**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure each resident had the right to be free from abuse for three residents (Resident #1, Resident #2, and Resident #3) of 12 residents reviewed for abuse/neglect. The facility failed to ensure: -Resident #1 and Resident #2 were free of abuse, Resident #1 and Resident #2 sustained facial injuries from being hit in the face by Resident #3 multiple times, while they laid in bed resulting in bruising, cuts and discoloration to their face. -Facility nursing staff failed to assess residents after being notified of residents with injuries. -Resident #1 verbalized he was fearful of the alleged perpetrator and fearful that he was going to get assaulted again, since the perpetrator was not removed from the vicinity. An IJ was identified on 02/21/24. The IJ template was provided to the facility on [DATE] at 10:01 AM. While the IJ was removed on 02/23/24, the facility remained out of compliance at a scope of pattern and a severity level of potential for more than minimal harm that is because all staff were not aware of and did not implement the facility's abuse prevention and reporting policy and procedure. These failures have the potential to result in serious injury or death as a result of abuse and neglect. The findings included: Resident #1 Resident#1 is an [AGE] year-old male initially admitted on [DATE], and readmitted on [DATE] with diagnosis of cerebral infarction, dysphagia, cognitive communication deficit, dementia and muscle wasting and atrophy. Record review of Resident #1's MDS Quarterly dated 11/25/2023 revealed Resident #1 had a BIMS Score of 01-severe cognitive impairment and needed extensive assistance with all ADLs. Record review of Resident #1's Care Plan date initiated on 11/27/2023 revealed Resident #1 had an ADL self-care performance deficit related to weakness, limited mobility. Resident #1 is dependent on staff for meeting emotional, intellectual, physical, and social needs r/t Cognitive deficits, Immobility. Interventions, Bed mobility: Resident #1 requires extensive assistance by x 1 staff to turn and reposition in bed frequently and as necessary. Transfers: requires Mechanical Lift (hoyer) with (2) staff assistance for transfers. The resident needs 1:1 bedside/in-room visits and activities if unable to attend out of room events. Record review of Resident #1's Weekly Skin Evaluation dated 2/14/2024, revealed site: face, description: swelling under left eye with bruising and three small cuts to left inner eye area. Additional comments: was hit by another resident. Signed by LVN A on 02/15/2024. Record review of Resident #1's progress note dated 2/14/2024 at 23:14 (11:14PM) revealed Patient was in his room when another patient entered the room and hit the patient in the face. The patient sustained an injury he has swelling and bruising to left eye. Patient also has several small cuts to the left side of his face. Dr was notified along with Facility administrator and director of nursing. Patient family member was also notified. Patient showing no signs of distress noted at this time. Record review of Resident #1's incident report conducted by LVN A dated 2/15/2024, Incident description: Nursing description: Nurse was called to patient room by CNA. CNA informed nurse that patient was hit by another resident. Patient was laying in bed. Resident Description: Noted to have bruising and swelling to left eye with several small cuts to left inner and outer eye; Injuries observed at time of incident: No injuries observed at time of incident. Record review of Resident #1's incident report dated 2/15/2024 Injuries Report Post incident (conducted by DON): Injury Type: Bruise/Discoloration to: chest, right hand (back), face, left upper arm, left shoulder (front). Notes: Upon assessment resident identified with discoloration to top of right hand approximately 6.0x5.0cm. Large purple/green discoloration to left shoulder radiating towards left chest resembling as fingerprints. Left eye with swelling with red/purple discoloration. Left cheek with 2 superficial scratches and 1 small scratch below left eye. Small discoloration to left elbow. Other info: patient was hit by another resident. Record review of Resident#1's Pain Evaluation indicated it was not performed on 02/14/2024. Record review of Resident #1's Weekly Skin Evaluation conducted by the DON dated 02/15/2024 at 10:19AM revealed Resident #1 sustained injury to: left elbow (discoloration), right hand (back)(discoloration), beneath left eye scratch, left cheek scratches, left chest discoloration, left eye discoloration with swelling, left shoulder discoloration. Additional comments: This is follow-up skin assessment for resident-to-resident altercation on 2/14/2024. Record review of Resident #1's Pain Evaluation conducted by the DON on 02/15/2024 at 12:07PM revealed Resident #1 complained of pain to his left eye-pain expressed post resident to resident altercation (receiver). Resident #1 exhibited facial pain expression of grimacing. Body language: tense. What alleviates the pain? Pain medication. What makes the pain worse? movement, touch. Resident #2 Resident #2 is an [AGE] year-old male initially admitted on [DATE] and readmitted on [DATE] with diagnosis of cerebral infarction, acute and chronic respiratory failure, and hemiplegia and hemiparesis following cerebral infarction. Record review of Resident #2's Quarterly MDS dated [DATE] revealed a BIMS score of 01-severe cognitive impairment and needed extensive assistance with all ADLs. Record review of Resident #2's Care Plan date initiated 12/04/2023 revealed, the resident has an ADL self-care performance deficit r/t Hemiplegia. Interventions: functional performance: chair/bed-to-chair transfer: the resident requires dependent assistance required to transfer to and from a bed to a wheelchair. Functional performance: eating: The Resident requires Substantial Max assistance required for eating. Functional performance: lower body dressing: The Resident requires Extensive assistance required for lower/upper body dressing. Functional performance: lying to sitting on side of bed: The Resident requires Extensive assistance required to move from lying on the back to sitting on the side of the bed and with no back support. Functional performance: oral hygiene: The Resident requires Extensive assistance required for oral hygiene. Functional performance: roll left to right: The Resident requires Extensive assistance to roll from lying on back to left and right side and return to lying on back on the bed. BED MOBILITY: The resident requires extensive assistance by 1 staff to turn and reposition in bed at least Q2 hours and as necessary. TRANSFER: [Resident #2] requires Mechanical Lift (hoyer) with (2) staff assistance for transfers. Record review of Resident #2's progress notes by LVN A dated 2/14/2024 at 23:00 (11:00PM) revealed, Patient was laying in bed when another patient went into his room and hit him in the face. The patient received a bruise and several small cuts to right side of face. Patient stated another resident hit him with his fist. Facility Director DON and DR. were notified patient family RP was called and notified. Record review of Resident #2's Weekly Skin Evaluation dated 02/14/2024 conducted by LVN A, revealed Resident #2's face with bruising noted to right and left side of face with small cut to left side of face. Additional comments: Patient was hit by another patient. Signed by LVN A on 02/15/2024. Record review of Resident#1's Pain Evaluation indicated it was not performed on 02/14/2024. Record review of Resident #2's Incident report dated 2/14/2024 conducted by LVN A revealed, Incident Description: Nursing Description: CNA called nurse to patient room. Patient was hit by another resident in the face. Resident Description: Patient was laying in bed was noted to have red areas and cuts to both sides of his face. Immediate Action Taken: Description: Patient face was cleaned, and vitals were taken. Vitals WNL. Patient not showing any signs of distress at this time. RP, MD notified. Injury Type: Abrasion to face, injury type: bruise/discoloration to face. Record review of Resident #2's Incident report dated 2/14/2024 Injury Report Post Incident conducted by DON, Injury type: bruise/discoloration to face. Notes: Upon assessment resident identified with redness (with small areas of purple) discolorations throughout entire face and neck area. Resident has had small scratches to cheeks, beneath left eye, chin and left eyebrow. Other info: patient was hit by another resident. Record review of Resident #2's Weekly Wound progress dated 2/15/2024 conducted by the DON revealed, bruising and scratches, dark red/purple, Redness (with small areas of purple) discolorations throughout entire face, scratches beneath left eye, cheeks, chin and above left eyebrow. Record review of Resident #2's Progress note by LVN C dated 2/15/2024 at 6:50AM revealed, Resident assessed head to toe by this nurse. Resident's right jaw and ear with swelling and redness. Beneath left eye, cheek, and chin several scratches and redness. Resident asked if he had any pain and resident reports that his jaw hurts but unable to rate pain on scale of 0-10 which is baseline. Pain was treated with PRN Morphine 0.25ml SL which was effective. Record review of Resident #2's Progress note by DON dated 2/15/2024 at 13:00 (1:00PM) revealed, on 2/14/2024 Charge nurse reports resident was involved in a resident-to-resident altercation. Upon assessment resident identified with redness (with small areas of purple) discolorations throughout entire face and neck area. Resident also had small scratches to cheeks, beneath left eye, chin and left eyebrow.AM charge nurse reports she received an order for facial x-ray related to swelling and complaints of pain, x-ray results pending. Record review of Resident #2's Pain Evaluation dated 02/15/2024 at 15:03 (3:03PM) conducted by the DON, revealed Resident #2's face exhibited Pain expressed post resident to resident altercation (receiver). Resident #2 exhibited facial grimacing and tense body language. What alleviates the pain? Pain medication. What makes the pain worse? movement, touch. Resident #3 Resident#3 is an 80- year-old male admitted on [DATE] with diagnosis of congestive heart failure, dementia, without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, and cognitive communication deficit. Record review of Resident #3's quarterly MDS dated , 12/19/23 revealed a BIMS score of 2-severe cognitive impairment, physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) ranging 4-6days, uses walker for mobility, and can walk 50 feet with supervision. Record review of Resident #3's Care Plan revised on 10/02/2023 revealed, [Resident #3] is/has potential to be physically aggressive related to poor impulse control. Interventions: 12/16/2023, and 9/9/2023 Resident had a physical altercation with other resident, both were separated immediately. 