**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents were treated with respect and dignity, including the right to be free from any physical restraints imposed for purposes of discipline or convenience for 3 of 3 residents (Residents #1, #2, and #3) reviewed for abuse and failed to provide ongoing oversight and supervision of staff to assure that its policies are implemented as written for three (Residents #1, #2, and #3) of three residents reviewed for abuse, oversight, and supervision. 1. Resident #1 was placed in a chair and tied to it with a lab coat by LVN A. 2. Resident #2 was held down with the full force of LVN A's body. 3. Resident #3 had her hands held above her head and her mouth covered when she protested by LVN A. On 7/11/2023 at 2:10 PM, the facility Administrator, DON, and the Corporate HR were notified that an Immediate Jeopardy situation had been identified due to the above failures. The Administrator was provided with an Immediate Jeopardy Template at that time, with a revised Template on 7/13/2023 at 2:47 PM. These failures resulted in the identification of Immediate Jeopardy (IJ) on 07/11/23 at 2:10 PM. While the immediacy was removed on 7/14/2023 at 12:00 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 after the IJ immediacy was removed due to the facility's need to monitor the implementation of the plan of removal. The findings included: A review of Resident #1's face sheet accessed on 7/7/2023 indicated a [AGE] year-old female with a diagnosis included dementia, senile degeneration (of older individuals who suffered from cognitive decline, memory loss), epilepsy, anxiety, and age-related osteoporosis. A review of Resident #1's Annual Minimum Data Set assessment for Cognitive Patterns dated 5/26/2023 and accessed on 7/7/2023 revealed a BIMS score of 00, which indicated severe cognitive impairment. A review of Resident #1's care plan initiated on 5/25/2023 indicated she was unable to sit still for any length of time and will sit herself down on the floor from chair, wheelchair and bed and crawl around on the floor. Interventions included, among other things, to approach/speak in a calm manner. Divert attention. Monitor for restlessness and assist Resident to sit on the floor in a safe space. A review of Resident #2's face sheet accessed on 7/7/2023 revealed an [AGE] year-old female with a diagnosis of dementia with other behavioral disturbance and major depressive disorder. A review of Resident #2's Quarterly Minimum Data Set assessment for Cognitive Pattern dated 4/13/2023 and accessed 7/7/2023 revealed a BIMS score of 6, which indicated severe cognitive impairment. A review of Resident #2's care plan initiated on 3/1/2023 revealed she was an elopement risk/wanderer and had behavioral problems with episodes of aggression. Interventions included diverting attention and speaking to Resident in a calm manner. A review of Resident #3's face sheet accessed on 7/7/2023 indicated an [AGE] year-old female with a diagnosis of Alzheimer's disease, dementia, osteoporosis, and anxiety disorder. A review of Resident #3's Annual Minimum Data Set assessment for Cognitive Pattern dated 4/3/2023 and accessed 7/7/2023 indicated a BIMS score of 1, which indicates severe cognitive impairment. A review of Resident #3's care plan initiated on 11/4/2022 indicates Resident becomes physically aggressive with staff during Resident care with interventions that include redirection, provide physical and verbal cues to alleviate anxiety, and 1:1 supervision until calm. Record review of a witness statement dated 6/15/2023 at 5:10 PM authored by CNA C documented that LVN A was aggressive with residents and that CNA C saw Resident #1 tied up. Record review of a witness statement dated 6/15/2023 authored by LVN B documented she untied Resident #1 with the help of CNA C. LVN B said she asked LVN A why she tied the Resident up and LVN A said she was exhausted by Resident #1 wandering up and down the halls. Record review of transcript of training for LVN A indicate training on abuse (6/2/2022), managing aggressive behaviors (6/21/2022), preventing abuse (6/22/2022) and (9/27/2022). Record review of Resident #1 incident report dated 6/15/2023 at 5:45 PM documented in the investigation summary the following: On 6-15-2023 at 4:00 PM CNA C was assigned to the 100 hall memory unit. She then noticed that Resident #1 had been tied to a chair at the nurse's station by means of a lab coat that belonged to LVN A. She tried to untie Resident #1 but was not able to. She then contacted LVN B, charge nurse assigned to 200 hall, about the situation. Both attempted to unite the resident but needed to have the resident slip underneath the knot in order to get her free. LVN B then contacted LVN A to ask if Resident #1 was OK. LVN A answered that she was exhausted due to the resident wandering all over. Upon learning of this