**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the resident had the right to be free of abuse for 1 of 6 (Resident #1) residents reviewed for abuse. The facility failed to prevent LVN A from physically abusing Resident #1 on 9/9/2025 witnessed by CNA B and CNA C. An IJ was identified on 9/12/25 The IJ template was provided to the facility on 9/12/25 at 3:34 p.m While the IJ was removed on 9/13/25 the facility remained out of compliance at a scope of Isolated and severity level of no actual harm with potential for more than minimal harm that is not IJ due to ongoing need for in-services on abuse and neglect, abuse coordinator and notification of abuse process. This failure could place residents at risk for physical and verbal abuse, psychosocial harm, and decreased quality of life. Findings included: Record review of the face sheet dated 9/11/2025 indicated that Resident #1 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including severe intellectual disability which was below average intelligence, anxiety disorder which was intense, excessive, and persistent worry and fear about everyday situations, schizoaffective disorder which was a lifelong pattern of social withdrawal and limited emotional expression, ADHD which was a chronic condition including attention difficulty, hyperactivity and impulsiveness, cerebral palsy which was a congenital disorder of movement, muscle tone or posture, and cognitive communication deficit which was a group of disorders that affect a person's ability to communicate effectively due to underlying cognitive impairments. Record review of the MDS dated [DATE] indicated that Resident #1 had a BIMS score of 03 (severe cognitive impairment). His score indicates that he had difficulty communicating some words or finishing thoughts but was able if prompted or given time and that he missed parts or intent of conversation but comprehends most conversation. Record review of the care plan dated 9/7/25 which showed that Resident#1 was last admitted to the facility on [DATE] and was receiving services at the facility. Record review of a progress note dated 9/10/2025 indicated that Resident #1 was on the floor of his bedroom fighting with his roommate and LVN A documented attempting to sooth Resident #1 by rubbing his back and his chest and his hand getting caught in the shirt of Resident #1. It indicated that LVN A instructed CNA B and CNA C to take Resident # 1 into the hallway. LVNA indicated that he assessed Resident # 1 and noted no injury. During an interview on 9/11/25 at 4:11 p.m. CNA B said that on 9/9/25 she worked with CNA C on the evening shift. She said that at around 7:30 p.m. they were assisting Resident #1 to bed and he was being combative, hitting them and not cooperating. She said that she went to get LVN A, and he said that there was nothing he could do. She said that when she went back to the room, Resident #1 was still being combative and trying to fight with his roommate. She said that she and CNA C separated the residents and placed Resident #1 back in his wheelchair. She said that around 10:30 p.m. she and CNA C attempted to put Resident #1 in bed and he stood up and was cooperative at first but then became combative again and yelling at his roommate. Resident #1 was sitting in his chair with nothing but his shirt on and was still attempting to hit CNA B and CNA C. CNA B said that she went to get assistance from LVN A. LVN A was outside of the room and Resident #1 said you want to fight, N word?. She said that LVN A came in the room and said, you got one now and grabbed Resident #1 by the shirt up by his neck and Resident #1 was making a choking noise and crying. CNA B said that when LVN A let him go, Resident #1 sat crying in his wheelchair. Record review of the voice recording provided by CNA B on 9/11/25 at 4:30 p.m. that was recorded on 9/10/25 sometime after 6:00 p.m. and included the voice of LVA A, CNA B and CNA C as identified by CNA B. A summary of the recording was that LVN A approached CNA B and CNA C letting them know that he had to complete an incident report after being accused of abusing Resident #1. LVN A asked them what occurred in the bedroom and said that he was not confirming nor denying what occurred, but he did not remember. Both CNA B and CNA C told him that he had grabbed Resident #1 by the shirt around his neck and got into Resident #1's face when Resident #1 used a racial slur toward his roommate. LVN A then excused himself to go fill out the incident report. During an interview on 9/11/25 at 3:18 p.m. Resident #1 said that LVN A had choked him and that he was scared of LVN A. Resident #1 cried and left the interview. During an interview on 9/11/25 at 3:57 p.m. LVN A said that on 9/9/2025 he worked at the facility. He went into Resident #1's bedroom when he was fighting with his roommate. LVN A said that he was trying to calm Resident #1 down by rubbing his back and trying to talk to him. LVN A said that Resident #1 was on the floor and he was assisting him back to his chair and his hand got caught in Resident #1's t-shirt and when he pulled it out his hand went up toward Resident# 1's neck. LVN A said that Resident #1 was one of his favorite residents and that he would never abuse him. He said that residents have called him the N word before and he was not one so it does not bother him. LVN A said that he did not choke Resident #1. LVN A said that there were two CNAs in the room with him when his hand got caught in Resident #1's t-shirt. LVN A confirmed that the CNA's in the room were CNA B and CNA C. During an interview on 9/12/25 at 1:18 p.m. CNA C said that she worked on the night shift on 9/9/2025 alongside CNA B. She said around 7:30 p.m. she and CNA B were having issues with Resident #1 as he was being combative and fighting with them and his roommate. CNA C said that CNA B went to ask LVN A to come and assist them with Resident #1 and his roommate who were fighting. CNA B and CNA C got the two residents separated and they moved Resident #1 out into the day room area for a while and he was able to calm down. CNA C said that at around 10:30 p.m. she and CNA B asked Resident #1 if they could change him and get him ready for bed. She said that Resident #1 agreed and they took him to his room. She said that when they got Resident #1's brief off he became combative again and said, N word, do you want to fight? to his roommate. CNA C said that at that time LVN A came into the room and said, if you want an N, now you got one and he grabbed Resident #1 by his shirt up by his neck and got into his face. CNA C said that she was shocked and did not remember what all LVN A said to Resident #1. CNA C said that it sounded like Resident #1 was making a choking noise but he may also have been crying because when LVN A released him, Resident #1 started crying. CNA C said that LVN A said, I did not hurt you, I hurt your feelings and left the room. She said that there were no further incidents that evening. During an interview on 9/11/25 at 11:55 a.m. the Administrator said she expected staff to act professional and not choke the residents or react to anything the residents might say. The Administrator said all residents had the right to be safe from abuse. Record review of facility's Abuse and Neglect Clinical Protocol policy last revised March 2018 indicated, .This policy defines abuse as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish . Record review of facility's Abuse-Reportable Events policy last revised May 2017 indicated, .it is the policy of this home to prohibit resident abuse or neglect in any form . Record review of facility's termination document for LVN A indicated that he was terminated on 9/11/2025 for abuse. Record review of Resident # 1's assessment dated [DATE] at 11:44 a.m. that showed no injuries on his head to toe assessment related to the incident. The Administrator was notified on 9/12/25 at 3:30 p.m. that an Immediate Jeopardy situation was identified due to the above failure. The Administrator was provided the Immediate Jeopardy template on 9/12/25 at 3:34 p.m. The facility's plan of removal was accepted on 9/13/2025 at 7:46 p.m. and included: Interventions: LVN A suspended on 9/10/25 at 7:50 a.m. Resident # 1 assessed for injury on 9/10/25 at 11:44 a.m. Roommate of Resident #1 assessed. Residents on secured unit were not showing signs of distress or pain on 9/10/25. LVN A terminated on 9/12/25 at 2:00 p.m. In-service of all staff regarding abuse and neglect started. Monitoring: Staff in-serviced on abuse and neglect included types of abuse, who to report to and when to report Resident counsel held on 9/13/2025 at 10:00am was held to discuss the incident, what was considered abuse and who must be called immediately when abuse was suspected. Residents were informed that abuse coordinator signs are posted at the end of each hall and throughout facility. All residents were given a safety survey asking if they felt safe in the facility, whether they had seen anyone in the facility being abused or neglected and who they are to report abuse to if they have a concern of abuse or neglect. On 9/13/25 at 8:30 p.m. the investigator confirmed the plan of removal had been implemented sufficiently to remove the IJ by the following: During an interview with LVN F who worked the 2-10 shift on 9/13/25 at 4:38 p.m. she was able to articulate who the abuse coordinator was, the types of abuse, reporting timeframes and appropriate methods of reporting. During an interview with LVN D who worked the 2-10 shift on 9/13/25 at 4:40 p.m. she was able to articulate who the abuse coordinator was, the types of abuse, reporting timeframes and appropriate methods of reporting. During an interview with LVN E who worked the 2-10 shift on 9/13/25 at 4:54 p.m. she was able to articulate who the abuse coordinator was, the types of abuse, reporting timeframes and appropriate methods of reporting. During an interview with CNA J who worked the 6 p.m. to 6 a.m. shift on 9/13/25 at 4:52 p.m. she was able to articulate who the abuse coordinator was, the types of abuse, reporting timeframes and appropriate methods of reporting. During an interview with CNA K who worked the 6 p.m.-6 a.m. shift on 9/13/25 at 4:54 p.m. she was able to articulate who the abuse coordinator was, the types of abuse, reporting timeframes and appropriate methods of reporting. During an interview with CNA L who worked the 2-10 shift on 9/13/25 at 5:00 p.m. she was able to articulate who the abuse coordinator was, the types of abuse, reporting timeframes and appropriate methods of reporting. During an interview with CNA B who worked the 6 p.m.-6 a.m. shift on 9/13/25 at 5:40 p.m. she was able to articulate who the abuse coordinator was, the types of abuse, reporting timeframes and appropriate methods of reporting. During an interview with CNA C who worked the 6 p.m.