2/14/24 - [Resident #3] had a physical altercation with other residents, both were separated immediately. 9/9/2023 Resident had a physical altercation with roommate, both were separated immediately. Roommate moved to another room. Administer medications as ordered. Monitor/document for side effects and effectiveness. Analyze times of day, places, or circumstances, triggers, and what de-escalates behavior and document. Assess and anticipate resident's needs: food, thirst. toileting needs, comfort level, body positioning, pain etc. COMMUNICATION: provide physical and verbal cues to alleviate anxiety; give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff member when agitated. Record review of Resident #3's weekly skin evaluation dated 2/14/2024 at 10:00AM and signed/lock date of 2/15/2024 at 12:57AM revealed, no injuries noted. - There was no other skin evaluation noted for the date 2/14/2024, post resident-to-resident altercation. Record review of Resident #3's progress notes revealed there were no progress notes for date 2/14/2024 regarding resident-to-resident altercation. Record review of Resident #3's Progress note dated 2/15/2024 at 12:00AM, Doctor/MD notes: was informed that patient had altercation with multiple residents causing injuries last night. Social worker received warrant to have patient sent to ER for clearance in preparation for admission to [hospital name] behavioral hospital. NP aware of patient status. Record review of Resident #3's Progress note dated 2/15/2024 at 1:13PM by the SW, Resident became combative with two other residents last night, then upon redirection he became combative towards staff. The SW sent referral to the behavioral health and requested services. The SW requested an emergency detention warrant from the county judge. Judge Signed Warrant. When the officers arrived at the facility to transport Resident #3 to [behavioral hospital], Resident #3 became agitated, verbally aggressive, and then combative towards the officers. Once officers were able to subdue Resident #3, he was transferred to ER to get medically cleared for behavioral health. Record review of Resident #3's Progress note dated 2/15/2024 at 3:43PM by the DON, on 2/14/2024 Charge nurse reports resident was involved in resident-to-resident altercation (initiator-aggressor). Upon assessment resident identified with noted with purple discoloration to left hand. Social services to detain a detention warrant. Resident continues on 1 on 1care. Resident does not appear to have any negative psych-social effects from incident and is unable to recall event. Will continue to monitor. During an observation and interview on 02/17/2024 at 3:14PM Resident #1 stated a man entered his room and began hitting him in the face a couple of days ago. Resident #1 stated a man hit him about 5 times on his face. Resident #1 stated he was fearful of living at facility because he is scared the man is going to hit him again. Resident #1 stated the man stopped himself, and that there was no other person in the room. Upon observation Resident #1 has black/purple discoloration on left eye within the eye socket area as well as extended toward the temporal area where green discoloration is present and covers 25% of face. During an observation on 02/17/2024 at 3:14PM Resident #2 had purple/green discoloration on left eye around the rim of left eye, as well as had red/ purple discoloration on the right side of his neck, resembling a handprint. Resident #2 also had red discoloration on the lower left portion, near the lower left eye lid, of the eye socket, which appears to measure about one inch in circumference (circle like appearance). During an interview on 02/17/2024 at 3:14PM Resident #2 (Resident #1's roommate) stated it hurts while pointing to his left eye. Resident #2 was not able to communicate what happened to his eye. During an interview on 02/17/2024 at 3:48PM NA A stated she worked the 6PM-6AM shift. NA A stated Resident #1 and Resident #2 were roommates, and she distinctly recalled on 02/14/2024 at 8:25PM, she entered Resident #1 and Resident #2's room as part of her rounds (brief changes, clothes changes for bedtime). NA A stated prior to entering Resident #1 and Resident #2's room, she saw that their lights were off, and stated she thought it was strange due to Resident #1 and Resident #2 both being bedbound but continued without turning the lights on. NA A stated once she entered their room, she started with Resident #1, and stated she looked at Resident #1's face and saw a dark shadow around his left eye, so she turned on the lights and saw bright red blood on at least half of Resident #1's face, as well as on Resident #1's blanket/covers, bed, and a little on the wall. NA A stated, when she asked Resident #1 what happened, Resident #1 stated that someone hit him and was trying to kill him. NA A stated she quickly ran out of the room and notified LVN A. NA A stated, while she notified LVN A at the nurse's station, she waited for LVN A to get up to check on Resident #1, but that LVN A did not immediately get up to assess the situation. NA A stated, while LVN A was at the nurse's station, LVN A directed NA A to go back into the room to clean up Resident #1, with perineal wet wipes, without LVN A assessing him first. NA A stated while cleaning up Resident #1, she saw he had bruises on his left side of chest, blood/bruising on his right hand and swelling on left eye with blood all over his face .NA A stated once she cleaned Resident #1's face, and changed his linen, she went back to the nurse's station and overheard LVN A speaking to an unknown caller, and overheard LVN A state Resident #3 hit Resident #1, without any other details given. NA A stated during the later part of the evening before approximately 10PM, she walked with LVN A into Resident #1's room, where LVN A looked at Resident #1 and then proceeded to exit the room. NA A stated while she walked out of the room with LVN A, NA A saw Resident #2 and saw blood on his Resident #2's face, as well as heard Resident #2 breathing irregularly. NA A stated Resident #2 had blood stains on his neck, and claw marks on both side of his neck, handprint on his right side of neck, as though someone choked him. NA A stated LVN A put a pulse oximeter on Resident #2's finger, and that LVN A stated, Resident #2 is breathing okay. NA A stated she walked out of Resident #1 and Resident #2's room with LVN A but did not see LVN A do any form of head-to-toe assessment on either of the Residents. NA A stated she then spoke to LVN B and explained the details of her initial findings of Resident #1's blood-soaked linen and face, and LVN B did not go with NA A to see Resident #1's injuries. NA A stated when she went back to her 600 hallway to check on Resident #1, she saw Resident #3 in the hallway with blood on his fists, and that Resident #3 stated I'll beat you up like I beat up the boys. NA A stated during her 02/14/2024-02/15/2024 6PM-6AM shift, she did not see any leadership staff arrive on site, nor any law enforcement. NA A stated when the morning shift (6AM on 2/15/24) arrived, she notified LVN C, and LVN C went into Resident #1 and Resident#2's room and observed that Resident #1 started to cry and complained he was hurting. NA A stated she was instructed to follow the chain of command whenever she suspected abuse and did notify her charge nurse as well as LVN B on 02/14/2024 but did not know of any other options she had to advocate for Resident #1 and Resident #2. Attempted to interview LVN A on 02/18/2024 at 9:18AM, 9:27AM, 5:07PM, as well as on 02/19/2024 at 4:39PM and on 02/23/24 at 5:10 PM, 5:11 PM, 5:12 PM but was unsuccessful . During an interview on 02/18/2024 at 9:54AM, LVN B stated she did not enter the room of Resident #1 to assess the resident's injuries. LVN B stated she asked LVN A if she had completed a head-to-toe assessment, behavior monitoring form, as well as asked if she did the incident report, to which LVN A stated she did. LVN B stated she took what LVN A stated as truthful, and stated LVN A described the resident-to-resident altercation with minimal severity. LVN B stated she believed LVN A notified the proper chain of command, as well as believed LVN A completed the proper documentation, and did not find a need to intervene on LVN A's residents. LVN B stated she was in another resident's room, when LVN A ran to LVN B stating that Resident #3 was running after LVN A trying to hit LVN A and that Resident #3 was also yelling and stating vulgar and derogative remarks to LVN A. LVN B stated she quickly confronted Resident #3, de-escalated Resident #3's behavior, and guided Resident #3 back to his room, tucked him in, and left Resident #3's room. After leaving Resident #3's room she had no other contact with Resident #3 and did not enter Resident #1 and Resident #2's room. During multiple interviews with the Administrator and DON, between 02/17/2024 at 6:17PM, and 02/19/2024 at 5:47PM, the DON stated on 2/14/24 around 8:40PM, LVN A called and notified the DON that Resident #3 hit Resident #1, but that LVN A did not present any details of the occurrence, only that Resident #3 hit Resident #1. The DON stated that she immediately instructed LVN A to call the Administrator. The Administrator stated around 8:45PM-9:00PM, she received a call from LVN A and that LVN A stated that Resident #3 hit Resident #1. The Administrator stated that during that one and only notification phone call, LVN A never gave any detailed description of the severity of Resident #1's injury. The DON stated that on 2/14/24 at 9:50PM, she texted (text reviewed) LVN A that LVN A needed to complete a change in condition form, risk management form, Q15min behavior monitoring form, skin assessments, supportive documentation (weekly wound progress), and pain assessments for both Resident #1 and Resident #3. The Administrator stated around 6AM on 2/15/24 she was notified by a 6AM-6PM clinical staff member that the clinical staff member entered Resident #2's room and Resident #2 appeared to have swelling to his face as well as serious facial injuries. The Administrator stated she arrived at the facility around 6:30AM and entered Resident #1 and Resident #2's room and found that Resident #1 had substantial facial injuries of dark purple discoloration around the left side of Resident #1's face as well as swelling throughout his face and did notice on the right side of Resident #1's right side of neck, red fingerlike marks on his neck. The Administrator stated she also saw Resident #2's face and observed purple discoloration on his face, red coloration around Resident #2's neck, with also swelling. Both Administrator and DON stated they were never notified about Resident #2's injuries until notified the morning of 2/15/24 around 6AM. Both stated, when they were notified by LVN A around 8:45PM, she never described