exact time). She reported that she was under the impression that the alleged incident with the staff member had occurred earlier in the day. She stated that when this was reported to the Administrator, the Administrator asked to speak with the nurses' aides that were present. She said as a result of the incident, she notified the doctor via text the same day she was informed on 12/25/22. She was unable to confirm the time as she was not familiar with how to screenshot and send on her phone. She stated the Administrator, or the doctor did not instruct her to get an x-ray of the resident. She said that she was not instructed to send or ensure that CNA E was to leave the facility. She stated the Administrator could have told CNA E, but she could not hear the conversation. She stated that the resident was not in pain when the incident was reported to her. She did not suspect that her arm was broken because she was able to move her arm at the time of the assessment. She stated she did not follow up with the x-rays because she was off on 12/26/22 and 12/27/22. She said that if a resident goes untreated, this could cause complications. She stated this could have caused issues with the resident nerves, and the resident could potentially lose the function of the injured hand. She said that she had been trained in how to report abuse, neglect, and exploitation. During an interview with CNA E on 12/30/22 at 12:29 PM, he stated that when he worked on 12/24/22, it was a regular day. He described regular, meaning nothing out of the ordinary happened. He stated nothing out of the ordinary occurred on 12/24/22 or 12/25/22. He said he was not sure what had happened. He stated Resident #1 tried to hit him. He stated the resident reached behind her while he was pushing her in her wheelchair. He said he was unsure which hand it was but that it may have been her left hand. He stated that the resident tried to pinch and grab him. He said she reached and tried to grab his pant leg. She stated that it was for a split second when this happened. He stated that he believed the resident was okay but that she was angry with him. He said he had been trained on reporting abuse, neglect, and exploitation. He was able to name who the abuse coordinator was (The Administrator). He stated the following day (12/25/22) when he worked that, he was asked to speak with the Administrator by LVN A, and he told her (the Administrator) the best he could what happened with Resident #1. He stated he reported that he did not know what happened to Resident #1. He stated that after speaking with the Administrator, he was not asked to leave the facility. He said he finished the remainder of his shift and left after 7:00 PM. He stated he had not specifically been trained on Resident #1 behaviors and how to deal with them. During an interview with CNA A on 12/30/22 at 12:37 PM, she stated that she learned about the incident with Resident #1 on 12/25/22. She said she was unsure of the exact time, but it had to be right after breakfast and before 11:00 AM when she got off that day. She stated she was going through memory care that day but was not assigned to work in that area of the facility on that day. She stated that Resident #1 got her attention when she walked through the memory unit and said her arm was hurting. When she asked the resident what happened, the resident stated she did not know what happened. CNA A stated she had Resident #1 move her arm, and the resident was able to move her arm up, down, and all around. She said that she had asked CNA B what had happened to the resident and was told that she did not know what had happened. She reported that she told LVN B, who was also in the dining area, when the resident complained that her arm hurt. She stated at this time, Resident #1 never named any staff specifically. She said on 12/26/22, Resident #1 was telling MA A that her arm was broken. She stated that Resident #1 never reported to MA A which staff member had broken her arm. She said that Resident #1 daughter and niece came to visit on 12/26/22. CNA A stated that she was not aware if an X-ray had been conducted. She stated the family had mentioned that they were told that Resident #1 would get an X-ray. During an interview with the Resident # 1's Family Member on 12/30/22 at 12:43 PM, she stated that she was notified on Christmas night at 9:00 PM that had bruising on the top of her hands. She said she was initially told the bruises came from her mother banging her hands on the wheelchair. She stated this was reported to her on 12/25/22 late evening. She stated she did not believe this because her mother was a larger woman, and there was not enough room for this to occur. She said that she and another family member visited her mother the next day (12/26/22). She stated that when she tried to touch her mother, her mother guarded her right arm and yelled. She said that she could see on the top and the bottom of her mother's arms what appeared to be fingerprints. She stated she was told that her mother would receive an X-ray. She said she had taken pictures of her mother's hand but could not get a clear picture of the underside of her hand because her mother was in so much pain. She stated the next day, on the 27th in the morning, she was called by the local hospital and was told that her mother was being admitted to the hospital. She stated she was not told why her mother was being admitted . She said lunch time on 12/27/22, she was told that her mom had a spiral fracture and that the plan was to splint it and then put it in a hard cast. She stated she was told by the hospital staff that a staff member had pulled too hard on her mother and that X-rays were not done. She said that she asked the nurse at the hospital for her mother to receive a spiral