incident, the person in charge of LVN A was contacted and advised of the incident involving her nurse. She was advised to never send the alleged perpetrator back to our facility. No further information at this time. Investigation findings: confirmed. During a telephone interview with the Administrator on 6/23/2023 at 3:45 PM he said I don't know where (LVN A) is now. She's not in my building. I did not report her to the BON. I thought you were going to do that. We are in the process of reporting her to the BON now. She doesn't work for me directly. She was contracted through the (company). During a telephone interview with the [company] regional staffing scheduler on 7/6/2023 at 10:30 AM revealed LVN A was suspended on June 15, 2023. She said LVN A was terminated after the investigation. She said they reported her to the BON for sure. She said their corporate RN, would have made the report to the BON. During a telephone interview with the [company] Corporate RN on 7/6/2023 at 1:30 PM she said she did not notify the BON. The Corporate RN said she assumed LVN A was already working at her previous job. She said she would report to the BON today. Record review of US Postal Service Certified First Class indicated notification to the Texas Board of Nursing was made on 7/6/2023. The Abuse Prevention Coordinator (APC) did not notify the licensing agent- Board of Nursing (BON) after an investigation was completed and until the surveyor's inquiry of LVN A's confirmed abuse of Residents #1, #2, and #3. The Abuse Prevention Coordinator did not notify the licensing agent (BON) after LVN B was issued a do-not-return to the facility for failure to immediately report witnessed abuse by LVN A to Resident #1 or being informed of abuse by LVN A to Residents #2 and #3. During an interview with the DON on 6/23/2023 at 4:40 PM she said she knew the nurse that tied up Resident #1. The DON said she did not report it to the BON. The DON said she called the agency the next day as soon as she found out. The DON said LVN A worked for the rest of her shift the night of the incidents after it was discovered she had tied up Resident #1 because no one immediately reported the incidents. The DON said LVN B was not allowed to work again for the facility because she did not report the abuse in a timely manner. The DON did not notify the BON about LVN B not reporting witnessed abuse. The DON said LVN B called her the next day to report the incident. The DON said she did call the police, but the police decided to not come out. The DON said the facility social worker assessed Resident #1 to make sure there were no ill effects they would have noticed. The DON said they have a lot of agency nurses, and she said she understood the nurses she got from agencies were the responsibility of the facility. The DON stated LVN B made her aware of the incident on 6/15/2023 when LVN B came in to work at 2 PM. During an observation and interview of Resident #1 on 7/6/2023 at 10:50 AM Resident #1 was found in her room, resting. Fall mat was in place. She was in no obvious distress. She was easily aroused and smiling upon hearing her name. Resident #1 was deemed un-interviewable. Resident #2 was observed in her room in bed. Resident #2 was deemed un-interviewable. Resident #2 was in no obvious distress. Resident #3 was observed in a common area in the locked unit. Resident #3 was deemed un-interviewable. Resident #3 was smiling and in no obvious distress. During an interview on 7/6/2023 at 11:00 AM with CNA D she said Resident #1 was usually nice, but around 4 PM her sundowners started kicking in and she would want to murder you. Resident #1 was usually sweet though. CNA D said there were enough staff on the floor. CNA D said her hall had two CNAs and a nurse for a census that was not that high. During an interview with CNA C on 7/7/2023 at 2:00 PM she indicated there were several things not in the witness statement she gave dated 6/15/2023 at 5:10 PM. CNA C said she told the DON, HR, and the ADON there were other things that happened, but they wanted to hear about Resident #1. CNA C said she asked LVN A to help her change Resident #2 during the early morning of June 15, 2023, and LVN A put her whole-body weight on Resident #2 to hold her down. CNA C said resident #2 seemed upset by being restrained. CNA C also indicated she asked LVN A for assistance changing Resident #3 on the night of June 14 and 15, 2023. CNA C said LVN A took Resident #3's hands and held them above her head and LVN A held her hand over Resident #3's mouth when Resident #3 screamed. CNA C said after she completed her rounds, she exited the secured unit and told LVN B about LVN A's actions towards Resident's #2 and #3. Further interview with CNA C revealed at approximately 3:30 AM, she and LVN B found Resident #1 sitting in a chair with a lab jacket tied around her and the chair with a