the severity of Resident #1's injuries only that he was hit, which lead them to determine that they did not need to move Resident #3, who lived directly in front of Resident #1 and Resident #2 (roommates), from his room to somewhere else. The DON stated she directed LVN A to conduct Q15min checks for Resident #1, Resident #2, and Resident #3. Both stated the Q15min surveillance was adequate at the time, but had they known the severity of the altercations, they would have put Resident #3 on a one-to-one to ensure the safety of the other residents. Both stated it was plausible, that during the Q15 surveillance, for the 14minutes when the nurse was not monitoring Resident #3, Resident #3 could have exited his room, inflicted more injury onto Resident #1 and Resident #2, and go back to his room, since these three residents were front door neighbors. The Administrator stated on the morning of 2/15/24 around 6:30-7:00AM, a 1:1 was implemented for Resident #3, and when speaking to Resident #1 first, in Spanish, Resident #1 stated that man beat me up, and when speaking to Resident #2, in Spanish he stated, he hit me. The Administrator stated she was unable to interview Resident #3, due to his aggressive behavior on 2/15/2024, and then later Resident #3 was removed from the facility. When asked about the facility's Abuse and Neglect policy, and their definition of physical abuse, the Administrator stated, Resident #3 hitting Resident #1 would fall under physical abuse, and stated had they known the severity of the injuries they would have entered the facility that evening of 2/14/24 and began an investigation into the resident-to-resident abuse, removed Resident #3 from his immediate accessibility of Resident #1 and Resident #2, as well as notified the local authorities, and state agencies. Both stated they did not begin an investigation, nor did they think to remove Resident #3 from his room, nor did they notify law enforcement or state agencies, due to LVN A not describing the severity of the physical altercations. Both stated they in-service staff regularly about abuse and neglect, and stated the last in-service regarding abuse and neglect was done on 02/15/2024 but was not 100% complete. Record review on 02/18/2024, of the facility's Abuse/Neglect in-service dated 2/15/24 documented 27 staff members attendance signatures, however two of the signatures were doubled, which made 25 staff members in attendance. During an interview on 02/19/2024 at approximately 6:00PM, the DON stated the Abuse and Neglect in-service was started on 02/15/2024 but was not 100% completed, and that the facility was lacking at least 4 staff members to be 100% completed with the in-service. Record review on 02/19/2024, of the facility's Abuse/Neglect in-service dated 2/15/24 had a continuation of additional signatures which made 50 staff members in attendance, however per the staff roster the facility employed 59 staff members. Record review of the facility's Abuse, Neglect and Exploitation policy dated 8/15/22 stated, Definitions: Physical abuse- includes but not limited to hitting, slapping, punching, biting and kicking. Identification of Abuse, Neglect and Exploitation: Possible indicators of abuse include, but are not limited to 2. Physical marks such as bruises or patterned appearances such as a handprint, belt or ring mark on a resident's body. Investigation of Alleged Abuse, Neglect and Exploitation: A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation or reports of abuse, neglect, or exploitation occur. Protection of Resident: D. Room or staffing changes, if necessary, to protection the resident(s) from the alleged perpetrator. Reporting/Response A.The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury. This was determined to be an Immediate Jeopardy (IJ) and the Administrator was notified of the IJ on 02/21/2024. The Administrator was provided with IJ templates on 02/21/2024 at 10:01AM. The following Plan of Removal was submitted by the facility was accepted on 02/22/24 at 3:58PM. The facility's Plan of Removal included: On February 21, 2024, the facility was notified by the surveyor, that an immediate jeopardy had been called and the facility needed to submit a letter of credible allegation. The Facility respectfully submits this Letter for Plan of Removal pursuant to Federal and State regulatory requirements. The immediate jeopardy allegations are as follows: F-Tag 600: Abuse. The facility failed to ensure the resident's right to be free from abuse and neglect. Done for those affected: oResident #3 was assessed by licensed nurse on 02/14/2024. MD was notified by licensed nurse on 02/14/2024. 02/14/2024 Resident #3 was placed on every 15-minute checks. Resident #3 was transferred to the hospital and was placed on 1:1 on 2/15/24 pending transfer to the hospital. Resident remains at the hospital. On Monday, 2/19/2024 Facility care planned with family. Referral is being sent to other facilities at the request of the family. If unable to find a transferring facility, the resident will return on a 1-1 until the decision is made on the 30-day notice of discharge. Resident will remain on 1-1 until he is discharged . oResident #1 was assessed on 02/14/2024 by [clinical staff name] to include pain and skin evaluation. Assessment revealed swelling under left eye with bruising and 3 small cuts to left inner eye. Psychosocial assessment was completed by Social Worker on 02/15/2024. Plan of care was reviewed and updated by licensed nurse on 02/15/2024. MD was notified by licensed nurse on 02/14/2024 and 02/15/2024. oResident #2 was assessed on 02/14/2024 by, [clinical staff name] to include pain and skin evaluation. Assessment revealed bruising noted to right and left side of face with small cut to left side of face. Psychosocial assessment was completed by Social Worker on 02/15/2024. Plan of care was reviewed and updated by licensed nurse on 02/15/2024. MD was notified by licensed nurse on 02/14/2024 and 02/15/2024. Identify residents who could be affected: o On 02/15/2024, the Facility Social Worker(s) completed 100% of interviews of interviewable residents to assess for potential abuse. No additional concerns were identified. Residents who are confused were asked yes and no questions. On the 2 residents who are unable to answer, their spouses were contacted. Out of the 2 one denied any allegations of abuse and the other did not answer his phone and has not returned the call. Was called each day and answered on 2/17/24 and he denied any allegations of abuse. o On 02/15/2024, the DON/designee reviewed the incident/accidents in the last 30 days to ensure that investigations, timely reporting to HHSC as indicated, resident assessments and supervision to include 1:1 supervision as needed were completed and provided. All other residents were identified to be in their room except 2 female residents who were up and watching television and do not have any history of behaviors. Systemic Process: oEffective immediately on 02/15/2024, the Administrator/ DON and/ or designee began reeducation to 100% of facility staff on the following: o Abuse and Neglect and Abuse Policy to include timely Investigation and HHSC Reporting to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. The Administrator who is the Abuse Prevention Coordinator will be immediately notified for any concerns with Abuse, Neglect and Misappropriation. o Resident Supervision to include 1:1 staff supervision o Quality of Care to include proper resident assessment with each resident incident/accidents - Please include what this process is/if using a P & P you may attach policy and include statement to refer to that policy #/name o See attached policy labeled Incidents and Accidents o During the Morning Meeting. Risk Management will be reviewed to ensure that all required assessments were completed. o when will an assessment be conducted after knowledge of an injury; o The assessment will be conducted at the time of incident and the nurse will enter all information into the appropriate forms within 8 hours of occurrence. o The assessment will include date, time, nature of incident, location, initial findings, immediate interventions, notifications and orders obtained or follow-up interventions. o The resident was placed on Q 15-minute checks immediately following the incident. Residents' doorway is visible from the nurses station and staff kept a watch on his door throughout the shift. Aides were on and off the halls throughout the night and the resident remained in his room and the other 2 residents were safe in bed. Resident remained in his room and no further behavior. At 6:00am the resident was placed on 1-1 in preparation for him to awaken. Social Worker went before Judge to obtain a detention warrant to [hospital name]. [local city police enforcement] called and notified of the incident and we requested assistance with transp[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review, the facility failed to implement its policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents for three residents (Resident #1, Resident #2, and Resident #3) of 12 residents reviewed for abuse and neglect. 1. The facility failed to immediately implement an investigation after they were made aware of an abuse allegation involving Resident #1, Resident #2, and Resident #3. 