-6 a.m. shift on 9/13/25 at 5:52 p.m. she was able to articulate who the abuse coordinator was, the types of abuse, reporting timeframes and appropriate methods of reporting. During an interview with LVN G who worked the 6 p.m. to 6 a.m. shift on 9/13/25 at 6:50 p.m. she was able to articulate who the abuse coordinator was, the types of abuse, reporting timeframes and appropriate methods of reporting. During an interview with RN H who worked the 8 a.m.-5 p.m. shift on 9/13/25 at 6:53 p.m. she was able to articulate who the abuse coordinator was, the types of abuse, reporting timeframes and appropriate methods of reporting. During an interview with DON who worked the 8 a.m.-5 p.m. shift on 9/13/25 at 6:58 p.m. she was able to articulate who the abuse coordinator was, the types of abuse, reporting timeframes and appropriate methods of reporting. During an interview with Resident # 2 on 9/13/25 at 6:15 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 3 on 9/13/25 at 6:20 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 4 on 9/13/25 at 6:23 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 5 on 9/13/25 at 6:27 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 6 on 9/13/25 at 6:33 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 7 on 9/13/25 at 6:37 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 8 on 9/13/25 at 6:42 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 1 on 9/13/25 at 6:46 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 9 on 9/13/25 at 7:52 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 10 on 9/13/25 at 7:55 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 11 on 9/13/25 at 7:57 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 12 on 9/13/25 at 8:00 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 13 on 9/13/25 at 8:05 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 14 on 9/13/25 at 8:08 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 15 on 9/13/25 at 8:12 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 16 on 9/13/25 at 8:15 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 17 on 9/13/25 at 8:18 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 18 on 9/13/25 at 8:20 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 19 on 9/13/25 at 8:23 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 20 on 9/13/25 at 8:25 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. Record review of safety surveys conducted on 9/13/25 indicated that they had conducted a safety survey with all residents at the facility and all who were able to participate were able to identify who to report abuse to and how to report and all indicated that they had not observed any abuse or neglect. Record review of in-service documentation dated 9/12/2025 showed that all but six staff on all shifts had been in-serviced on abuse and neglect and all staff had been notified that they would be taken off the schedule until they had been in-serviced on abuse and neglect. Record review of in-service documentation dated 9/12/2025 indicated that CNA B and CNA C were in-serviced on abuse, neglect and reporting requirements. This in-service shows that it included specific reporting requirements that abuse must be reported immediately to the abuse coordinator and that it must be reported by voice phone call, not text message. Observation conducted on 9/13/25 at 8:15 p.m. showed a notice over all facility time clocks notifying staff not to clock in until they had completed required in-services on abuse and neglect. Notification to the Administrator on 9/13/2025 at 8:30 p.m. that the IJ had been lifted. An IJ was identified on 9/12/25. The IJ template was provided to the facility on 9/12/25 at 3:34 p.m. While the IJ was removed on 9/13/25 the facility remained out of compliance at a scope of Isolated and severity level of no actual harm with potential for more than minimal harm that was not IJ due to ongoing need for in-services on abuse and neglect, abuse coordinator and notification of abuse process.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse to the administrator of the facility and to other officials including to the State Survey Agency in accordance with State law through established procedures for 1 of 6 (Resident #1) residents reviewed for abuse. The facility failed to ensure an allegation of abuse was immediately reported to the abuse coordinator. The facility failed to report the allegation of abuse within 2 hours. An IJ was identified on 9/12/25 The IJ template was provided to the facility on 9/12/25 at 3:34 p.m While the IJ was removed on 9/13/25 the facility remained out of compliance at a scope of Isolated and severity level of no actual harm with potential for more than minimal harm that is not IJ due to ongoing need for in-services on abuse and neglect, abuse coordinator and notification of abuse process. This failure could place residents at risk for physical and verbal abuse, psychosocial harm, and decreased quality of life. Findings included: Record review of the face sheet dated 9/11/2025 indicated that Resident #1 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including severe intellectual disability which was below average intelligence, anxiety disorder which was intense, excessive, and persistent worry and fear about everyday situations, schizoaffective disorder which was a lifelong pattern of social withdrawal and limited emotional expression, ADHD which was a chronic condition including attention difficulty, hyperactivity and impulsiveness, cerebral palsy which was a congenital disorder of movement, muscle tone or posture, and cognitive communication deficit which was a group of disorders that affect a person's ability to communicate effectively due to underlying cognitive impairments. Record review of the MDS dated [DATE] indicated that Resident #1 had a BIMS score of 03 which was indicative of severe cognitive impairment. Record review of the care plan dated 9/7/25 which shows that Resident#1 was last admitted to the facility on [DATE] and was receiving services at the facility. Record review of progress note dated 9/10/2025 indicated that Resident #1 was on the floor of his bedroom fighting with his roommate and LVN A documented attempting to sooth Resident#1 by rubbing his back and his chest and his hand getting caught in the shirt of Resident #1. It indicated that LVN A instructed CNA B and CNA C to take Resident # 1 into the hallway. LVNA indicated that he assessed Resident # 1 and noted no injury. During an interview on 9/11/25 at 4:11 p.m. CNA B said that on 9/9/25 she worked with CNA C on the evening shift. She said that at around 10:30 p.m. she observed LVN A grab Resident #1 by the shirt near his neck and that she heard Resident #1 make a choking noise and cry once released. She said that she would consider the actions she witnessed LVN A carry out to be abuse. She said she sent a text to the DON at 10:39 p.m. and 10:46 p.m. letting the DON know about the incident and that she did not know what to do. She said she did not contact anyone else and did not try to call the DON. CNA B said she did not know who the abuse coordinator was at the time of the incident and did not recall being trained on abuse and neglect. She said she got a text the next morning at 6:38 a.m. from the DON asking her to call her. She said that the risk of not reporting abuse immediately was that LVN A could have gone back and carried out more abuse or abused other residents before his shift ended. Record review of the voice recording provided by CNA B on 9/11/25 at 4:30 p.m. that was recorded on 9/10/25 sometime after 6:00 p.m. and included the voice of LVA A, CNA B, and CNA C as identified by CNA B. A summary of the recording was that CNA B and CNA C acknowledged that they observed LVN A grab Resident #1 by the shirt and around his neck on 9/9/25. Both CNA B and CNA C told him that they had observed him grab Resident #1 by the shirt around his neck and got into Resident #1's face when Resident #1 used a racial slur toward his roommate. During an interview on 9/11/25 at 3:18 p.m. Resident #1 said that LVN A had choked him and that he was scared of LVN A. Resident #1 cried and left the interview. During an interview on 9/11/25 at 3:57 p.m. LVN A said that on 9/9/2025 he worked at the facility. He went into Resident #1's bedroom when he was fighting with his roommate. LVN A said that he was trying to calm Resident #1 down by rubbing his back and trying to talk to him. LVN A said that Resident #1 was on the floor and he was assisting him back to his chair and his hand got caught in Resident #1's t-shirt and when he pulled his hand out of Resident #1's shirt and it went up toward Resident #1's neck. LVN A said that Resident #1 was one of his favorite residents and that he would never abuse him. He said that residents have called him the N word before and he was not one so it does not bother him. LVN A said that he did not choke Resident #1. LVN A said that there were two CNAs in the room with him when his hand got caught in Resident #1's t-shirt. LVN A confirmed that the CNA's in the room were CNA B and CNA C. During an interview on 9/12/25 at 1:18 p.m. CNA C said that she worked on the night shift on 9/9/2025 alongside CNA B. She said around 10:30 p.m. she witnessed LVN A enter the bedroom and grab Resident #1 by the shirt causing him to make a choking noise and cry when he was released. She said that what she witnessed was abuse and she had 24 hours to report it and intended to after the shift was over, but never got the chance to report it because she was contacted by the DON at around 7:00 a.m. the next morning. She said the Administrator was the abuse coordinator. She said that the risk of not reporting abuse immediately was that further abuse can occur. During and interview with the DON on 9/12/2025 at 9:11 a.m. DON said that she was notified by text of the abuse at 10:45 p.m. on 9/9/2025 but did not see the text until the following morning and immediately asked CNA B to call her. She said that once she spoke to CNA B and CNA C she reported the incident to the abuse coordinator who was the administrator and started the investigation process. During an interview on 9/11/25 at 11:55 a.m. the Administrator said she expected staff to report abuse within two hours so that appropriate protections can be put in place to protect the residents. The Administrator said she reported the incident of alleged abuse on 9/10/25 as soon as she found out about the incident on 9/9/25. The Administrator said she expected staff to immediately report any incidents of alleged or suspected abuse to her immediately. The Administrator said the importance of reporting abuse to the state agency in a timely manner was to aid in preventing further abuse and to protect the residents from abuse. Record review in TULIP on 9/11/25 indicated that the incident of abuse occurred on 9/9/25 at 10:45 p.m. and was reported to the