tight knot at Resident #1's stomach area. CNA C said at first Resident #1 was calm but then she began to scream for help and was attempting to get up and out of the restraint. CNA C said she observed LVN A cover Resident #1's mouth with LVN A's hand when she started to scream. CNA C said she and LVN B attempted to remove the knot, but both were unsuccessful since the knot was too tight. CNA C said LVN B was going to cut the lab coat to get Resident #1 free, but LVN A protested saying it was an expensive jacket. CNA C said LVN A just stood there and watched while CNA C and LVN B attempted to free Resident #1. CNA C said LVN B had to tilt the chair back on its two back legs as CNA C slid Resident #1 out of the chair from under the jacket. CNA C said she was not aware how to report the things that happened but was aware that abuse should be reported to the administrator or DON immediately after the incident. She stated, We weren't taught those things in my class. CNA C said she was made aware of the protocol after it happened. She said she was trained to call the cops if she saw someone hitting a resident. CNA C said she was going to come in the next day and leave a note under the DONs door. An attempt was made to interview LVN A via telephone on 07/07/23 at 2:46 PM and 07/09/23 at 7:20 PM. No answer, voice message was left and return phone call received. Interview with LVN B on 07/09/23 at 5:35 PM revealed she was working the 6:00 PM- 6:00 AM shift on 06/14/23-06/15/23 on the 200 Hall. LVN B stated she was a pool nurse for the facility's parent company as was LVN A. LVN B said she worked with LVN A on a couple of other occasions and had not had any issues with her. LVN B said at approximately between 2:00 AM - 3:00 AM, CNA C walked out of the 100 Hall (secured unit) into the 200 Hall and approached LVN B as CNA C was crying and appeared upset. LVN B said CNA C told LVN B that she was upset and frustrated because LVN A was being rough with the residents, further saying LVN A was rough handling the residents, pinning them down. LVN B said CNA C took a few minutes to calm down and then went back to the 100 hall to finish her rounds. LVN B said she heard yelling coming from the 100 hall and when she went to check, she saw both LVN A and CNA C changing Resident #2 and was told by LVN A We got this, we got it. LVN B said she did not see anything wrong, so she went back to her hall. LVN B said later on (unsure of time lapse) CNA C again came out of the 100 hall looking upset with a flushed red face saying she could not take this. LVN B said she was dealing with two residents arguing on the 200 hall but she told CNA C she would go to the 100 Hall as soon as she could. LVN B said approximately 30-45 minutes later she opened the 100 hall locked doors, entered the 100 hall, and walked toward the dining area, hearing someone crying. LVN B said she saw Resident #1 sitting in a dining room chair with her arms down to her sides. A lab jacket was tied around the chair and tied into a tight knot in front of Resident #1's stomach. LVN B said Resident #1 was crying, screaming, and attempting to get loose from the tied lab jacket. LVN B said LVN A was standing by her medication cart approximately 3-4 feet away from Resident #1 and CNA C stood behind Resident #1 trying to remove the lab jacket. LVN B said she asked LVN A what was going on and LVN A said she was frustrated and tired that Resident #1 was agitated and was waking everyone else up. LVN B said she told LVN A This cannot happen, you're trippin, untie her now. LVN B said LVN A refused so LVN B attempted to remove the knot but was unable. LVN B said CNA C tried to undo the knot but was also unsuccessful. LVN B said she told LVN A that she was going to cut her jacket and that LVN A began to argue that her jacket was expensive, and it was not going to be cut. LVN B said Resident #1 was getting more agitated and her screaming was getting louder, Resident #1 was attempting to stand up with the chair on her back and LVN A began laughing at her. LVN B said she and CNA C leaned the chair back on the back to legs and slid Resident #1 out from under the jacket. LVN A said she did not do a head-to-toe assessment on Resident #1, but that Resident #1 did not seem to have any injuries or to be hurt. LVN B said she asked LVN A since she was frustrated, for her to take the 200 hall and she would cover the 100 hall but LVN A refused. LVN B said she went back to the 200 hall to continue her duties and check on the residents. LVN B said she did not go back to check any resident in the 100 hall after that. LVN B said she did not call any management at any time during her shift to report the incidents because she was overwhelmed and was also dealing with two residents fighting and trying to remove televisions from the walls. LVN B said she dealt with the two agitated residents for approximately