2. The facility failed to report the abuse allegation to the State Survey Agency and local law enforcement in accordance with state law. 3.The facility failed to ensure that all residents were protected from physical and psychosocial harm after made aware of the incident involving a resident to resident assault when Resident #3 assaulted Resident #1 and Resident #2 and they sustained facial bruising, cuts, and discoloration. An IJ was identified on 02/21/23. The IJ template was provided to the facility on [DATE] at 10:01 AM. While the IJ was removed on 02/23/24, the facility remained out of compliance at a scope of pattern and a severity level of potential for more than minimal harm that is because all staff were not aware of and did not implement the facility's abuse prevention and reporting policy and procedure. These failures had the potential to result in serious injury or death as a result of the resident-to-resident physical abuse and the facility's systemic failure. The findings include: Resident #1 Resident#1 is an [AGE] year-old male initially admitted on [DATE], and readmitted on [DATE] with diagnosis of cerebral infarction, dysphagia, cognitive communication deficit, dementia and muscle wasting and atrophy. Record review of Resident #1's MDS Quarterly dated 11/25/2023 revealed Resident #1 had a BIMS Score of 01-severe cognitive impairment and needed extensive assistance with all ADLs. Record review of Resident #1's Care Plan date initiated on 11/27/2023 revealed Resident #1 had an ADL self-care performance deficit related to weakness, limited mobility. Resident #1 is dependent on staff for meeting emotional, intellectual, physical, and social needs r/t Cognitive deficits, Immobility. Interventions, Bed mobility: Resident #1 requires extensive assistance by x 1 staff to turn and reposition in bed frequently and as necessary. Transfers: requires Mechanical Lift (hoyer) with (2) staff assistance for transfers. The resident needs 1:1 bedside/in-room visits and activities if unable to attend out of room events. During an observation and interview on 02/17/2024 at 3:14PM Resident #1 stated a man entered his room and began hitting him in the face a couple of days ago. Resident #1 stated a man hit him about 5 times on his face. Resident #1 stated he was fearful of living at facility because he is scared the man is going to hit him again. Resident #1 stated the man stopped himself, and that there was no other person in the room. Upon observation Resident #1 has black/purple discoloration on left eye within the eye socket area as well as extended toward the temporal area where green discoloration is present and covers 25% of face. Resident #2 Resident #2 is an [AGE] year-old male initially admitted on [DATE] and readmitted on [DATE] with diagnosis of cerebral infarction, acute and chronic respiratory failure, and hemiplegia and hemiparesis following cerebral infarction. Record review of Resident #2's Quarterly MDS dated [DATE] revealed a BIMS score of 01-severe cognitive impairment and needed extensive assistance with all ADLs. Record review of Resident #2's Care Plan date initiated 12/04/2023 revealed, the resident has an ADL self-care performance deficit r/t Hemiplegia. Interventions: functional performance: chair/bed-to-chair transfer: the resident requires dependent assistance required to transfer to and from a bed to a wheelchair. Functional performance: eating: The Resident requires Substantial Max assistance required for eating. Functional performance: lower body dressing: The Resident requires Extensive assistance required for lower/upper body dressing. Functional performance: lying to sitting on side of bed: The Resident requires Extensive assistance required to move from lying on the back to sitting on the side of the bed and with no back support. Functional performance: oral hygiene: The Resident requires Extensive assistance required for oral hygiene. Functional performance: roll left to right: The Resident requires Extensive assistance to roll from lying on back to left and right side and return to lying on back on the bed. BED MOBILITY: The resident requires extensive assistance by 1 staff to turn and reposition in bed at least Q2 hours and as necessary. TRANSFER: [Resident #2] requires Mechanical Lift (hoyer) with (2) staff assistance for transfers Resident #3 Resident#3 is an 80- year-old male admitted on [DATE] with diagnosis of congestive heart failure, dementia, without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, and cognitive communication deficit. Record review of Resident #3's quarterly MDS dated , 12/19/23 revealed a BIMS score of 2-severe cognitive impairment, physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) ranging 4-6days, uses walker for mobility, and can walk 50 feet with supervision. Record review of Resident #3's Care Plan revised on 10/02/2023 revealed, [Resident #3] is/has potential to be physically aggressive related to poor impulse control. Interventions: 12/16/2023, and 9/9/2023 Resident had a physical altercation with other resident, both were separated immediately. 2/14/24 - [Resident #3] had a physical altercation with other residents, both were separated immediately. 9/9/2023 Resident had a physical altercation with roommate, both were separated immediately. Roommate moved to another room. Administer medications as ordered. Monitor/document for side effects and effectiveness. Analyze times of day, places, or circumstances, triggers, and what de-escalates behavior and document. Assess and anticipate resident's needs: food, thirst. toileting needs, comfort level, body positioning, pain etc. COMMUNICATION: provide physical and verbal cues to alleviate anxiety; give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff member when agitated. During an observation and intervention on 02/17/2024 at 3:14 PM Resident #2 had purple/green discoloration on left eye around the rim of left eye, as well as had red/ purple discoloration on the right side of his neck, resembling a handprint. Resident #2 also had red discoloration on the lower left portion, near the lower left eye lid, of the eye socket, which appears to measure about one inch in circumference (circle like appearance). Resident #2 (Resident #1's roommate) stated it hurts while pointing to his left eye. During an interview on 02/17/2024 at 4:47 PM the SW stated on 2/15/2024 around 8AM, the Administrator notified him of the resident-to-resident altercation, and that a warrant was needed for Resident #3, as necessary step to initiate a transfer to a behavioral hospital. The SW stated from what he saw, Resident #1 and Resident #2 on 02/15/2024, after lunch, did not look good. The SW stated Resident #1 had bruises on body, had a black eye that was swollen, and Resident #2's face looked red and swollen. The SW stated both Resident #1 and Resident #2 were bed bound. The SW stated on 2/15/2024 around 12PM lunch time, the local city police entered the nursing facility to execute the warrant for Resident #3. The SW stated when the police entered Resident #3's room, Resident #3 became aggressively agitated, to which the police attempted to calm Resident #3 down, yet Resident #3 continued to swing and kick the officers. The SW stated any suspicion of abuse must be reported to the Administrator and could not definitively state the next steps of the Administrator and had limited knowledge of the clinical staff steps. During multiple interviews with the Administrator and DON, between 02/17/2024 at 6:17PM and 02/19/2024 at 5:47PM, the DON stated on 2/14/24 around 8:40PM, LVN A called and notified the DON that Resident #3 hit Resident #1, but that LVN A did not present any details of the occurrence, only that Resident #3 hit Resident #1. The DON stated that she immediately instructed LVN A to call the Administrator. The Administrator stated around 8:45PM-9:00PM, she received a call from LVN A and that LVN A stated that Resident #3 hit Resident #1. The Administrator stated that during that one and only notification phone call, LVN A never gave any detailed description of the severity of Resident #1's injury. The DON stated that on 2/14/24 at 9:50PM, she texted (text reviewed) LVN A that LVN A needed to complete a change in condition form, risk management form, Q15min behavior monitoring form, skin assessments, supportive documentation (weekly wound progress), and pain assessments for both Resident #1 and Resident #3. The Administrator stated around 6AM on 2/15/24 she was notified by a 6AM-6PM clinical staff member that the clinical staff member entered Resident #2's room and Resident #2 appeared to have swelling to his face as well as serious facial injuries. The Administrator stated she arrived at the facility around 6:30AM and entered Resident #1 and Resident #2's room and found that Resident #1 had substantial facial injuries of dark purple discoloration around the left side of Resident #1's face as well as swelling throughout his face and did notice on the right side of Resident #1's right side of neck, red fingerlike marks on his neck. The Administrator stated she also saw Resident #2's face and observed purple discoloration on his face, red coloration around Resident #2's neck, with also swelling. Both Administrator and DON stated they were never notified about Resident #2's injuries until notified the morning of 2/15/24 around 6AM. Both stated, when they were notified by LVN A around 8:45PM, she never described the severity of Resident #1's injuries only that he was hit, which lead them to determine that they did not need to move Resident #3, who lived directly in front of Resident #1 and Resident #2 (roommates), from his room to somewhere else. The DON stated she directed LVN A to conduct Q15min checks for Resident #1, Resident #2, and Resident #3. Both stated the Q15min surveillance was adequate at the time, but had they known the severity of the altercations, they would have put Resident #3 on a one-to-one to ensure the safety of the other residents. Both stated it was plausible, that during the Q15 surveillance, for the 14minutes when the nurse was not monitoring Resident #3, Resident #3 could have exited his room, inflicted more injury onto Resident #1 and Resident #2, and go back to his room, since these three residents were front door neighbors. The Administrator stated on the morning of 2/15/24 around 6:30-7:00AM, a 1:1 was implemented for Resident #3, and when speaking to Resident #1 first, in Spanish, Resident #1 stated that man beat me up, and when speaking to Resident #2, in Spanish he stated, he hit me. The Administrator stated she was unable to interview Resident #3, due to his aggressive behavior on 2/15/2024, and then later Resident #3 was removed from the facility. When asked about the facility's Abuse and Neglect policy, and their definition of physical abuse, the Administrator stated, Resident #3 hitting Resident #1 would fall under physical abuse, and stated had they known the severity of the injuries they would have entered the facility that evening of 2/14/24 and began an investigation into the resident-to-resident abuse, would have removed Resident #3 from his immediate accessibility of Resident #1 and Resident #2, as well as notified the local authorities, and state agencies. Both stated they did not begin an investigation, nor did they think to remove Resident #3 from his room, nor did they notified law enforcement or state agencies, due to LVN A not describing the severity of the physical altercations. Both stated they in-service staff regularly about abuse and neglect, and stated the last in-service regarding abuse and neglect was done on 02/15/2024 but was not 100% complete. During an interview on 02/192024 at 3:47PM with the Regional Consultant and DON. The DON was asked about who would be in charge if the Administrator was unavailable, the DON stated she would be. The DON stated she did not have access to TULIP to complete incidental self-reports and does not know the process to report, and continued by stating she would look to the Administrator or the Regional Consultant for guidance when needing to notify state agencies. The Regional Consultant stated another way to notify state agencies would be to email CII, to which the DON did not respond. The DON stated, had she known the severity of Resident #1 and Resident #2's injuries she would have begun an investigation immediately on 02/14/2024, she would have removed Resident #3 from Resident #1 and Resident #2's immediate