State on 9/10/25 at 8:30 a.m. TULIP is a web based online platform developed and maintained by the Texas Health and Human Services Commission. It served as a centralized electronic system for handling licensure, credentialing, renewals, and related regulatory processes for long-term care providers in Texas, with a particular focus on nursing facilities. Record review of a screenshot obtained on 9/11/25 at 4:25 p.m. showed a text message from CNA B to DON at 10:39 p.m. asking if DON was awake. Another message sent at 10:44 p.m. indicated that CNA B did not know what to do in a situation that she described by saying that Resident #1 had been combative and that LVN A had put his hands around Resident #1's neck causing him to make a choking noise. LVN A was raising his voice and Resident #1 was crying. A return text from DON at 6:38 a.m. asked CNA B to call her. Record review of facility's Abuse and Neglect Clinical Protocol policy last revised March 2018 indicated, .This policy defines abuse as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish . Record review of facility's Abuse-Reportable Events policy last revised May 2017 indicated, .it was the policy of this home to prohibit resident abuse or neglect in any form, and to report in accordance with the law and any incident/event in which there was cause to believe a resident's physical or mental health or welfare has been or may be adversely affected by abuse or neglect caused by another person.Nursing facility must report the above immediately but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or result in serious bodily injury . The Administrator was notified on 9/12/25 at 3:30 p.m. that an Immediate Jeopardy situation was identified due to the above failure. The Administrator was provided the Immediate Jeopardy template on 9/12/25 at 3:34 p.m. The facility's plan of removal was accepted on 9/13/2025 at 7:46 p.m. and included: Interventions: LVN A suspended on 9/10/25 at 7:50 a.m. Resident # 1 assessed for injury on 9/10/25 at 11:44 a.m. Roommate of Resident #1 assessed. Residents on secured unit were not showing signs of distress or pain on 9/10/25. LVN A terminated on 9/12/25 at 2:00 p.m. In-service of all staff regarding abuse and neglect to include reporting abuse immediately to the administrator who was the abuse coordinator. Administrator completed one on one in-service with both witness CNA B on 9/12/2025 at 10:00pm. Witness CNA C was in serviced on 9/13/2025 at 1:30pm. Resident counsel held on 9/13/2025 at 10:00am was held to discuss the incident, what was considered abuse and who must be called immediately when abuse was suspected. Residents were informed that abuse coordinator signs are posted at the end of each hall and throughout facility. Monitoring: Staff in-serviced on abuse and neglect included types of abuse, reporting timely, who to report to and when to report In-service on facility abuse coordinator and back up coordinator and that a phone call must be made, text was not acceptable when it was regarding abuse. All residents were given a safety survey asking if they felt safe in the facility, whether they had seen anyone in the facility being abused or neglected and who they are to report abuse to if they have a concern of abuse or neglect. Abuse coordinator signs are throughout the facility and there will continue to be ongoing training to ensure the staff was knowledgeable of who to report to and what to report. Staff was in serviced by Administrator, DON, Dietary supervisor, and housekeeping supervisor. All staff in facility must be in serviced. As of 9/13/2025 at 11:54am 66 employees in all departments have signed in services. Twelve employees that need to be still in-services, all employees must be in-serviced by 9/13/2025 by 3:30pm any staff that has not been in-serviced was not to clock into the facility until they have been in serviced by DON or administrator anyone who fails to complete in-service will be removed from schedule and not allowed to work until they have been in serviced. On 9/13/25 at 8:30 p.m. the investigator confirmed the plan of removal had been implemented sufficiently to remove the IJ by the following: During an interview with LVN F who worked the 2-10 shift on 9/13/25 at 4:38 p.m. she was able to articulate who the abuse coordinator was, the types of abuse, reporting timeframes and appropriate methods of reporting. During an interview with LVN D who worked the 2-10 shift on 9/13/25 at 4:40 p.m. she was able to articulate who the abuse coordinator was, the types of abuse, reporting timeframes and appropriate methods of reporting. During an interview with LVN E who worked the 2-10 shift on 9/13/25 at 4:54 p.m. she was able to articulate who the abuse coordinator was, the types of abuse, reporting timeframes and appropriate methods of reporting. During an interview with CNA J who worked the 6 p.m. to 6 a.m. shift on 9/13/25 at 4:52 p.m. she was able to articulate who the abuse coordinator was, the types of abuse, reporting timeframes and appropriate methods of reporting. During an interview with CNA K who worked the 6 p.m.-6 a.m. shift on 9/13/25 at 4:54 p.m. she was able to articulate who the abuse coordinator was, the types of abuse, reporting timeframes and appropriate methods of reporting. During an interview with CNA L who worked the 2-10 shift on 9/13/25 at 5:00 p.m. she was able to articulate who the abuse coordinator was, the types of abuse, reporting timeframes and appropriate methods of reporting. During an interview with CNA B who worked the 6 p.m.-6 a.m. shift on 9/13/25 at 5:40 p.m. she was able to articulate who the abuse coordinator was, the types of abuse, reporting timeframes and appropriate methods of reporting. During an interview with CNA C who worked the 6 p.m.-6 a.m. shift on 9/13/25 at 5:52 p.m. she was able to articulate who the abuse coordinator was, the types of abuse, reporting timeframes and appropriate methods of reporting. During an interview with LVN G who worked the 6 p.m. to 6 a.m. shift on 9/13/25 at 6:50 p.m. she was able to articulate who the abuse coordinator was, the types of abuse, reporting timeframes and appropriate methods of reporting. During an interview with RN H who worked the 8 a.m.-5 p.m. shift on 9/13/25 at 6:53 p.m. she was able to articulate who the abuse coordinator was, the types of abuse, reporting timeframes and appropriate methods of reporting. During an interview with DON who worked the 8 a.m.-5 p.m. shift on 9/13/25 at 6:58 p.m. she was able to articulate who the abuse coordinator was, the types of abuse, reporting timeframes and appropriate methods of reporting. During an interview with Resident # 2 on 9/13/25 at 6:15 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 3 on 9/13/25 at 6:20 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 4 on 9/13/25 at 6:23 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 5 on 9/13/25 at 6:27 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 6 on 9/13/25 at 6:33 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 7 on 9/13/25 at 6:37 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 8 on 9/13/25 at 6:42 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 1 on 9/13/25 at 6:46 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 9 on 9/13/25 at 7:52 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 10 on 9/13/25 at 7:55 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 11 on 9/13/25 at 7:57 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 12 on 9/13/25 at 8:00 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 13 on 9/13/25 at 8:05 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 14 on 9/13/25 at 8:08 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 15 on 9/13/25 at 8:12 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 16 on 9/13/25 at 8:15 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 17 on 9/13/25 at 8:18 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 18 on 9/13/25 at 8:20 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 19 on 9/13/25 at 8:23 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 20 on 9/13/25 at 8:25 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. Record review of facility's in-service documentation reviewed on 9/11/25 for Reporting Abuse and Neglect dated 9/10/2025 indicated that 13 employees had been in-serviced. CNA B and CNA C were not listed on this document. Record review of safety surveys conducted on 9/13/25 indicated that they had conducted a safety survey with all residents at the facility and all who were able to participate were able to identify who to report abuse to and how to report and all indicated that they had not observed any abuse or neglect. Record review on 9/13/25 at 8:10 p.m. of in-service documentation showed that all but six staff had been in-serviced on abuse and neglect and all staff had been notified that they would be taken off the schedule until they had been in-serviced on abuse and neglect and reporting requirements. Record review of in-service documentation dated 9/12/2025 indicated that CNA B and CNA C were in-serviced on abuse, neglect and reporting requirements. This in-service shows that it included specific reporting requirements that abuse must be reported immediately to the abuse coordinator and that it must be reported by voice phone call, not text message. Observation conducted on 9/13/25 at 8:15 p.m. showed a notice over all facility time clocks notifying staff not to clock in until they had completed required in-services on abuse and neglect. Observation conducted on 9/13/25 at 8:00 p.m. of abuse coordinator signs located on each hallway, at each nurses station and in the dining room. It included the name of the Administrator as well as the number to the abuse hotline. Record review of Resident #1's skin assessment dated [DATE] at 11:44 a.m. showed no signs of injury. Notification to Administrator on 9/13/2025 at 8:30 p.m. that the IJ had been lifted. An IJ was identified on 9/12/25. The IJ template was provided to the facility on 9/12/25 at 3:34 p.m. While the IJ was removed on 9/13/25 the facility remained out of compliance at a scope of Isolated and severity level of no actual harm with potential for more than minimal harm that is not IJ due to ongoing need for in-services on abuse and neglect, abuse coordinator and notification of abuse process.