two hours which led to her being behind with her other duties such as passing medications, collecting lab draws, and making the schedule for the next shift. LVN B said she got so behind that she did not finish her shift until 9 AM that morning. LVN B stated she did not know how long Resident #1 was restrained but estimated it was at least 30 minutes. LVN B said she left the facility without reporting any incident that happened. LVN B said she was tired and said she had worked her fifth 16-hour shift and had to return to the facility at 2:00 PM for another double shift. LVN B said she realized she had not reported the incident until she returned to the facility at 2:00 PM. LVN B said she immediately told the DON and then called the ADON with the DON present and LVN B's supervisor on the phone listening to her statement of the incident. LVN B said she was asked why she did not report the incident immediately or before the end of her shift, and she said she knew she should have reported the situation immediately but was so busy and tired and distraught that she simply forgot to report it before she left the building. LVN B said she did not remember to report the incident until she arrived back at the facility later that day at 2:00 PM and saw she was assigned to the secured unit and that was when she remembered the incident and to report it. During an interview with the ADON on 7/10/2023 at 10:25 AM she said no one had complained about LVN A before this event. The ADON said LVN A worked at the facility quite a bit, for the corporation. She said that none of the other nurses had reported any previous complaints about LVN A. The ADON said she wrote CNA C's statement of witnessed incident during her interview and CNA C did not mention there were other things that happened besides Resident #1 being tied up. During an interview with the Administrator on 7/10/2023 at 12:45 PM he said no one had complained to him about LVN A before this incident. During an interview with LVN E on 7/12/2023 at 12:40 PM she said she knew why the surveyor was present for physical restraints on Resident #1, and LVN A. LVN E said it tore her up when she heard it. LVN E came back on 6/19/2023 and heard it. LVN E said the CNAs told her what happened. LVN E said nurse B relieved her a few times. LVN E said she didn't know LVN B well, but she threatened her and that is why LVN E went back to PRN. LVN E said she was not aware that LVN A restrained anyone before Resident #1. LVN E said she never saw LVN A restrain anyone. LVN E said she never saw LVN A be abusive with any residents. LVN E said she would have stopped the abuse and reported it immediately. During an interview with the DON on 7/13/2023 at 2:50 PM revealed she knew why notification to the BON was important and stated it was important To remove their license and to protect the patients. Record review of facility's policy on abuse (Revised December 2017) indicated Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Record review of facility's policy on restraints (Implemented 8/15/2022) indicated that it is the policy of the facility that each resident shall attain and maintain his/her highest practicable well-being in an environment that prohibits the use of restraints for discipline or convenience and limits restraint use to circumstances in which the resident has medical symptoms that warrant the use of restraints. On 07/11/23 at 2:10 PM, an Immediate Jeopardy (IJ) was identified. The Administrator and DON were notified. The Administrator and DON were provided with the IJ template, and a Plan of Removal (POR) was explained and requested at that time. On 7/12/2023 at 5:37 PM, the facility was notified of the acceptance of the Plan of Removal (POR). The facility's Plan of Removal documented: PLAN OF REMOVAL 7/12/2023 LETTER OF CREDIBLE ALLEGATION FOR REMOVAL OF IMMEDIATE JEOPARDY On July 11, 2023, at approximately 2:30pm the Administrator was notified by the surveyor that an Immediate Jeopardy had been called for Resident #1. The Facility respectfully submits this Letter for Plan of Removal pursuant to Federal and State regulatory requirements. The immediate jeopardy allegations are as follows: Issue: F-Tag: 604 Right to be free from physical restraints Done for those affected: Head to toe assessment was completed on 6/15/23 for Resident #1 with no negative outcome. The Medical Director and the attending physician were notified on 6/15/23. Social Services completed a psychosocial assessment on Resident #1 on 6/16/23 with no ill effects. Head to toe assessment was completed by Licensed Nurse on Resident #2 on 7/11/23 with no negative outcome. Social Service completed a psychosocial assessment on Resident #2 on 7/11/23 with no ill effects. Head to toe assessment was completed on 07/12/2023 for Resident #3 with no negative outcome. The Medical Director and the attending physician