vicinity, she would have placed Resident #3 on a 1:1 and not Q15min checks, and would have reported it sooner to the state agencies as well as notified local authority. The Regional Consultant stated during the evening of 02/14/2024, nursing aides as well as nurses were active within the halls, however when asked how the facility could definitely ensure supervision was maintained if the clinical staff were in and out of residents' rooms, no response was given. The DON stated it was plausible that while nurses and aides were busy in other residents' rooms, Resident #3 could have exited his room, walked across to Resident #1 and Resident #2's room, and inflict additional harm to the residents. Record review on 02/17/2024 at 9:12AM reviewed TULIP intakes which documented receiving the facility's self-report on 2/15/2024 at 7:58AM, which was 11 hours after the resident-to-resident physical altercation. On 02/22/2024 at 4:07PM, the local city law enforcement police department was called to verify event #24-002817, dispatcher stated the event number was linked to a police officer, who was on site at the nursing facility on 02/15/2024, requesting an ambulance for medical assistance. The dispatcher stated the call was received on 02/15/2024 at 11:56AM. The call did not come from the nursing facility. The dispatcher stated there was no record of any other call from the nursing facility, nor regarding the nursing facility on 02/14/2024 nor anytime prior to 11:56AM on 02/15/2024. On 02/22/2024 at 4:09PM called CCPD to verify event #24-002817, the dispatcher stated they do not dispatch to another city's jurisdiction. Record review of the facility's Abuse/Neglect in-service was conducted on 02/15/2024 and completed on 02/21/2024 Record review of the facility's Abuse, Neglect and Exploitation policy dated 08/15/2022 stated, Reporting/Response A.The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury. This was determined to be an Immediate Jeopardy (IJ) on 02/20/2024. The Administrator was notified. The Administrator was provided with IJ templates on 02/21/2024 at 10:01AM. The following Plan of Removal submitted by the facility was accepted on 02/22/24 at 3:58PM. The facility's Plan of Removal included: On February 21, 2024, the facility was notified by the surveyor, that an immediate jeopardy had been called and the facility needed to submit a letter of credible allegation. The Facility respectfully submits this Letter for Plan of Removal pursuant to Federal and State regulatory requirements. The immediate jeopardy allegations are as follows: F- Tag 607: The facility must develop and implement written policies and procedures that: Prohibit and prevent abuse, neglect, and exploitation of residents a misappropriation of resident property, of residents and misappropriation of resident property. Done for those affected: o Resident #3 was assessed by licensed nurse on 02/14/2024. MD was notified by licensed nurse on 02/14/2024. 02/14/2024 Resident #3 was placed on every 15-minute checks. Resident #3 was transferred to the hospital and was placed on 1:1 on 2/15/24 pending transfer to the hospital. Resident remains at the hospital. On Monday, 2/19/2024 Facility care planned with family. Referral is being sent to other facilities at the request of the family. If unable to find a transferring facility, the resident will return on a 1-1 until the decision is made on the 30-day notice of discharge. Resident will remain on 1-1 until he is discharged . o Resident #1 was assessed on 02/14/2024 by [clinical staff name] to include pain and skin evaluation. Assessment revealed swelling under left eye with bruising and 3 small cuts to left inner eye. Psychosocial assessment was completed by Social Worker on 02/15/2024. Plan of care was reviewed and updated by licensed nurse on 02/15/2024. MD was notified by licensed nurse on 02/14/2024 and 02/15/2024. o Resident #2 was assessed on 02/14/2024 by, [clinical staff name] to include pain and skin evaluation. Assessment revealed bruising noted to right and left side of face with small cut to left side of face. Psychosocial assessment was completed by Social Worker on 02/15/2024. Plan of care was reviewed and updated by licensed nurse on 02/15/2024. MD was notified by licensed nurse on 02/14/2024 and 02/15/2024. Identify residents who could be affected: o On 02/15/2024, the Facility Social Worker(s) completed 100% of interviews of interviewable residents to assess for potential abuse. No additional concerns were identified. Residents who are confused were asked yes and no questions. On the 2 residents who are unable to answer, their spouses were contacted. Out of the 2 one denied any allegations of abuse and the other did not answer his phone and has not returned the call. Was called each day and answered on 2/17/24 and he denied any allegations of abuse. o On 02/15/2024, the DON/designee reviewed the incident/accidents in the last 30 days to ensure that investigations, timely reporting to HHSC as indicated, resident assessments and supervision to include 1:1 supervision as needed were completed and provided. All other residents were identified to be in their room except 2 female residents who were up and watching television and do not have any history of behaviors. Systemic Process: o Effective immediately on 02/15/2024, the Administrator/ DON and/ or designee began reeducation to 100% of facility staff on the following: o Abuse and Neglect and Abuse Policy to include timely Investigation and HHSC Reporting to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. The Administrator who is the Abuse Prevention Coordinator will be immediately notified for any concerns with Abuse, Neglect and Misappropriation. o Resident Supervision to include 1:1 staff supervision o Quality of Care to include proper resident assessment with each resident incident/accidents - Please include what this process is/if using a P & P you may attach policy and include statement to refer to that policy #/name o See attached policy labeled Incidents and Accidents o During the Morning Meeting. Risk Management will be reviewed to ensure that all required assessments were completed. o when will an assessment be conducted after knowledge of an injury; o The assessment will be conducted at the time of incident and the nurse will enter all information into the appropriate forms within 8 hours of occurrence. o The assessment will include date, time, nature of incident, location, initial findings, immediate interventions, notifications and orders obtained or follow-up interventions. o The resident was placed on Q 15-minute checks immediately following the incident. Residents' doorway is visible from the nurses station and staff kept a watch on his door throughout the shift. Aides were on and off the halls throughout the night and the resident remained in his room and the other 2 residents were safe in bed. Resident remained in his room and no further behavior. At 6:00am the resident was placed on 1-1 in preparation for him to awaken. Social Worker went before Judge to obtain a detention warrant to [hospital name]. [local city police enforcement] called and notified of the incident and we requested assistance with transportation to [hospital name]. Staff will be reeducated prior to the start of their next scheduled shift. Any facility staff on FMLA, Leave of Absence, non-scheduled workday or PTO will be reeducated prior to the start of their next scheduled shift. o The facility maintains an onsite Weekend Manager and Nursing Supervisor that conduct rounds and may initiate and address resident incidents and will escalate to the appropriate administrative staff when required. The Administrator who is the Abuse Prevention Coordinator will be immediately notified for any concerns with Abuse, Neglect and Misappropriation. Is there a weekend manager/nurse supervisor on site in evening/night shift? Yes, there is a weekend manager/ nurse supervisor on the evening shift. After 6pm the 2 Charge Nurse are the supervisor's along with on call Director of Nurses and Administrator. o To monitor, the Director of Nursing/ designee will review resident incidents in facility Stand-up Morning Meeting, attended Monday - Friday. Resident incidents will be reviewed for potential abuse situations and need for reporting as per HHSC guidelines. Review will also include to ensure investigation was completed, resident assessments and supervision to include 1:1 supervision as needed was completed and provided. o The Administrator will monitor to ensure new resident incidents are reviewed daily Monday-Friday to ensure concerns are addressed timely and if necessary, reported per HHSC guidelines, investigation was completed, resident assessments and supervision to include 1:1 supervision as needed was completed and provided. - How long will this process occur? o On going as part of our Morning Meeting Process. o Administrator/designee will conduct quarterly and as needed on Abuse, Neglect, & Exploitation education to ensure facility staff remains knowledgeable on the identification and reporting of abuse/neglect/exploitation. o The facility has the Essential Rounds Program in place where administrative staff is assigned to residents. Staff will round and visit to ensure resident wellness and safety. Findings will be reported during Morning Stand-up meetings to address and follow up on concerns/grievances. Who conducts visits/rounds with residents on weekends? Manager on Duty and/or RN Supervisor Monitoring: o DON/designee will audit residents' incidents for possible abuse/neglect/exploitation issues 3 times per week for 3 months. o Administrator/designee will present findings to the QAPI committee monthly for 3 months. The QAPI Committee will make recommendations accordingly. o An AdHoc QAPI was conducted on 02/15/2024 attended by the Administrator, DON, Medical Director and Regional Clinical Specialist to discuss the Immediate Jeopardy concerning F 607 - develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents misappropriation of resident property and develop the above Action Plan. Please accept this letter as our plan of removal for the determination of Immediate Jeopardy issued on 2/21/24. Verification of the Plan of Removal: On 02/22/24 and 02/23/24 a total of 25 staff members from various departments from both day and night shifts were interviewed: -The staff had been trained over abuse and neglect and were aware of what to report, who to report to and time frames for reporting. -The staff members were aware of 1:1 supervision of residents and what that meant. -Nursing staff had been trained and were aware of required assessments under risk management to complete when dealing with an alleged violation that occurred at the facility or involved a resident. -Nursing staff were aware of what information would be documented on assessments and timeframe for completing those assessments. -The DON and