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to in response to allegations of abuse, neglect, exploitation, or mistreatment, prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress for 1 of 6 (Resident #1) residents reviewed for abuse. LVN A physically abused Resident #1 on 9/9/25 and the facility failed to protect residents from further potential abuse when LVN A returned to the facility on the night shift of 9/10/2025 after being suspended at 7:50 a.m. on 9/10/25. An IJ was identified on 9/12/25. The IJ template was provided to the facility on 9/12/25 at 3:34 pm. While the IJ was removed on 9/13/25 the facility remained out of compliance at a scope of Isolated and severity level of no actual harm with potential for more than minimal harm that is not IJ due to ongoing need for in-services on abuse and neglect, abuse coordinator and notification of abuse process. This failure could place residents at risk for physical and verbal abuse, psychosocial harm, and decreased quality of life.Findings included: Record review of the face sheet dated 9/11/2025 indicated that Resident #1 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including severe intellectual disability which was below average intelligence, anxiety disorder which was intense, excessive, and persistent worry and fear about everyday situations, schizoaffective disorder which was a lifelong pattern of social withdrawal and limited emotional expression, ADHD which was a chronic condition including attention difficulty, hyperactivity and impulsiveness, cerebral palsy which was a congenital disorder of movement, muscle tone or posture, and cognitive communication deficit which was a group of disorders that affect a person's ability to communicate effectively due to underlying cognitive impairments. Record review of the MDS dated [DATE] indicated that Resident #1 had a BIMS score of 03 which was indicative of severe cognitive impairment. Record review of the care plan dated 9/7/25 which showed that Resident#1 was last admitted to the facility on [DATE] and was receiving services at the facility. During an interview on 9/11/25 at 4:11 p.m. CNA B said that on 9/10/25 she worked with CNA C on the evening shift. She said that they were outside smoking around 9:40 p.m. when LVN A approached them and asked them about the incident the night before between LVN A and Resident #1 and that he did not remember but was at the facility to document an incident report about it. She said that she did not know that LVN A was under investigation and that if she had she would have reported it. She said that the risk of not knowing that he was under investigation was that he could have come to the facility for retaliation which placed the staff and residents at risk of abuse. She said that LVN A got onto the computer and went onto the secured unit but she did not see him interact with any residents. CNA A said that the incident the night before that she was referring to was LVN A grabbing Resident # 1 by the shirt and making him choke. Record review of the voice recording provided by CNA B on 9/11/25 at 4:30 p.m. that was recorded on 9/10/25 sometime after 6:00 p.m. and included the voice of LVA A, CNA B, and CNA C as identified by CNA B. A summary of the recording was that CNA B and CNA C acknowledged that they observed LVN A grab Resident #1 by the shirt and around his neck on 9/9/25. LVN A admitted that he had returned to the facility to document the incident from last night with Resident #1. LVN A said that he got allegations for beating up on [unintelligible]. During an interview on 9/11/25 at 3:18 p.m. Resident #1 said that LVN A had choked him and that he was scared of LVN A. Resident #1 cried and left the interview. During an interview on 9/11/25 at 3:57 p.m. LVN A said that on 9/9/2025 he worked at the facility. He went into Resident #1's bedroom when he was fighting with his roommate. LVN A said that he was trying to calm Resident #1 down by rubbing his back and trying to talk to him. LVN A said that Resident #1 was on the floor and he was assisting him back to his chair and his hand got caught in Resident #1's t-shirt and when he pulled his hand out of Resident #1's shirt and his hand went up toward Resident #1's neck . LVN A said that Resident #1 was one of his favorite residents and that he would never abuse him. He said that residents have called him the N word before and he was not one so it does not bother him. LVN A said that he did not choke Resident #1. LVN A said that there were two CNAs in the room with him when his hand got caught in Resident #1's t-shirt. LVN A confirmed that the CNA's in the room were CNA B and CNA C. LVN A said that he was informed by DON that he was suspended pending an investigation on the morning of 9/10/25 and was told that he could likely return to work on Saturday if everything looked good. During an interview on 9/12/25 at 1:18 p.m. CNA C said that she worked on the night shift on 9/10/2025 alongside CNA B. She said around 9:30 p.m. LVN A came up to her and CNA B and started talking to them about the incident that had occurred the night before with LVN A grabbing Resident #1 by the shirt and throat and making him make a choking sound. She said that he told them that he comes back to work on Saturday 9/13/25, but he had come up to the facility on the night of 9/10/25 to document an incident report about the night before. She said that she did not know he was suspended and if she had she would have reported it and not allowed him to have access to the residents. She said that she saw LVN A get on the computer but did not see him go onto the secured unit or interact with any residents. She said the risk of not knowing who was suspended was that the suspended person could come to the facility to do harm to staff or residents. Record review of facility Incident Audit Report indicated that LVN A entered an incident audit report into PCC on 9/10/25 at 10:53 p.m. PCC was the electronic medical record used by the facility. The note indicated that LVN A entered the bedroom of Resident #1 and Resident #1 was on the floor trying to fight with his roommate. LVN A documented that he directed the CNA to put Resident #1 in his wheelchair and get him out of the room. LVN A documented that Resident #1 was agitated and that LVN A was rubbing his back to calm him down and then was rubbing his chest as a calming procedure. LVN A documented that his hand slipped inside the shirt of Resident #1 as he was bending down to fight with his roommate and LVN A stated that he removed his hand immediately and asked the CNAs to removed Resident #1 from the room. LVN A noted that Resident #1 was assessed for injury and none were found. During an interview on 9/11/25 at 11:55 a.m. the Administrator said she expected suspended staff to not enter the facility during their suspension and there was a policy entitled Disciplinary Action and Suspension Pending Investigation Policy that told them. She said that they did not tell other staff when a staff member was suspended as they did not want to spread their business and that she was not aware of any policy that directed the Administrator or DON to notify anyone of a suspended staff member. She said she assumed that a suspended staff member's common sense would tell them that they should not be at the facility during suspension in addition to that policy. She said that she understands the need for a process for others to know about the suspension as a suspended person coming to the facility places everyone at the facility at risk of abuse or assault. She said that she was not aware that LVN A was at the facility after he was notified on 9/10/25 at 7:50 a.m. that he was suspended. She said that they started the investigation upon being notified of the incident by interviewing CNA B and CNA C, assessing Resident # 1 and in-servicing staff on abuse and neglect. Record review of facility's Disciplinary Action and Suspension Pending Investigation Policy undated indicated, .In cases involving serious allegations, employees may be placed on suspension pending investigation and are not permitted to return to the facility until the investigation was concluded.the employee was not permitted on facility premises or to engage with residents or staff during the suspension . Record review of the document titled {Facility} New Hire/Status Change Form which indicated that LVN A was terminated on 9/11/25 for abuse. This document did not show a suspension date or time. Record review of facility's Employee Discipline Policies and Professional and Personal Responsibility policy indicated that the suspended employee was not to enter premises until suspension was complete or until results are determined from suspension. Record review of facility's Abuse-Reportable Events policy last revised May 2017 indicated, .it is the policy of this home to prohibit resident abuse or neglect in any form . The Administrator was notified on 9/12/25 at 3:30 p.m. that an Immediate Jeopardy situation was identified due to the above failure. The Administrator was provided the Immediate Jeopardy template on 9/12/25 at 3:34 p.m. The facility's plan of removal was accepted on 9/13/2025 at 7:46 p.m. and included: Interventions: LVN A suspended on 9/10/25 at 7:50 a.m. Resident # 1 assessed for injury on 9/10/25 at 11:44 a.m. Roommate of Resident #1 assessed on 9/10/25. Residents on secured unit were not showing signs of distress or pain on 9/10/25. LVN A terminated on 9/12/25 at 2:00 p.m. In-services related to abuse/neglect started 9/10/2025 at 8:00am. Updated policy on suspension pending investigation with Be informed when an employee is suspended-suspended employee is not allowed to be in facility and all staff must ask the suspended staff to leave and call the administrator/DON if they enter the facility. Monitoring: Policy on suspension pending investigation updated. All staff will be informed each time an employee was suspended and will be responsible for asking staff to leave if they come to the premises and contact Administrator and DON. Any employee suspected of abuse will be removed from the facility immediately. Abuse coordinator signs are throughout the facility and there will continue to be ongoing training to ensure the staff was knowledgeable of who to report to and what to report. Staff was in serviced by Administrator, DON, Dietary supervisor, and housekeeping supervisor. All staff in facility must be in serviced. As of 9/13/2025 at 11:54am 66 employees in all departments have signed in services. There are twelve employees that need to be still in-services. All employees must be in-serviced by 9/13/2025 by 3:30pm. Any staff that has not been in-serviced was not to clock into the facility until they have been in serviced by DON or administrator. Anyone who fails to complete in-service will be removed from schedule and not allowed to work until they have been in-serviced. On 9/13/25 at 8:30 p.m. the investigator confirmed the plan of removal had been implemented sufficiently to remove the IJ by the following: During an interview with LVN F who worked the 2-10 shift on 9/13/25 at 4:38 p.m. she was able to articulate who the abuse coordinator was, the types of abuse, reporting timeframes and appropriate methods of reporting. During an interview with LVN D who worked the 2-10 shift on 9/13/25 at 4:40 p.m. she was able to articulate who the abuse coordinator was, the types of abuse, reporting timeframes and appropriate methods of reporting. During an interview with LVN E who worked the 2-10 shift on 9/13/25 at 4:54 p.m. she was able to articulate who the abuse coordinator was, the types of abuse, reporting timeframes and appropriate methods of reporting. During an interview with CNA J who worked the 6 p.m. to 6 a.m. shift on 9/13/25 at 4:52 p.m. she was able to articulate who the abuse coordinator was, the types of abuse, reporting timeframes and appropriate methods of reporting. During an interview with CNA K who worked the 6 p.m.