were notified on 07/12/2023. Regional Clinical Nurse completed a psychosocial assessment on Resident #3 on 07/12/2023 with no ill effects. Identify residents who could be affected: Director of Nursing and/ or designee reviewed the last 30 days of incident reports to evaluate if anyone else could have been affected. No other residents were identified. Action Taken: Effective immediately on 7/11/2023, the Administrator/ DON and/ or designee began education to all staff on the new process. This process includes defining of restraints, demonstration of said restraints, and what the observer/employee should do if they observe behavior issues or catastrophic behaviors from residents. This should include providing safety of the resident and contacting abuse coordinator. The education will also include the different types of Abuse including restraints, timely reporting, and reporting to the Abuse Prevention Coordinator. The facility Administrator and/or Director of Nursing will be responsible for monitoring the implementation of the new process. This will be conducted by utilization of designated check list to be completed three times a week for four weeks. 24 Hour Report and Incident Reports will be reviewed in the morning clinical meeting attended by the Administrator and Director of Nursing to review for any inappropriate use of restraints. Re-education of all staff will be completed by 07/12/2023. Those that are PRN and/ or out on FMLA/ LOA will have the education completed prior to accepting assignment for their next scheduled shift. Involvement of Medical Director: The Medical Director was notified about the immediate jeopardy on 7/11/2023. Involvement of QA: On 7/11/2023 an Ad Hoc QAPI meeting was held with the Administrator, Director of Nursing, Regional Clinical Specialist, Medical Director, Regional [NAME] President of Operations, to review the plan of removal. Who is responsible for the implementation of the process? The Director of Nursing and Administrator will be responsible for the implementation of the new process. The new process/system was started on 7/11/2023. Who is responsible for the monitoring of the process? The Facility Administrator will be responsible for monitoring the implementation of this new process. Please accept this letter as our plan of removal for the determination of Immediate Jeopardy issued on 7/11/2023. Sincerely, Administrator The surveyor confirmed the Plan of Removal had been implemented sufficiently to remove the Immediate Jeopardy by: Record reviews of In-services included: In-Service training report for nursing, therapy, dietary, housekeeping, maintenance, managers (7/11/2023) abuse/neglect and restraint management. The in-service included definitions of abuse and restraints, and instructions on procedures to follow if abuse is witnessed, i.e. stopping the abuse, calling the abuse Coordinator immediately and not going home. Other tools used for training included the [company] Restraints Policy (8/15/2022) and Abuse/Neglect Policy (8/15/2022). A staff roster was used to ensure training was received by all staff. 92 staff were identified, and 9 PRN staff were pending in-service as of 7/14/2023 at 12:00 PM. Provisions were made to in-service untrained staff upon entrance to facility. A staff education tracking list was created to review in-service retention for staff with 100% success for ten out of ten staff on 7/13/2023. During in-person and telephone interviews with day, evening, and night facility staff on 7/13/2023 and 7/14/2023 it was determined 14 out of 14 staff interviewed were able to define types of restraints, identify restraints as a form of abuse, and describe steps to be taken in the event of witnessing such an occurrence. The following 14 staff were interviewed: CNA G LVN H Nursing assistant in training I CNA J LVN K CNA L LVN M CNA N LVN O CNA P CNA Q LVN R Med Aid S LVN T Record review of the facility's Abuse Policy dated 8/15/2022 indicated the facility will implement policies and procedures to prevent and prohibit all types of abuse that achieves: Assigning responsibility for the supervision of staff on all shifts for identifying inappropriate staff behaviors . Reporting/Response: the facility will have written procedures that include reporting to the state nurse aide registry or licensing authorities any knowledge it has of any actions by a court of law which would indicate an employee is unfit for service. The Administrator will follow up with government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within 5 working days of the incident, as required by state agencies. Review of the Nursing Practice Act, Texas Occupations Code, Section 301.401 - 301.419, requires nurse, nursing peer view committees, employers of nurses, as well as other entities, to report to the Texas Board of Nursing any nurse who engages in conduct subject to reporting, pursuant