Administrator had been trained over abuse and neglect, timely reporting, management and residents with behaviors and completing through investigations. -The DON and Administrator were aware of what should be reported, the appropriate time frames to report and had provided facility staff with training over abuse and neglect reporting. -The DON and Administrator and ADON stated they reviewed incidents for any potential abuse by reviewing items such as the 24-hour report, clinical notes, incident reports, risk management items and any report from nursing over incidents from the previous 24 hours during their morning meetings and stated this was something that was already apart of their procedures and something they would continue doing indefinitely. -Leadership staff stated items such as the 24-hour report and risk management items are also reviewed on the weekend by the RN supervisor or the DON. -The Administrator stated when any abuse or neglect occurrence were identified it would also be discussed during their monthly QAPI meeting with the medical director. -Leadership staff stated rounds were completed daily Monday through Friday morning by department heads with any concerns, grievances, or issues discussed during their morning meeting. -The Administrator also stated these rounds were completed by the manager on duty and the RN supervisor on the weekends and stated staff would receive education over abuse and neglect at least monthly. An IJ was identified on 02/21/23. The IJ template was provided to the facility on [DATE] at 10:01 AM. While the IJ was removed on 02/23/24, the facility remained out of compliance at a scope of pattern and a severity level of potential for more than minimal harm that is because all staff were not aware of and did not implement the facility's abuse prevention and reporting policy and procedure.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan, for two residents (Resident #1 and Resident #2) of 12 residents reviewed for quality of care, in that: The facility failed to promptly respond and assess Resident #1 and Resident #2 on 2 separate occasions by 2 different LVNs when they were made aware of Resident #1 and Resident #2 having injuries from an assault after being hit in the face multiple times, while they laid in bed resulting in bruising, cuts and discoloration to their face. An IJ was identified on 02/21/23. The IJ template was provided to the facility on [DATE] at 10:01 AM. While the IJ was removed on 02/23/24, the facility remained out of compliance at a scope of pattern and a severity level of potential for more than minimal harm that is because all staff were not aware of and did not implement the facility's abuse prevention and reporting policy and procedure. These deficient practices could affect residents and place them at risk of not receiving the who receive care and treatment needed from facility staff and affect their quality of life. The findings included: 1.) Resident #1 Resident#1 is an [AGE] year-old male initially admitted on [DATE] and readmitted on [DATE] with diagnosis of cerebral infarction (stroke), dysphagia (problem swallowing), cognitive communication deficit, dementia (cognitive memory deficit) and muscle wasting (decrease in size and wasting of muscle tissue) and atrophy (waste away). Record review of Resident #1's MDS Quarterly dated 11/25/2023 revealed Resident #1 had a BIMS Score of 01-severe cognitive impairment and needed extensive assistance with all ADLs. Record review of Resident #1's Care Plan date initiated on 11/27/2023 revealed Resident #1 had an ADL self-care performance deficit related to weakness, limited mobility. Resident #1 is dependent on staff for meeting emotional, intellectual, physical, and social needs r/t Cognitive deficits, Immobility. Interventions, Bed mobility: Resident #1 requires extensive assistance by x 1 staff to turn and reposition in bed frequently and as necessary. Transfers: requires Mechanical Lift (hoyer) with (2) staff assistance for transfers. The resident needs 1:1 bedside/in-room visits and activities if unable to attend out of room events. Record review of Resident #1's Weekly Skin Evaluation by LVN A dated 2/14/2024, revealed site: face, description: swelling under left eye with bruising and three small cuts to left inner eye area. Additional comments: was hit by another resident. Signed by LVN A on 02/15/2024. Record review of Resident #1's progress note dated 2/14/2024 at 23:14 (11:14PM) revealed Patient was in his room when another patient entered the room and hit the patient in the face. The patient sustained an injury he has swelling and bruising to left eye. Patient also has several small cuts to the left side of his face. Dr was notified along with Facility administrator and director of nursing. Patient family member was also notified. Patient showing no signs of distress noted at this time. Record review of Resident #1's incident report conducted by LVN A dated 2/15/2024, Incident description: Nursing description: Nurse was called to patient room by CNA. CNA informed nurse that patient was hit by another resident. Patient was laying in bed. Resident Description: Noted to have bruising and swelling to left eye with several small cuts to left inner and outer eye; Injuries observed at time of incident: No injuries observed at time of incident. Record review of Resident #1's incident report dated 2/15/2024 Injuries Report Post incident (conducted by DON): Injury Type: Bruise/Discoloration to: chest, right hand (back), face, left upper arm, left shoulder (front). Notes: Upon assessment resident identified with discoloration to top of right hand approximately 6.0x5.0cm. Large purple/green discoloration to left shoulder radiating towards left chest resembling as fingerprints. Left eye with swelling with red/purple discoloration. Left cheek with 2 superficial scratches and 1 small scratch below left eye. Small discoloration to left elbow. Other info: patient was hit by another resident. Record review of Resident#1's Pain Evaluation, revealed it was not performed by LVN A on 02/14/2024. Record review of Resident #1's Weekly Skin Evaluation conducted by DON dated 02/15/2024 at 10:19AM revealed Resident #1 sustained injury to: left elbow (discoloration), right hand (back)(discoloration), beneath left eye scratch, left cheek scratches, left chest discoloration, left eye discoloration with swelling, left shoulder discoloration. Additional comments: This is follow-up skin assessment for resident-to-resident altercation on 2/14/2024. Record review of Resident #1's Pain Evaluation conducted by the DON on 02/15/2024 at 12:07PM revealed Resident #1 complained of pain to his left eye-pain expressed post resident to resident altercation (receiver). Resident #1 exhibited facial pain expression of grimacing. Body language: tense. What alleviates the pain? Pain medication. What makes the pain worse? movement, touch. 2.) Resident #2 Resident #2 is an [AGE] year-old male initially admitted on [DATE] and readmitted on [DATE] with diagnosis of cerebral infarction (stroke), acute and chronic respiratory failure, and hemiplegia (paralysis) and hemiparesis (weakness or the inability to move on one side of the body) following cerebral infarction. Record review of Resident #2's Quarterly MDS dated [DATE] revealed a BIMS score of 01-severe cognitive impairment and needed extensive assistance with all ADLs. Record review of Resident #2's Care Plan date initiated 12/04/2023 revealed, the resident has an ADL self-care performance deficit r/t Hemiplegia. Interventions: functional performance: chair/bed-to-chair transfer: the resident requires dependent assistance required to transfer to and from a bed to a wheelchair. Functional performance: eating: The Resident requires Substantial Max assistance required for eating. Functional performance: lower body dressing: The Resident requires Extensive assistance required for lower/upper body dressing. Functional performance: lying to sitting on side of bed: The Resident requires Extensive assistance required to move from lying on the back to sitting on the side of the bed and with no back support. Functional performance: oral hygiene: The Resident requires Extensive assistance required for oral hygiene. Functional performance: roll left to right: The Resident requires Extensive assistance to roll from lying on back to left and right side and return to lying on back on the bed. BED MOBILITY: The resident requires extensive assistance by 1 staff to turn and reposition in bed at least Q2 hours and as necessary. TRANSFER: [Resident #2] requires Mechanical Lift (hoyer) with (2) staff assistance for transfers. Record review of Resident #2's progress notes by LVN A dated 2/14/2024 at 23:00 (11:00PM) revealed, Patient was laying in bed when another patient went into his room and hit him in the face. The patient received a bruise and several small cuts to right side of face. Patient stated another resident hit him with his fist. Facility Director DON and DR. were notified patient family RP was called and notified. Record review of Resident #2's Weekly Skin Evaluation dated 02/14/2024 conducted by LVN A, revealed Resident #2's face with bruising noted to right and left side of face with small cut to left side of face. Additional comments: Patient was hit by another patient. Signed by LVN A on 02/15/2024. Record review of Resident#1's Pain Evaluation revealed no evaluation was conducted/completed by LVN A on 02/14/2024. Record review of Resident #2's Incident report dated 2/14/2024 conducted by LVN A revealed, Incident Description: Nursing Description: CNA called nurse to patient room. Patient was hit by another resident in the face. Resident Description: Patient was laying in bed was noted to have red areas and cuts to both sides of his face. Immediate Action Taken: Description: Patient face was cleaned, and vitals were taken. Vitals WNL. Patient not showing any signs of distress at this time. RP, MD notified. Injury Type: Abrasion to face, injury type: bruise/discoloration to face. Record review of Resident #2's Incident report dated 2/14/2024 Injury Report Post Incident conducted by DON, Injury type: bruise/discoloration to face. Notes: Upon assessment resident identified with redness (with small areas of purple) discolorations throughout entire face and neck area. Resident has had small scratches to cheeks, beneath left eye, chin and left eyebrow. Other info: patient was hit by another resident. Record review of Resident #2's Weekly Wound progress dated 2/15/2024 conducted by the DON revealed, bruising and scratches, dark red/purple, Redness (with small areas of purple) discolorations throughout entire face, scratches beneath left eye, cheeks, chin and above left eyebrow. Record review of Resident #2's Progress note by LVN C dated 2/15/2024 at 6:50AM revealed, Resident assessed head to toe by this nurse. Resident's right jaw and ear with swelling and redness. Beneath left eye, cheek, and chin several scratches and redness. Resident asked if he had any pain and resident reports that his jaw hurts but unable to rate pain on scale of 0-10 which is baseline. Pain was treated with PRN Morphine 0.25ml SL which was effective. Record review of Resident #2's Progress note by DON dated 2/15/2024 at 13:00 (1:00PM) revealed, on 2/14/2024 Charge nurse reports resident was involved in a resident-to-resident altercation. Upon assessment resident identified with redness (with small areas of purple) discolorations throughout entire face and neck area. Resident also had small scratches to cheeks, beneath left eye, chin and left eyebrow.AM charge nurse reports she received an order for facial x-ray related to swelling and complaints of pain, x-ray results pending. Record review of Resident #2's Pain Evaluation dated 02/15/2024 at 15:03 (3:03PM) conducted by the DON, revealed Resident #2's face exhibited Pain expressed post resident to resident altercation (receiver). Resident #2 exhibited facial grimacing and tense body language. What alleviates the pain? Pain medication. What makes the pain worse? movement, touch. 