-6 a.m. shift on 9/13/25 at 4:54 p.m. she was able to articulate who the abuse coordinator was, the types of abuse, reporting timeframes and appropriate methods of reporting. During an interview with CNA L who worked the 2-10 shift on 9/13/25 at 5:00 p.m. she was able to articulate who the abuse coordinator was, the types of abuse, reporting timeframes and appropriate methods of reporting. During an interview with CNA B who worked the 6 p.m.-6 a.m. shift on 9/13/25 at 5:40 p.m. she was able to articulate who the abuse coordinator was, the types of abuse, reporting timeframes and appropriate methods of reporting. During an interview with CNA C who worked the 6 p.m.-6 a.m. shift on 9/13/25 at 5:52 p.m. she was able to articulate who the abuse coordinator was, the types of abuse, reporting timeframes and appropriate methods of reporting. During an interview with LVN G who worked the 6 p.m. to 6 a.m. shift on 9/13/25 at 6:50 p.m. she was able to articulate who the abuse coordinator was, the types of abuse, reporting timeframes and appropriate methods of reporting. During an interview with RN H who worked the 8 a.m.-5 p.m. shift on 9/13/25 at 6:53 p.m. she was able to articulate who the abuse coordinator was, the types of abuse, reporting timeframes and appropriate methods of reporting. During an interview with DON who worked the 8 a.m.-5 p.m. shift on 9/13/25 at 6:58 p.m. she was able to articulate who the abuse coordinator was, the types of abuse, reporting timeframes and appropriate methods of reporting. During an interview with Resident # 2 on 9/13/25 at 6:15 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 3 on 9/13/25 at 6:20 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 4 on 9/13/25 at 6:23 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 5 on 9/13/25 at 6:27 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 6 on 9/13/25 at 6:33 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 7 on 9/13/25 at 6:37 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 8 on 9/13/25 at 6:42 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 1 on 9/13/25 at 6:46 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 9 on 9/13/25 at 7:52 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 10 on 9/13/25 at 7:55 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 11 on 9/13/25 at 7:57 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 12 on 9/13/25 at 8:00 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 13 on 9/13/25 at 8:05 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 14 on 9/13/25 at 8:08 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 15 on 9/13/25 at 8:12 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 16 on 9/13/25 at 8:15 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 17 on 9/13/25 at 8:18 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 18 on 9/13/25 at 8:20 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 19 on 9/13/25 at 8:23 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 20 on 9/13/25 at 8:25 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. Record review of facility's in-service documentation reviewed on 9/11/25 for Reporting Abuse and Neglect dated 9/10/2025 indicated that 13 employees had been in-serviced. CNA B and CNA C were not listed on this document. Record review on 9/13/25 at 8:10 p.m. of in-service documentation showed that all but six staff had been in-serviced on the changes to the suspension pending investigation policy and all staff had been notified that they would be taken off the schedule until they had been in-serviced. Record review of in-service documentation dated 9/12/2025 indicated that CNA B and CNA C were in-serviced on abuse, neglect and reporting requirements. This in-service shows that it included specific reporting requirements that abuse must be reported immediately to the abuse coordinator and that it must be reported by voice phone call, not text message. Record review on 9/13/25 at 8:12 p.m. of the facility suspension pending investigation policy update. There was no date on the policy but the change from the old policy to the new policy was the addition that was as follows: All staff must be informed when an employee is suspended- Suspended employee is not to be in the facility and staff must ask them to leave and call the administrator/DON if they enter the facility. Observation conducted on 9/13/25 at 8:00 p.m. of abuse coordinator signs located on each hallway, at each nurses station and in the dining room. It included the name of the Administrator as well as the number to the abuse hotline. Observation conducted on 9/13/25 at 8:15 p.m. showed a notice over all facility time clocks notifying staff not to clock in until they had completed the required in-services on recent policy changes. Record review of Resident #1's skin assessment dated [DATE] at 11:44 a.m. showed no signs of injury. Notification to Administrator on 9/13/2025 at 8:30 p.m. that the IJ had been lifted. An IJ was identified on 9/12/25 The IJ template was provided to the facility on 9/12/25 at 3:34 p.m. While the IJ was removed on 9/13/25 the facility remained out of compliance at a scope of Isolated and severity level of no actual harm with potential for more than minimal harm that is not IJ due to ongoing need for in-services on abuse and neglect, abuse coordinator and notification of abuse process.

**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 for 2 of 3 residents (Resident #1 and Resident #4) reviewed for accidents. The facility failed to keep Resident #1 in a safe environment to prevent an elopement on 4/26/2024 when he climbed out of a window in the secured unit. The facility failed to keep Resident #2 in a safe environment to prevent an elopement on 8/23/2024 when he walked out an unlocked door in the secured unit. An Immediate Jeopardy (IJ) situation was identified on 12/10/2024 at 1:32 PM. While the IJ was removed on 12/12/2024 at 1:27 PM, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of their corrective systems. These failures could place residents at risk for serious injury and accidents. Findings included: 1. Record review of an admission Record dated 5/08/2024 for Resident #1 indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnoses of Major Depressive Disorder and mild cognitive impairment. Record review of an admission Elopement/Wandering Evaluation dated 4/10/2024 for Resident #1 indicated he admitted to the facility on [DATE]. He had diagnoses of dementia/cognitive impairment, ambulated without assistance, could communicate, and had a history of wandering in the last month. He was indicated as a high risk for elopement with a score of 11. Score ranges: low risk 0-8, at risk 9-10 and high risk 11 or above . Record review of a Quarterly MDS assessment dated [DATE] for Resident #1 indicated he had moderate impairment in thinking with a BIMS score of 8. Resident had history of rejecting care, and dangerous wandering that intruded on the privacy and activities of others. Record review of an Elopement/Wandering Evaluation dated 4/19/2024 for Resident #1 indicated he admitted to the facility on [DATE]. He had diagnoses of dementia/cognitive impairment, ambulated without assistance, could communicate, and had a history of wandering in the last month. He was indicated as a high risk for elopement with a score of 12. Score ranges: low risk 0-8, at risk 9-10 and high risk 11 or above . Record review of a care plan dated 4/25/2024 for Resident #1 indicated he had secure unit placement and was an elopement risk/wanderer related to dementia. History of wandering, elopement attempts, previous elopement on 4/19/24. Interventions included identify and document wandering behavior and attempted diversional interventions. Record review of a witness statement dated 5/03/2024 by LVN F indicated she observed Resident #1 sitting on the couch in the TV room talking to CNA H approximately 10 minutes before the incident. LVN F reported Resident #1 had not exhibited any elopement attempts this shift. LVN F reported when Resident #1 was returned to the unit he was alert and oriented to person and place and told her he pulled a nail out of the wall and used it to open the window and crawled out to go to the store and buy smokeless tobacco. LVN F reported there were no injuries and resident was placed on 1-1 staff observation for safety . Record review of a witness statement dated 5/03/2024 by CNA H indicated he was sitting on the sofa talking to Resident #1 when Resident #1 said he wanted to go to the store to buy Skoal and diet Mt. Dew. CNA H reported he told Resident #1 the store was closed right now, but someone would get it for him when it opened. CNA H reported Resident #1 went into his room and closed the door, which was Resident #1's usual behavior. Record review of a witness statement in provider investigation report dated 5/03/2024 by CNA G indicated she was returning from break and observed Resident #1 walking through the parking lot of the facility. CNA G asked Resident #1 if he was okay and he said he was trying to go to the store for snuff. CNA G redirected Resident #1 back into the facility and reported the incident to the charge nurse. Record review of a Q 15-minute observation form for Resident #1 indicated Q 15-minute monitoring started at the facility on 4/26/24 at 5:15 PM and ended on 4/27/2024 at 1:15 PM when resident was transferred out of the facility. Record review of an elopement/wandering evaluation post incident on 5/08/2024 indicated he had diagnoses dementia/cognitive impairment, ambulated without assistance, could communicate, and had a history of wandering in the last month, and had eloped twice in one week. He was indicated as a high risk for elopement with a score of 18. Score ranges: low risk 0-8, at risk 9-10 and high risk 11 or above. 