of Section 301,401 in that: Constitutes abuse Indicates that a nurse lacks knowledge, skill, judgement, or conscientiousness to such an extent that the nurse's continued practice of nursing could reasonably be expected to pose a risk of harm to a patient, regardless of whether the conduct consists of a single incident or a pattern of behavior. If an employer terminates, suspends for 7 or more days, makes an agency nurse a do-not-return, or takes other substantive disciplinary action against a nurse for practice related errors, a report to the BON is required. Review of the Texas Administrative Code, Title 22, Part 11, Chapter 217, Rule 217.11, Standards of Nursing Practice revealed The Texas Board of Nursing is responsible for regulating the practice of nursing within the State of Texas for Vocational Nurses, Registered Nurses, and Registered Nurses with advanced practice authorization. The standards of practice establish a minimum acceptable level of nursing practice in any setting for each level of nursing licensure or advanced practice authorization. Failure to meet these standards may result in action against the nurse's license even if no actual patient injury resulted. (1) Standards Applicable to All Nurses. All vocational nurses, registered nurses and registered nurses with advanced practice authorization shall: (A) Know and conform to the Texas Nursing Practice Act and the board's rules and regulations as well as all federal, state, or local laws, rules or regulations affecting the nurse's current area of nursing practice; (B) Implement measures to promote a safe environment for clients and others; . (D) Accurately and completely report and document: (i) the client's status including signs and symptoms; .(ii) abuse . (v) client response(s); and (vi) contacts with other health care team members concerning significant events regarding client's status; . The Texas Administrative Code, Title 22, Part 11, Chapter 217, Rule 217.12, Unprofessional Conduct revealed The unprofessional conduct rules are intended to protect clients and the public from incompetent, unethical, or illegal conduct of licensees. The purpose of these rules is to identify unprofessional or dishonorable behaviors of a nurse which the board believes are likely to deceive, defraud, or injure clients or public. Actual injury to a client need not be established. These behaviors include but are not limited to: Unsafe Practice--actions or conduct including, but not limited to: (A) Carelessly failing, repeatedly failing, or exhibiting an inability to perform vocational, registered, or advance practice nursing in conformity with the standards of minimum acceptable level of nursing practice set out in Rule 217.11 Record review of facility's policy on abuse (Revised December 2017) indicated Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Record review of facility's policy on restraints (Implemented 8/15/2022) indicated that it is the policy of the facility that each resident shall attain and maintain his/her highest practicable well-being in an environment that prohibits the use of restraints for discipline or convenience and limits restraint use to circumstances in which the resident has medical symptoms that warrant the use of restraints. Record review of training for LVN A indicates on 6/2/2022 and 9/27/2022 Preventing, Recognizing and Reporting Abuse training was completed. Record review of training for LVN B indicates on 5/30/2023 a last reminder was received and acknowledged by LVN B for Abuse Prevention Program ([NAME] 2) training due. No transcript was forthcoming from the facility. Record review of training for CNA C indicates Certification as a Texas Nurse Aid on 6/1/2023, with expiration on 6/1/2025. On 7/14/2023 at 12:00 PM, the Administrator and DON were informed the IJ was lifted. However, 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 after the IJ immediacy was removed due to the facility's need to monitor and evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that all alleged violations involving abuse 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 to the administrator of the facility and to other officials (including to the State Survey Agency where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures, for 3 of 3 residents (Residents #1, #2, and #3) reviewed for abuse. Resident #1 was placed in a chair and tied to it with a lab coat by LVN A. Resident #2 was held down with the full force of LVN A's body. Resident #3 had her hands held above her head and her mouth covered when she protested by LVN A. LVN B and CNA C had knowledge and witnessed LVN A abuse Residents #1, #2, and #3 and failed intervene to remove LVN A away from the residents to further prevent abuse. LVN B and CNA C had knowledge and/or witnessed LVN A abuse Residents #1, #2, and #3 and failed to notify the Abuse Prevention