fracture, which meant someone had to twist her arm, and she was told this was correct. She was unable to identify which nurse at the hospital told her this. She stated that she was not told why the x-rays were not done at the facility when the bruising was initially found. She said that she was told by the Administrator that the staff working with her mother when the incident happened would not work with her. She stated that they would be terminated, which was the only reason she would be okay with her mother returning to the facility. She said that she was told that the staff was uncooperative, which was why they would not return to work. She stated her mother was in pain on 12/26/22, and two staff and a nurse were present. She identified the staff as CNA A, CNA D, and LVN B. She said she was not sure who initially notified her that her mother had hurt her arm on the wheelchair. She stated she could not remember if it was the nurse, a CNA, or the Administrator. During an interview with the Administrator on 12/30/22 at 1:29 PM, she stated that CNA E was supposed to leave the building when the allegation was made around 12/25/22 at 6:30 PM. She said that she had talked to him at around 6:30 PM. She stated she was unaware that he had finished his shift. During an interview with CNA D on 12/30/22 at 1:33 PM, she stated that she did not work Friday (12/23/22), Saturday (12/24/22), or Sunday (12/25/22). She said that when she came to work on Monday (12/26/22), she received a report from the overnight worker. She stated that she was told that Resident #1's arm was bruised and that she complained of pain. She stated she had spoken with the resident in Spanish and asked her what was wrong and what had happened to her arm. She stated the resident grimaced and said she did not know what happened and that her arm was broken. She said the medication aide was present and was on the phone with the Administrator and instructed the resident to do a series of exercises, such as moving her arm and fingers. She said the resident called her crazy in Spanish because she was in pain. She stated this occurred around 8:00 AM or 8:30 AM. She stated she was told that an x-ray had been ordered for the resident. She stated the resident did not get an x-ray on 12/26/22 and was unsure why. She said she was uncertain if it was because of the holiday. She stated that there were no office workers at the facility that day, and this was because it was a holiday. She assumed that was why the x-ray was not conducted that day. She stated it was her understanding that the x-ray was ordered on 12/26/22. During an interview with the NP on 12/30/22 at 2:21 PM, she stated that she was not notified of Resident #1 fracture until 12/27/22. She said she initially ordered a soft splint, but after thinking about it more, she ordered that she go to the emergency room and get a heavy-duty splint. She stated she was unaware of the source of the injury and was not told that the resident was a potential victim of abuse. She stated that failure to treat the injury could have further impaired mobility, worsened, and have potentially put the resident at risk for infection. She stated the resident's specific injury was from direct trauma. She reported with her osteoporosis, the resident was at higher risk of broken bones. She said even squeezing or holding could harm the resident. During an interview with MD on 12/30/22 at 2:57 PM, he stated that he was notified via text message at 9:17 PM on 12/25/22 that Resident #1 had bruises on the back of both hands and was not in pain. He said he was not told that the resident was a potential victim of abuse. He stated if he had been notified that the resident was an alleged victim of abuse, he would have ordered an x-ray and notified the state entity. He said failure to address the injury could cause severe arthritis and severe pain. He stated an injury of this nature could be caused by someone grabbing the resident and twisting the area. During an interview with CNA C on 12/30/22 at 3:09 PM, she stated that she did not know much about the incident with Resident #1 and her fractured arm, but it was being discussed amongst other CNAs. She stated that she was told that a CNA was really mean to one of the residents. She said that it was easy to figure out which CNA it was because, as a worker, you know which workers were rough. She stated the resident never expressed any pain when she was around the resident. On 12/30/22 the Administrator and DON they were notified that the facility would be placed in immediate jeopardy status due to failure to keep the resident safe from abuse. The following Plan of Removal submitted by the facility was accepted on 12/31/22 at 11:58 AM: Record review of the facility Plan of Removal revealed the following: Problem: Facility failed to ensure that Resident #1 was free from abuse. On 12/25/22 at 6:15 pm the Administrator was notified of an allegation of abuse. The staff member finished his shift and worked until 7:11 pm. The Administrator failed to follow up to ensure that CNA E was not around the resident. The LVN A on duty stated she was not instructed for CNA E to leave the facility. CNA E indicated that he was not instructed that he would be suspended until after his shift. Interviews with Resident #1 of the resident indicated Resident #1 was in pain to the point where she would not allow them to move her arm. Interviews with the medical professionals indicated that the type of fracture is a result of direct trauma, squeezing and twisting action. Like residents identified: All residents in memory care unit 12/25/22 Plan Regional [NAME] President suspended the Administrator today 12/30/22 at 6:30 pm for failure to follow up that the alleged CNA E was not around resident. The DON was in-serviced