2. Record review of a facility face sheet dated 8/22/24 for Resident #2 indicated he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including: Major Depressive Disorder. Record review of a Quarterly MDS assessment dated [DATE] for Resident #2 indicated he had a BIMS score of 12, which indicated he had moderate cognitive impairment. He had no wandering behaviors during assessment period, had delusions (misconceptions or beliefs that are firmly held, contrary to reality), ambulated without assistance, and was dependent with most ADLs. Record review of a comprehensive care plan dated 9/27/24 for Resident #2 indicated he was an elopement risk/wanderer related to history of attempts to leave facility unattended and he wandered aimlessly. Focus included secure unit placement on 8/29/2024. Record review of a facility form titled Elopement/Wandering Evaluation dated 8/22/24 for Resident #2 indicated he was an elopement risk/wanderer related to history of attempts to leave facility unattended, he wandered aimlessly, and has medical diagnose of dementia/cognitive impairment. Record review of Provider Investigation Report dated 8/30/2024 indicated Resident #2 opened secure unit door and walked outside when door failed to lock. During an observation and interview on 12/09/24 at 9:05 a.m., Resident #2 was observed lying in his bed in his room on secured unit. He said he told the nurse he was going to the red light and then walked out of the secured unit doors. Resident #2 said he wanted to go to a local city . He said facility staff found him at a building next door (approximately 300ft away and next to a busy road) and gave him a ride back to the facility. During an interview on 12/9/24 at 9:10 AM with CNA K, she said she works day shift and usually works on the secured unit. She said she thinks the Maintenance Man checks door locks and alarms, but she does not know how often. She said she checks all doors on secured unit when she was rounding. During an interview on 12/9/24 at 9:15 AM with LVN A, she said she works day shift on hall 900, which was the secured unit. She said she has not had an elopement on her shift. She said Resident #1 was transferred to another facility and Resident #2 will pack up his belongings and ask to leave, but he was easy to redirect. She said all staff were expected to verify door locks and alarms were functioning each shift. She said there was no documentation to record security checks. She said the Maintenance Man also was responsible for checking door locks and alarms, but she does not know the schedule. Attempted telephone interviews with LVN D, LVN F, CNA H, left voice mail messages requesting return call. During a telephone interview on 12/9/24 at 12:10 PM, CNA G said the night Resident #1 eloped, she was coming back from break and saw Resident #1 walking through the facility parking lot. She said he told her he was going to buy snuff and asked her for a ride. She said he got into her car, and she drove him back to the facility entrance where she could see staff members outside. An observation on 12/09/2024 at 1:00 PM of the sunroom, which leads to the secured unit smoking exit door, revealed 1 of 5 windows checked did not have safety locks and opened fully. The volume of the alarm on the exit door was low, alarm was activated and monitored for approximately 10 minutes with no staff response. The exit door in sunroom exited into a fenced smoking area, which had a wooden gate that was unlocked and standing open. During an interview on 12/9/24 at 1:48 PM, the Maintenance Man said he checked all doors, windows, and alarms weekly. He said he had not been told of any problems with the doors or alarms on secured unit. He said staff turned off the alarm on the exit door to the secured smoking area, and he had to reset it with the key. He said he had trained all staff on proper securement of doors and alarms, and he had installed safety locks to keep the windows on secured unit from opening fully to prevent any resident from climbing out. He said he does not keep any maintenance logs. During an interview on 12/9/24 at 2:00 PM, CNA E said she works day shift and usually works on the secured unit. She said all staff were responsible for checking doors and alarms. She said alarms were loud enough for staff can hear them on the unit. During a telephone interview on 12/9/24 at 2:30 PM, LVN F said she was not working the night Resident #1 eloped, but it was reported to her he was able to disable the safety lock on his bedroom window and climb out. She said following the incident he was placed on 1 to 1 observation and staff tried to keep his room door open as much as he would allow them. She said the Maintenance Man installed safety locks on all windows on the secured unit following the incident. She said all staff were responsible for checking doors and alarms to make sure the unit is secured. She said risks for a resident who eloped were injuries or getting lost. An observation on 12/10/2024 at 8:35 AM of secured unit smoking area revealed the wooden gate was unlocked and standing open. An observation on 12/10/2024 at 8:50 AM of secured unit revealed a window in the dining room did not have a safety lock and opened fully. During an interview on 12/10/24 at 9:30 AM, LVN B said she works day shift and always works the secured unit. She said the unit was staffed with one dedicated nurse and two dedicated CNAs. She said nurses were responsible for checking door locks and alarms at the start of every shift and then every few hours during shift. She said CNAs on unit also assist with checking doors and alarms. She said maintenance man was responsible for ensuing all secured unit door locks and alarms were functioning properly, but she does not know how often he checks them. She said she has told the maintenance man the wooden gate in the secured smoking area does not stay locked and he told her the wind was probably blowing it open. During an interview on 12/10/24 at 12:15 AM, the DON said it was the Maintenance Man's responsibility to ensure all locks and alarms are in working order by performing weekly maintenance. She said she doesn't know if he keeps any records of work performed. She said nurses working on the secured unit were also responsible for checking door locks and alarms every shift. She said no one should be using the wooden gate in the secured smoking area except for Maintenance Man, but other staff probably uses it as well. She said it was the expectation of staff to immediately notify DON and Administrator if a resident was missing. She said staff should search the unit, perform a headcount of residents, and expand the search outside if resident isn't found. She said risks for a resident who elope from the facility were hyperthermia, heat exhaustion, or injuries. Attempted telephone interviews with LVN D and Administrator, left voice mail messages requesting return call. During a telephone interview on 12/10/24 at 4:00PM, CNA H said he was working the night of both elopements involving Resident #1 and Resident #2. He said on the evening Resident #1 eloped he had been sitting in the dining room watching TV. He said Resident #1 asked staff to get him a mountain dew and some skoal. He said LVN D explained they wouldn't be able to get him a mountain dew or skoal tonight. He said Resident #1 became agitated and went to his room and shut the door. He said he was not sure what time Resident #1 eloped, but he was seen in the parking a few minutes later by another staff member returning from break and escorted back inside facility. He said on the evening Resident #2 eloped he was rounding on residents and Resident #2 was not in his room. He said he notified LVN D, and searched hall 900 and adjoining hall 800, but Resident #2 was not located. He said about 20 minutes later resident was located outside of the facility and escorted back to the secured unit . Record review of Policy and Procedure, Subject Elopement, dated 5/2027 indicated Administration / Supervisory staff would .Determine what measures can be taken to prevent it from happening again. This was determined to be an Immediate Jeopardy (IJ) on 12/10/2024 at 1:32 PM. The facility's Administrator and DON were notified. The DON was provided the IJ template on 12/10/2024 at 1:32 PM. The following Plan of Removal (POR) submitted by the facility was accepted on 12/11/2024 at 1:15 PM. [facility] Plan of Removal 12/10/2024 Elopement Immediate actions: 1. Review of facility records by the DON identified 16 residents on the unit at risk. 12/10/2024 at 2:45pm. 2. Unit staff moved onto floor and out of nurses station to provide safety and hall monitoring while correcting findings completed at 2:45PM 12/10/24. 3. Maintenance conducted a tour of secure unit and identified the following at 2:45 PM o Secured doors on 800,900 Halls, dining room and entrance doors into secured unit.(Contractor) contacted and assessed the issues on 12/10 at 3:07 will return 12/11 to repair. Hall monitoring by designated staff in place until repairs are made. Every shift until repairs are made and documented on safety monitoring log as of 12/11. o Replaced batteries of door alarms and checked sound/volume to ensure they are heard on the unit by the staff. o Checked and provided safety locking for any identified windows without safety locks in place. One window in the sun room was not safety locked corrected 12/10 at 3:00 PM o Secured gate and added to daily maintenance round sheet to check for security. Summit security contacted to test mag lock on secured unit gate and 900 exit doors for safety purposes. 12/10/2024 will be date of visit, arrived at 3:07pm. Weekend RN manager or manager on duty will monitor and document on weekend. Weekend managers and managers on duty inserviced 12/11/2024 at 2:00 PM in-service started for all staff regarding the following: o Elopement risk and policies on preventing elopement. o Maintaining a safe and secure facility to prevent elopement, monitoring of doors, door alarms and windows for safety. 