2.) Resident #3 Resident#3 is an 80- year-old male admitted on [DATE] with diagnosis of congestive heart failure, dementia, without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, and cognitive communication deficit. Record review of Resident #3's quarterly MDS dated , 12/19/23 revealed a BIMS score of 2-severe cognitive impairment, physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) ranging 4-6days, uses walker for mobility, and can walk 50 feet with supervision. Record review of Resident #3's Care Plan revised on 10/02/2023 revealed, [Resident #3] is/has potential to be physically aggressive related to poor impulse control. Interventions: 12/16/2023, and 9/9/2023 Resident had a physical altercation with other resident, both were separated immediately. 2/14/24 - [Resident #3] had a physical altercation with other residents, both were separated immediately. 9/9/2023 Resident had a physical altercation with roommate, both were separated immediately. Roommate moved to another room. Administer medications as ordered. Monitor/document for side effects and effectiveness. Analyze times of day, places, or circumstances, triggers, and what de-escalates behavior and document. Assess and anticipate resident's needs: food, thirst. toileting needs, comfort level, body positioning, pain etc. COMMUNICATION: provide physical and verbal cues to alleviate anxiety; give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff member when agitated. Record review of Resident #3's weekly skin evaluation dated 2/14/2024 at 10:00AM and signed/lock date of 2/15/2024 at 12:57AM revealed, no injuries noted. - There was no other skin evaluation noted for the date 2/14/2024, post resident-to-resident altercation. Record review of Resident #3's progress notes, revealed no progress notes for date 2/14/2024 regarding resident-to-resident altercation. Record review of Resident #3's Progress note dated 2/15/2024 at 12:00AM, Doctor/MD notes: was informed of that patient had altercation with multiple residents causing injuries last night. Social worker received warrant to have patient sent to ER for clearance in preparation for admission to [hospital name] behavioral hospital. NP aware of patient status. Record review of Resident #3's Progress note dated 2/15/2024 at 1:13PM by the SW, Resident became combative with two other residents last night, then upon redirection he became combative towards staff. SW sent referral to behavioral health and requested services. SW requested an emergency detention warrant from the county judge. Judge Signed Warrant. When the officers arrived at the facility to transport Resident #3 to [behavioral hospital], Resident #3 became agitated, verbally aggressive, and then combative towards the officers. Once officers were able to subdue Resident #3, he was transferred to ER to get medically cleared for behavioral health. Record review of Resident #3's Progress note dated 2/15/2024 at 3:43PM by the DON, on 2/14/2024 Charge nurse reports resident was involved in resident-to-resident altercation (initiator-aggressor). Upon assessment resident identified with noted with purple discoloration to left hand. Social services to detain a detention warrant. Resident continues on 1 on 1care. Resident does not appear to have any negative psych-social effects from incident and is unable to recall event. Will continue to monitor. During an observation and interview on 02/17/2024 at 3:14PM Resident #1 stated a man entered his room and began hitting him in the face a couple of days ago. Resident #1 stated a man hit him about 5 times on his face. Resident #1 stated he was fearful of living at facility because he is scared the man is going to hit him again. Resident #1 stated the man stopped himself, and that there was no other person in the room. Upon observation Resident #1 has black/purple discoloration on left eye within the eye socket area as well as extended toward the temporal area where green discoloration is present and covers 25% of face. During an observation and intervention on 02/17/2024 at 3:14PM Resident #2 had purple/green discoloration on left eye around the rim of left eye, as well as had red/ purple discoloration on the right side of his neck, resembling a handprint. Resident #2 also had red discoloration on the lower left portion, near the lower left eye lid, of the eye socket, which appears to measure about one inch in circumference (circle like appearance). Resident #2 (Resident #1's roommate) stated it hurts while pointing to his left eye. During an interview on 02/17/2024 at 3:48PM NA A stated on 02/14/2024 at 8:25PM, she entered Resident #1 and Resident #2's room (roommates), and stated she looked at Resident #1's face and saw a dark shadow around his left eye, so she turned on the lights and saw bright red blood on at least half of Resident #1's face, as well as on Resident #1's blanket/covers, bed, and a little on the wall. NA A stated, when she asked Resident #1 what happened, Resident #1 stated that someone hit him and was trying to kill him. NA A stated she quickly ran out of the room and notified LVN A. NA A stated, while she notified LVN A at the nurse's station, she waited for LVN A to get up to check on Resident #1, but that LVN A did not immediately get up to assess the situation. NA A stated, while LVN A was at the nurse's station, LVN A directed NA A to go back into the room to clean up Resident #1, with perineal wet wipes, without LVN A assessing him first. NA A stated while cleaning up Resident #1, she saw he had bruises on his left side of chest, blood/bruising on his right hand and swelling on left eye with blood all over his face. NA A stated around 10:00 PM, LVN A accompanied NA A to observe Resident #1 in his room. NA A stated while LVN A was with her, LVN A did not assess under Resident #1's clothes or blankets, nor did she witness any head-to-toe assessment being conducted. NA A stated while NA A and LVN A were exiting the room, NA A noticed that Resident #2 was breathing irregular, to which NA A stated LVN A put a pulse oximeter on Resident #2's finger, and that LVN A stated, Resident #2 is breathing okay. NA A stated while LVN A was with her, she did not witness LVN A assess under Resident #2's clothes or blankets, nor did not see LVN A conduct a full head-to-toe assessment on Resident #2. NA A stated she then spoke to LVN B and explained the details of her initial findings of Resident #1's blood-soaked linen and face, and LVN B did not go with NA A to see Resident #1's injuries. NA A stated when she went back to her hall to check on Resident #1, when she saw Resident #3, the aggressor, in the hallway with blood on his fists. NA A stated when the morning shift (6AM on 2/15/24) arrived, she notified LVN C, and LVN C went into Resident #1 and Resident#2's room and observed that Resident #1 start to cry and complained he was hurting. Attempted to interview LVN A on 02/18/2024 at 9:18AM, 9:27AM, 5:07PM, as well as on 02/19/2024 at 4:39PM and on 02/23/24 at 5:10 PM, 5:11 PM, 5:12 PM but was unsuccessful. During an interview on 02/18/2024 at 9:54AM with LVN B, LVN B stated she did not enter the room of Resident #1 and Resident #2 (roommates) to assess the resident's injuries. LVN B stated she asked LVN A if she had completed, for Resident #1 and Resident #2, full head-to-toe assessments, behavior monitoring forms, as well as asked if she did the incident report, to which LVN A stated she did. LVN B stated she took what LVN A stated as truthful, and stated LVN A described the resident-to-resident altercation with minimal severity. LVN B stated she believed LVN A notified the proper chain of command, as well as believed LVN A completed the proper documentation, and did not find a need to intervene on LVN A's residents. LVN B stated she was in another resident's room, when LVN A ran to LVN B stating that Resident #3 was running after LVN A trying to hit LVN A and that Resident #3 was also yelling and stating vulgar and derogative remarks to LVN A. LVN B stated she quickly confronted Resident #3, de-escalated Resident #3's behavior, and guided Resident #3 back to his room, tucked him in, and left Resident #3's room. After leaving Resident #3's room she had no other contact with Resident #3 and did not enter Resident #1 and Resident #2's room. LVN B stated I don't remember anything from the night of the incident, I don't know exactly what happened or when because I was on the other side. LVN B stated she knew she needed to calm down Resident #3 and then he was okay after then. LVN B stated she was not sure the exact details of the altercation or injuries, LVN B stated she does not believe Resident #3 was put on a 1:1 the night of 2/14/2024. During an interview on 2/19/2024 at 5:47PM the DON and Administrator, the DON stated around 8:40PM she instructed LVN A to call the Administrator and stated that LVN A stated Resident #3 hit Resident #1. The Administrator stated that during that one and only notification phone call on 02/14/2024 at 8:45PM, LVN A never gave any detailed description of the severity of Resident #1's injury. The DON stated that on 2/14/24 at 9:50PM, she texted (text reviewed) LVN A that LVN A needed to complete a change in condition form, risk management form, Q15min behavior monitoring form, skin assessments, supportive documentation (weekly wound progress), and pain assessments for both Resident #1 and Resident #3 . The DON and Administrator stated LVN A skin assessments for Resident #1 and Resident #2 were not appropriate as they lacked substantial details. The DON stated the expectation of the facility was when performing a skin assessment/head-to-toe assessment the nurses are expected to describe the wound with measurements, color, type of tissue and