by the Nurse Educator 12/30/22 on Abuse/neglect and injury of unknown origin - reporting timely- suspending immediately and ensuring suspension by briefing the licensed nurse on assignment. The Administrator was in-serviced today 12/30/22 by the Regional [NAME] President on investigating incidents of unknown origin and on immediately suspending and ensuring suspension of any CNA E by briefing the licensed nurse on assignment. DON assessed all residents in the memory unit for any signs of physical trauma. Staff were in-serviced report any abuse/neglect/resident behaviors to their Licensed nurse immediately. Licensed nurses were in-serviced on reporting abuse and neglect immediately and ensuring to suspend the AP immediately and ensuring the AP exits the center immediately. NOTE: All education has been completed approximately _100___% No staff will clock in until education has been completed. Inservice was completed on event documentation to ensure accurate information was communicated to the attending physician/designee and Responsible Party to include Medical record documentation education indicating significant change and to always be specific on reporting any allegations of abuse/neglect to the attending in order for physician to respond as needed. Weekend RN was in-serviced and will follow up on any event (Incident Report) to ensure clinical review on a daily basis. DON/designee does this M-F. This is addressing to prevent any delay in treatment of the resident. The Abuse prevention coordinator/designee is ultimately responsible to ensure the Alleged Perpetrator (AP) is escorted out of the facility by his supervisor. The DON and the Administrator were in-serviced on this by the Clinical Resource Nurse. The charge nurses were in-serviced if there is an allegation of abuse, suspend immediately and escort out of the center. In-service licensed nurses on radiology results notification to attending physician immediately to include nurse assignment responsibility. Do not assume anyone else is taking care of your resident orders, if you are assigned to this resident it is ultimately your responsibility to inform the MD and follow up. Education was provided to the licensed nurses on X ray portal. If there are no results, the Licensed nurse will call the imaging company to inquire about x-ray and results pending Inservice on head to toe assessments to include pain. Licensed nurses Assessment competencies were completed to ensure licensed staff are competent on assessments and reporting abuse/neglect Inserviced on abuse and neglect policy/timely reporting/who the abuse coordinator is, suspension immediately, removing AP off the floor, exiting the center immediately and consequences of not reporting timely. -All Competencies were completed on abuse/neglect-test- all Educated on SBAR significant change- pain assessment and reporting to attending License Nurses. On 12/31/22 at 12:45 PM the Final Plan of Removal was approved. Record review of the facility policy and Inservice attached, Abuse/ Neglect/ Injury of unknown injury, dated 12/30/22, revealed the following documentation: Must be reported timely asap as soon as incident happens. Abuse does not have to be true but must be reported immediately and AP suspended, escorted out of the facility by the charge nurse. It is the abuse prevention coordinator responsibility to ensure that the AP is out of the building. If the Administrator is not there or out then the DON assumes that responsibility. Record review of the facility's policy and Inservice attached, Accidents and Incidents- Investigating and Reporting, dated July 2017, revealed the following documentation: Policy Statements: All accidents or incidents involving residents, employees, visitors, vendors etc., occurring on our premises shall be investigated and reported to the administrator. A handwritten statement was written at the bottom stating: Any xray results should be called in to the MD immediately. Family and DON should be made aware as well (along with any other orders from the MD) If no results are received document date, time and person you spoke with Record review of the facility's policy, inservice and signature sheets attached, Incident Report follow up Inservice for weekend RN, dated 12/31/22, revealed the following documentation: Weekend RN will be responsible for reviewing incident reports for the last 72 hours and ensure appropriate notifications, treatment and follow up are done. Weekend RN will give report of incident reports on Monday morning to the Admin, DON or designee. Record review of the facility's policy, inservice and signature sheets attached, Daily Work Assignments , dated August 2006, revealed the following documentation: Policy Statements: All nursing service personnel shall follow daily work assignments and perform assigned duties in accordance with professional standards of practice and facility policy. Record review of the facility's policy, inservice and signature sheets attached, SBAR Communication Form, dated 2014, revealed the following documentation: Before calling the physician/NP/PA/ other health care professional the resident must be evaluated, vital signs checked, review record and have relevant information available when reporting. SBAR is an acronym used to remind the staff to assess the Situation, Background, Appearance & Review and Notify. Record review of the facility's policy, inservice and signature sheets attached, Resident Rights, dated February 2021, revealed the following documentation: Policy Statements: Employees shall treat all residents with kindness, respect, and dignity. Policy Interpretation: (1) Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: (c.) be free from abuse Record review of Abuse and Neglect Skills test completed for all empl[TRUNCATED]