4. Maintenance man inserviced 1:1 on safety monitoring and checking batteries in alarms, mag locks on secure areas and other protocol to prevent elopement. lnservice to be completed by 12/11/2024 at 5 PM. By DON, ADON and designated administrative / manager staff. In person and via phone for all remaining staff. All of the findings will be added to QA meeting for further review and recommendations. On 12/12/2024, the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy by: Monitoring: During an observation on 12/11/24 at 2:40 PM of hall 800, 900, and secured smoking area exit revealed doors, windows, and wooden gate locked. All alarms were audible, and a staff member was posted at secured smoking area exit with. Staff member was signing a check log every 15 minutes. All other CNAs were on the floor interacting with and monitoring residents. In interviews from 12/11/24 through 12/12/24 CNA Q, Med Aide T, RN P, LVN B, CNA S, Housekeeper Supervisor, Housekeeper U, LVN V, CNA W, CNA X, CNA Y, CNA Z, ADON, CNA R, LVN BB, Activity Director, MDS nurse, LVN AA, RN CC, LVN F. All staff were able to verbalize duties related to checking doors, windows, and alarm systems as well as duties in the event of a missing resident or elopement. All staff able to demonstrate or verbalize process to ensure alarms were armed. Attempted multiple telephone interviews for additional staff members RN DD, LVN D, LVN EE. Left messages requesting return calls on voicemails. No calls were returned. In an interview on 12/11/24 at 1:48 PM, the Maintenance Man said he had received training on checking alarms, windows, and doors for security. He said he checked, daily, all windows and doors to verify they were secured, and no window opens more than 6 inches with safety locks in place. He said he checks alarms daily to verify they were loud enough to be audible for staff. Record review of an in-service training report dated 12/10/24 indicated the Maintenance Man had a 1:1 training on his roll related to all alarms, windows, and doors to be checked daily, documented, and who to report findings to. Record review of an in-service training report dated 12/11/24 training was provided to managers on duty/RN to check secured unit doors, alarms, and gates on Saturdays and Sundays in the secured unit. There were 7 staff trained, which included Activity Director, Housekeeper FF, RN P, RN GG, RN CC, RN DD, Housekeeping Supervisor. Record reviews on 12/12/24 of Elopement Risk Assessments dated 12/11/24 through 12/12/24 indicated 16 of 16 residents identified as high risk on the secured unit received an updated Elopement Risk Assessment. Record review of Secured Unit Maintenance work order dated 12/12/24 signed by Maintenance Man indicated an independent contractor repaired all door maglocks and Maintenance Man installed two window safety locks, replaced 800 hall magnet doorstop, verified all other door stops were in correct position and batteries were working, and trained all employees on both maglocks and door stop alarms. Record review of a local independent contractor invoice for work completed at the facility indicated .(local contractor performed repairs at (facility address) the door system. All doors were functioning when we left 12/11/2024. Record review of Door Stop Checklist dated 12/11/24 and 12/12/24 indicated all doorstops were checked and working properly. Record review of ALARM FUNCTION checklist for December 2024 indicated all alarms were checked, necessary repairs made, and were working properly on 12/11/24 and 12/12/24. Record reviews of the following documents: *Inservice titled Return demonstration for alarms and door magnets on secured unit dated 12/11/2024. *Inservice titled Elopement/Safety dated 12/10/2024. *Inservice titled MOD-RN managers are required to check secured unit doors, alarms and gates for proper functioning for all secured unit residents safety on Saturdays and Sundays dated 11/11/2024. *Checklist template for DOOR ALARM/FUNCTION CHECHKS (sic) *Checklist template for ALARM FUNCTION *Checklist template WINDOW CHECKS On 12/12/24 at 1:32 pm, the DON was informed the IJ was removed. However, the facility remained out of compliance at a severity no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope identified as pattern. The facility was continuing to monitor all secured doors, windows, and exit alarms daily, in addition to implementing documentation to record compliance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive care plan, and the residents' goals and preferences for 1 of 1 resident (Resident #1) reviewed for respiratory care. The facility failed to ensure LVN C did not reuse a single use suction catheter with Resident #1 on 10/31/24. The facility failed to ensure LVN C employed sterile technique during suctioning and tracheostomy care with Resident #1 on 10/31/24. The facility failed to ensure LVN C did not use tap water when performing tracheal suctioning for Resident #1 on 10/31/24. The facility failed to ensure LVN C used intermittent suctioning during care on 10/31/24. The facility failed to train nursing staff on proper tracheostomy care and tracheal suctioning procedures. An Immediate Jeopardy (IJ) was identified on 10/31/2024. While the IJ was removed on 11/2/2024 at 3:02 p.m., the facility remained out of compliance at a scope of no actual harm with potential for more than minimal harm that is not immediate jeopardy and scope of isolated due to the facility's need to monitor and evaluate the effectiveness of their corrective systems. These failures could place residents requiring tracheostomy care and tracheal suctioning at risk for respiratory complications, infections, and/or death. Findings included: Record review of a facility face sheet dated 10/26/24 for Resident #1 indicated that he was a [AGE] year-old male originally admitted to the facility on [DATE] and subsequently readmitted on [DATE] with diagnoses that included: quadriplegia (a symptom of paralysis that affects all limbs and body from the neck down. Record review of a comprehensive MDS assessment dated [DATE] for Resident #1 indicated that interview for BIMS score should not be conducted due to resident being rarely/never understood. Section C (cognitive patterns) indicated that he was independent with cognitive skills for daily decision making. He was dependent with all ADLs. He had a tracheostomy, an indwelling urinary catheter and an ostomy. Record review of a comprehensive care plan dated 10/3/24 for Resident #1 indicated that he had a tracheostomy and had the following interventions: .will have sterile suctioning procedure as needed . and .will have sterile tracheostomy care: cleanse around trach site and replace drain sponge. Change trach ties as needed . Record review of a physician's order summary report dated 11/2/24 for Resident #1 indicated he had the following physician's orders: .Tracheostomy care one time a day . and .may suction prn for secretions . During an interview and observation on 10/28/24 at 2:30 pm Resident #1 was observed at [hospital name] lying in his hospital bed. Resident #1 said the facility changed his ties and did trach care once a week. He said he felt like the facility was unequipped to handle his trach care. During an interview and observation on 10/31/24 at 7:50 am Resident #1 was observed in bed sitting up in bed. He said the facility did not have the staff to properly take care of him and they did not clean his trach often as they should. During an observation on 10/31/24 at 7:37 am LVN C was in Resident #1's room to provide suctioning to his trach per his request. She went into the room and washed her hands, put on a gown and nonsterile gloves in the hallway and entered the room with a plastic cup and a sterile water container. She then put on another pair of nonsterile gloves on top of the pair of gloves that were on her hands for a total of 2 gloves on each hand. She then placed the cup and sterile water on the nightstand beside the bed. She turned on the overbed light and then removed a pair of gloves and placed them in the trash. She placed another pair of nonsterile gloves on top of the gloves that were on her hands. She pulled the linens down on the resident and removed the cap that was on the trach. She removed a pair of gloves and placed them in the trash. She put on another pair of nonsterile gloves on top of the pair of gloves that were already present on her hands for a total of 2 gloves on each hand. She turned the suction machine on and removed the suction tubing from the plastic package that was already opened on one end and inserted the tubing down into the trach and suctioned. She placed the tubing in the sterile water to clean the tubing of any secretions and placed it back inside the plastic packaging that it was in previously. She placed the cap on the trach and removed her gloves and gown and placed them in the biohazard box that was in the room. She washed her hands in the bathroom and exited the room. During an observation on 10/31/24 at 9:25 am LVN C was observed performing suctioning and tracheostomy care on Resident #1. She did not use sterile technique during care. She was observed wiping down overbed table, she then washed her hands, donned gown, mask, and non-sterile gloves. She was observed to apply a second pair of non-sterile gloves over the first pair. She then opened a packet containing a sterile drape/towel and laid it on the cleaned table. She then opened trach care kit and with non-sterile gloved hands, removed each item from kit and placed it on the sterile field/drape that had been laid on an overbed table. She then opened the sterile water container and poured it into the open tray that was on sterile field with lid folded underneath it. She then opened the peroxide, also pouring it into the tray. She was observed touching all the ends of the cotton swabs and twirling them around in her fingers before placing them back down onto the sterile field. She then opened another trach kit and removed supplies from it with non-sterile gloved hand, also placing them on the sterile field and placed kit tray with lid folded underneath it on sterile field as well. She then removed top pair of gloves and discarded them. Resident #1 then requested to be suctioned. She walked away from sterile field with the supplies on it and left room. She reenters room with another sterile water container. She then removed her PPE, placed water on table next to sterile field and washed hands in restroom. She returned to hall to don more PPE, re-entered room and with non-sterile gloved hands, applied a second pair of non-sterile gloves. She then poured sterile water into a non-sterile plastic cup, turned on suction machine and removed the purple cap from resident's trach. She laid the cap on his hoodie on his chest. She then took the suction tubing in non-sterile gloved hand and removed suction catheter from previously opened bag and inserted it into resident's tracheostomy opening. After resident began to cough, she put her thumb over the opening in the tubing and suctioned the entire time she slowly withdrew (approximately 10-15 seconds, then suctioned water into the tubing. She repeated this twice. She then placed the suction catheter back into the open packaging and laid it back on table. Resident exhibited facial grimacing during the procedure. She threw away the outer gloves and applied another pair of non-sterile gloves over the first pair. She then removed the inner cannula. Inner cannula was placed in peroxide to soak. She picked up the package of sterile gloves and moved them to the edge of the sterile field. She then unvelcroed the right side of his trach collar and removed the split gauze. She then removed outer gloves and opened sterile gloves. She applied the sterile gloves over her non-sterile gloves. She then took sterile drape and placed it over his chest and just underneath his neck. She poured sterile water into the 2nd trach care plastic tray and then peroxide as well. She then placed gauze in the peroxide, squeezed out excess liquid and cleaned top of trach tube flange. She then repeated to clean the bottom. She then cleaned with cotton swabs to remove thick, yellow substance from underneath trach tube. She was observed cleaning the inside of inner cannula with pipettes and then