if there is any pain. The DON continued by stating she called LVN B around 8:54PM on 02/14/2024, and she instructed LVN B to aide LVN A in calming down Resident #3. During that 8:54PM call, the DON did not instruct LVN B to do any form of assessment on Resident #1 or Resident#2 due to her belief that LVN A would follow her directive, and that the severity of the injuries was not fully detailed, to which would warrant an immediate commencement of investigation. The Administrator stated now looking back, she would have begun the investigation when she was notified, she would have removed Resident #3 from the immediate vicinity of Resident #1 and Resident #2, she would have put Resident #3 on a 1:1 to advocate for resident safety and would have notified the local authorities and state agencies. The Administrator stated a normal person, who is cognitively aware, may exhibit fearfulness if they knew their abuser was still close to them without constant supervision, and continued by stating it is unknown how a resident, who is not cognitively aware, would feel knowing the perpetrator was within their proximity. Both stated, in the future they will follow the facility's policy on abuse and neglect. Record review of LVN B's written and signed statement undated stated, Statement for incident on 2-14-24: At about 8:30PM on 2-14-24 [Resident #3] was observed walking down 100 Hall. The nurse for side 2 [clinical nurse name] informed me that Resident #3 had hit two other residents [Resident #2 and Resident #1]. [clinical nurse name ] asked me to calm Resident #3 down because he was trying to hit her and another aide. I assisted Resident #3 to his room and administered his evening medications.'- written statement does not indicate that LVN B checked on nor assessed Resident #1, Resident #2, nor Resident #3. Record review of the facility's Abuse/Neglect in-service was conducted on 02/15/2024 and completed on 02/21/2024. Record review of the facility's Abuse, Neglect and Exploitation policy dated 08/15/2022 stated, Protection of Resident- The facility will make efforts to ensure all resident are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. B. Examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed. C. Increased supervision of the alleged victim and residents; D. Room or staffing changes, if necessary, to protect the resident(s) from the alleged Perpetrator Record review of the facility's Skin Assessment policy dated 12/07/2022 stated, 1. A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse. The assessment may also be performed after a change of condition. 7. D. Describe wound (measurements, color, type of tissue in wound bed, drainage, order, pain). This was determined to be an Immediate Jeopardy (IJ) on 02/20/2024. The Administrator was notified. The Administrator was provided with IJ templates on 02/21/2024 at 10:01AM. The following Plan of Removal submitted by the facility was accepted on 02/22/24 at 3:58PM. The facility's Plan of Removal included: On February 21, 2024, the facility was notified by the surveyor, that an immediate jeopardy had been called and the facility needed to submit a letter of credible allegation. The Facility respectfully submits this Letter for Plan of Removal pursuant to Federal and State regulatory requirements. The immediate jeopardy allegations are as follows: F-Tag 600/67/684: Abuse Done for those affected: o Resident #3 was assessed by licensed nurse on 02/14/2024. MD was notified by licensed nurse on 02/14/2024. 02/14/2024 Resident #3 was placed on every 15-minute checks. Resident #3 was transferred to the hospital and was placed on 1:1 on 2/15/24 pending transfer to the hospital. Resident remains at the hospital. On Monday, 2/19/2024 Facility care planned with family. Referral is being sent to other facilities at the request of the family. If unable to find a transferring facility, the resident will return on a 1-1 until the decision is made on the 30-day notice of discharge. Resident will remain on 1-1 until he is discharged . o Resident #1 was assessed on 02/14/2024 by [clinical staff name] to include pain and skin evaluation. Assessment revealed swelling under left eye with bruising and 3 small cuts to left inner eye. Psychosocial assessment was completed by Social Worker on 02/15/2024. Plan of care was reviewed and updated by licensed nurse on 02/15/2024. MD was notified by licensed nurse on 02/14/2024 and 02/15/2024. o Resident #2 was assessed on 02/14/2024 by, [clinical staff name] to include pain and skin evaluation. Assessment revealed bruising noted to right and left side of face with small cut to left side of face. Psychosocial assessment was completed by Social Worker on 02/15/2024. Plan of care was reviewed and updated by licensed nurse on 02/15/2024. MD was notified by licensed nurse on 02/14/2024 and 02/15/2024. Identify residents who could be affected: o On 02/15/2024, the Facility Social Worker(s) completed 100% of interviews of interviewable residents to assess for potential abuse. No additional concerns were identified. Residents who are confused were asked yes and no questions. On the 2 residents who are unable to answer, their spouses were contacted. Out of the 2 one denied any allegations of abuse and the other did not answer his phone and has not returned the call. Was called each day and answered on 2/17/24 and he denied any allegations of abuse. o On 02/15/2024, the DON/designee reviewed the incident/accidents in the last 30 days to ensure that investigations, timely reporting to HHSC as indicated, resident assessments and supervision to include 1:1 supervision as needed were completed and provided. All other residents were identified to be in their room except 2 female residents who were up and watching television and do not have any history of behaviors. Systemic Process: o Effective immediately on 02/15/2024, the Administrator/ DON and/ or designee began reeducation to 100% of facility staff on the following: o Abuse and Neglect and Abuse Policy to include timely Investigation and HHSC Reporting to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. The Administrator who is the Abuse Prevention Coordinator will be immediately notified for any concerns with Abuse, Neglect and Misappropriation. o Resident Supervision to include 1:1 staff supervision o Quality of Care to include proper resident assessment with each resident incident/accidents - Please include what this process is/if using a P & P you may attach policy and include statement to refer to that policy #/name o See attached policy labeled Incidents and Accidents o During the Morning Meeting. Risk Management will be reviewed to ensure that all required assessments were completed. o when will an assessment be conducted after knowledge of an injury; o The assessment will be conducted at the time of incident and the nurse will enter all information into the appropriate forms within 8 hours of occurrence. o The assessment will include date, time, nature of incident, location, initial findings, immediate interventions, notifications and orders obtained or follow-up interventions. o The resident was placed on Q 15-minute checks immediately following the incident. Residents' doorway is visible from the nurses station and staff kept a watch on his door throughout the shift. Aides were on and off the halls throughout the night and the resident remained in his room and the other 2 residents were safe in bed. Resident remained in his room and no further behavior. At 6:00am the resident was placed on 1-1 in preparation for him to awaken. Social Worker went before Judge to obtain a detention warrant to [hospital name]. [local city police enforcement] called and notified of the incident and we requested assistance with transportation to [hospital name]. Staff will be reeducated prior to the start of their next scheduled shift. Any facility staff on FMLA, Leave of Absence, non-scheduled workday or PTO will be reeducated prior to the start of their next scheduled shift. o The facility maintains an onsite Weekend Manager and Nursing Supervisor that conduct rounds and may initiate and address resident incidents and will escalate to the appropriate administrative staff when required. The Administrator who is the Abuse Prevention Coordinator will be immediately notified for any concerns with Abuse, Neglect and Misappropriation. Is there a weekend manager/nurse supervisor on site in evening/night shift? Yes, there is a weekend manager/ nurse supervisor on the evening shift. After 6pm the 2 Charge Nurse are the supervisor's along with on call Director of Nurses and Administrator. o To monitor, the Director of Nursing/ designee will review resident incidents in facility Stand-up Morning Meeting, attended Monday - Friday. Resident incidents will be reviewed for potential abuse situations and need for reporting as per HHSC guidelines. Review will also include to ensure investigation was completed, resident assessments and supervision to include 1:1 supervision as needed was completed and provided. o The Administrator will monitor to ensure new resident incidents are reviewed daily Monday-Friday to ensure concerns are addressed timely and if necessary, reported per HHSC guidelines, investigation was completed, resident assessments and supervision to include 1:1 supervision as needed was completed and provided. - How long will this process occur? o On going as part of our Morning Meeting Process. o Administrator/designee will conduct quarterly and as needed on Abuse, Neglect, & Exploitation education to ensure facility staff remains knowledgeable on the identification and reporting of abuse/neglect/exploitation. o The facility has the Essential Rounds Program in place where administrative staff is assigned to residents. Staff will round and visit to ensure resident wellness and safety. Findings will be reported during Morning Stand-up meetings to address and follow up on concerns/grievances. Who conducts visits/rounds with residents on weekends? Manager on Duty and/or RN Supervisor Monitoring: o DON/designee will audit residents' incidents for possible abuse/neglect/exploitation issues 3 times per week for 3 months. o Administrator/designee will present findings to the QAPI committee monthly for 3 months. The QAPI Committee will make recommendations accordingly. o An AdHoc QAPI was conducted on 02/15/2024 attended by the Administrator, DON, Medical Director and Regional Clinical Specialist to discuss the Immediate Jeopardy concerning F tag 600 - Free from Abuse and Neglect; and develop the above Action Plan. Please accept this letter as our plan of removal for the determination of Immediate Jeopardy issued on 2/21/24. Verification of the Plan of Removal: On 02/22/24 and 02/23/24 a total of 25 staff members from various departments from both day and night shifts were interviewed: -The staff had been trained over abuse and neglect and were aware of[TRUNCATED]