placed it in sterile water to soak. She then removed the trach collar from the right side and attached the new collar to the right side and then walked around to the other side of resident, held outer tube in place with her left hand and unvelcroed the left side of old collar. She then pulled new collar behind his neck and velcroed in place. She then secured both sides with Velcro and placed a new split gauze. She then was observed patting dry the inner cannula with gauze pad and placed it back inside trach tube. She then removed her sterile gloves and put on a pair of non-sterile gloves over the original pair. She placed another sterile drape over his chest, turned on suction machine, took a non-sterile plastic cup into bathroom and came out with water in cup. She then suctioned him again using same technique as above with same suction catheter and then replaced suction tubing catheter back into packaging and left it lying on table. Resident again exhibited facial grimacing while suctioning. She then replaced purple trach tube cap, removed gloves and PPE, washed hands, and exited room. Date and time on suction catheter tubing observed to be 10/31/24 8:39 am. During an interview on 10/31/24 at 11:50 am LVN C said she had been employed at the facility for approximately 4 months. She said during the trach care provided to Resident #1 this morning, she was not sure what she did wrong, just maybe would have changed her gloves more. She said she did have training before employment but not a check off at the facility on trach care. She said she had never had any competency training with someone where she had to do a return demonstration and was told if the skills were correct or not. She said no skills check off were conducted. She said she thought that she had done all the correct steps. She said she was told the suction tubing was supposed to be changed out today, she thought it was changed out that morning. She said they normally use sterile water or distilled or sometimes they must use the water from the bathroom sink. She said she had not actually received any training. She said when she started, they asked her if she had trach training at another facility. She said she had 3 days of orientation, and she wasn't physically shown how to do the care but had just been told verbally how to do it. She said she was never asked if she felt comfortable with caring for him. She said sometimes she did not feel comfortable with caring for him and did not have the skills nor training to care for him. She said residents could be at risk for harm and not being properly cared for. During a telephone interview on 10/30/24 at 3:31 pm LVN D said she had been employed at the facility since August of 2024 and worked the 6am-2pm shift, rotating halls. She said she had not received any training since being in the facility. She said she had not had any training on trach care and suctioned him at least twice during her shifts and sometimes more. She said she had some trach knowledge from a previous job. During an interview on 10/31/24 at 12:20 pm the DON said trach care training with nursing staff was done on hire and yearly thereafter. She said they had an RT who would come to the facility yearly to conduct trach training with the staff. She said the last time they were at the facility was about a year ago and it was time for them to come back. She said she had trained the new employees in the facility as she had been trained by RT to train other staff on the proper procedures to care for a trach resident. She said she would train the staff unless the RT would be conducting the training. She said the training she provided to the staff was not as extensive as the RT's training. She said once the training was completed, the staff were to complete a return demonstration to show competency. She said there was a risk for improper care to the residents in the facility if the staff had not been trained on how to care for a resident who had a trach. She said trach care was a sterile technique and sterile water should be used when cleaning or suctioning. She said suction should be intermittent and not continuous when pulling the tubing out. She said trach care should be performed once a day and the floor nurses were responsible for providing trach care. During an interview on 10/31/24 at 12:46 pm Medical Director said he was the facility medical director and began his employment with the facility in September 2024. He said nursing was responsible for training the staff on proper tracheostomy care and technique. He said there was a risk for introducing organisms into the trach if the care was not done properly. He said he was not aware of any issues with tracheostomy procedures at the facility. He said he had made rounds at the facility the other day and he was aware that Resident #1 did have a trach. He said staff should follow sterile technique when providing care to a resident who had a trach. He said if care was not done properly with a trach resident, they could be at risk for pneumonia and aspiration. He said it was never acceptable for staff to use tap water when providing trach care. During a telephone interview on 10/31/24 at 4:10 pm LVN G said she had been trained on trach care by LVN C but mainly with LVN D. She said they had shown her how to suction Resident #1, clean the tubing, flush before and after fluid return, and if he asked her to go deeper when she suctioned him to tell him she could not go any farther than resistance when she inserted the tubing. She said she was told to tell him that she could not. She said she did not receive any training from RT or the DON on trach care. During an interview on 11/1/24 at 9:30 am the DON said in the last year they have had a lot of new staff, new management, and no consistent nurse manager to help her. She said LVN C was observed by her initially to do trach care and suctioning and breathing treatments, but she never received the training on trach care. The DON said she filled out the form yesterday for LVN C because she had done observation with her but did not take the test. She said the nurses should be trained yearly. She said they were done yearly. She said residents could be at risk for infections and incorrect care from not having proper training. During an interview on 11/1/24 at 9:57 am the Administrator said she was hired at the facility in August 2024. She said DON was responsible for training staff on respiratory care and said she was going to see about getting an RT to train the staff for more expertise in that area. She said residents could be at risk for trauma, infection if staff do not follow proper procedures. Record review of a competency evaluation for LVN D indicated that on 8/1/24 she was satisfactory with trach care. Record review of a competency evaluation for LVN K indicated that on 5/9/24 she was satisfactory with trach care. Record review of a competency evaluation for LVN C indicated that on 6/5/34 she was satisfactory with trach care. Record review of a competency evaluation for LVN J indicated that on 6/2/22 she was successfully trained on respiratory/trach. Record review of a facility policy titled Tracheostomy Care dated 5/2017 read .It is the policy of this home to provide Tracheostomy care in accordance with current standards of practice to ensure airway patency, maintain skin integrity, and prevent infection . and .Aseptic technique must be used/sterile gloves must be worn: during tracheostomy tube changes (non-disposable and disposable); during cleaning and sterilization of non-disposable tracheostomy tubes; .and .during endotracheal suctioning . The Administrator and DON were notified of an IJ on 10/31/24 at 2:07 pm and was given a copy of the IJ template and a Plan of Removal (POR) was requested. The Plan of Removal was accepted on 10/31/24 at 5:18 pm and included the following: 10/31/2024 Trach care Immediate actions: o Review of facility records identified 1 resident receiving Trach care. This was verified on 11/2/24 - Resident #1 o Resident #1 PCP notified, and care plan reviewed and updated as needed. o Resident #1 will be assessed and monitored q Shift for signs and/or symptoms of infection related to trach care. o One on one training and return demonstration to be conducted with LVN identified. o All nurses will show understanding by return demonstration. o One nurse from each shift will be properly trained by DON with return demonstration and be the sole nurse providing trach care on that shift by 5 pm on 10/31/2024 DON will be responsible for the procedure until one nurse on each shift is trained. o Remaining nurses will be trained and provide return demonstration by: in-service completed On: 11/01/2024 by 5 PM. Any nurse that is not trained will be trained prior to returning to their next shift. On 11/2/24 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: Verified that Resident #1 was the only resident in facility with a tracheostomy. PCP notification verified on 11/2/24 by record review of a progress note documenting MD notification and record review of Resident #1's care plan indicating update occurred on 11/2/24. Record review of TAR verified that trach monitoring was now included for Resident #1. In-service regarding tracheostomy care and suctioning and respiratory therapy training was held on 11/2/24 at 6 am and was signed by DON (instructor) and LVN C In-services on tracheostomy care and suctioning and respiratory therapy trainings were held 10/31/24 through 11/2/24, instructed by DON and attended by 14 licensed nurses. Return demonstration on dummy setup observed on 11/2/24 with 7 nurses in facility. At least one nurse from each shift. Observations and interviews on 11/2/24 between the hours of 12:00 pm and 2:45 pm Licensed nurses (LVN C, LVN G, LVN J, LVN L, LVN M, and LVN N) were observed performing a verbal return demonstration on a dummy setup and were able to verbalize procedure was a sterile technique and demonstrate sterile technique via return demonstration on dummy set-up. LVN C, LVN G, LVN J, LVN L, LVN M, and LVN N said they were in-serviced on tracheostomy care and suctioning. They said they would never use any water other than sterile water and would use intermittent suctioning and never continuous suctioning. Observation on 11/2/24 at 1:00 pm the DON was observed performing appropriate tracheostomy care and suctioning on Resident #1 with no breaks in infection control or sterile technique. She wore appropriate PPE, used sterile water in sterile water container, and appropriately used intermittent suctioning. On 11/2/24 at 3:02 pm the DON was informed the IJ was removed; however, the facility remained out of compliance at a scope of no actual harm with potential for more than minimal harm that is not immediate jeopardy and scope of isolated due to the facility's need to monitor and evaluate the effectiveness of their corrective systems.