Coordinator/Administrator immediately. This failure could place residents at risk of abuse and injury. The staff failing to immediately report the incidents to the administrator/other officials could have led to the further abuse from LVN A. If the administrator/other officials were immediately notified, actions could have been taken to remove LVN A from the facility therefor preventing further abuse. On 7/11/2023 at 2:10 PM, the facility Administrator, DON, and the Corporate HR were notified that an Immediate Jeopardy situation had been identified due to the above failures. The Administrator was provided with an Immediate Jeopardy Template at that time, with a revised Template on 7/13/2023 at 2:47 PM. These failures resulted in the identification of Immediate Jeopardy (IJ) on 07/11/23 at 2:10 PM. While the immediacy was removed on 7/14/2023 at 12:00 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 after the IJ immediacy was removed due to the facility's need to monitor the implementation of the plan of removal. The findings were: A review of Resident #1's face sheet accessed on 7/7/2023 indicated a [AGE] year-old female with a diagnosis included dementia, senile degeneration (of older individuals who suffered from cognitive decline, memory loss), epilepsy, anxiety, and age-related osteoporosis. A review of Resident #1's Annual Minimum Data Set assessment for Cognitive Patterns dated 5/26/2023 and accessed on 7/7/2023 revealed a BIMS score of 00, which indicated severe cognitive impairment. A review of Resident #1's care plan initiated on 5/25/2023 indicated she was unable to sit still for any length of time and will sit herself down on the floor from chair, wheelchair and bed and crawl around on the floor. Interventions included, among other things, to approach/speak in a calm manner. Divert attention. Monitor for restlessness and assist resident to sit on the floor in a safe space. A review of Resident #2's face sheet accessed on 7/7/2023 revealed an [AGE] year-old female with a diagnosis of dementia with other behavioral disturbance and major depressive disorder. A review of Resident #2's Quarterly Minimum Data Set assessment for Cognitive Pattern dated 4/13/2023 and accessed 7/7/2023 revealed a BIMS score of 6, which indicated severe cognitive impairment. A review of Resident #2's care plan initiated on 3/1/2023 revealed she was an elopement risk/wanderer and had behavioral problems with episodes of aggression. Interventions included diverting attention and speaking to resident in a calm manner. A review of Resident #3's face sheet accessed on 7/7/2023 indicated an [AGE] year-old female with a diagnosis of Alzheimer's disease, dementia, osteoporosis and anxiety disorder. A review of Resident #3's Annual Minimum Data Set assessment for Cognitive Pattern dated 4/3/2023 and accessed 7/7/2023 indicated a BIMS score of 1, which indicates severe cognitive impairment. A review of Resident #3's care plan initiated on 11/4/2022 indicates resident becomes physically aggressive with staff during resident care with interventions that include redirection, provide physical and verbal cues to alleviate anxiety, and 1:1 supervision until calm. Record review of a witness statement dated 6/15/2023 at 5:10 PM authored by CNA C documented that LVN A was aggressive with residents and that CNA C saw Resident #1 tied up. Record review of a witness statement dated 6/15/2023 authored by LVN B documented she untied Resident #1 with the help of CNA C. LVN B said she asked LVN A why she tied the resident up and LVN A said she was exhausted by resident #1 wandering up and down the halls. Interview with the DON on 6/23/2023 at 4:40 PM she said she knew the nurse that tied up Resident #1. The DON said she did not report it to the BON. The DON said she called the agency the next day, as soon as she found out. The DON said LVN A worked for the rest of her shift the night of the incidents after it was discovered she had tied up Resident #1 because no one immediately reported the incidents. The DON said LVN B was not allowed to work again for the facility because she did not report the abuse in a timely manner. The DON did not notify the BON about LVN B not reporting witnessed abuse. The DON said LVN B called her the next day to report the incident. The DON said she did call the police, but the police decided to not come out. The DON said the facility social worker assessed Resident #1 to make sure there were no effects they would have noticed. The DON said they have a lot of agency nurses, and she said she understood the nurses she got from agencies were the responsibility of the facility. During an observation and interview of Resident #1 on 7/6/2023 at 10:50 AM Resident #1 was found in her room, resting. Fall mat was in place. She was in no obvious distress. She was easily aroused and smiling upon hearing her name. Resident #1 was deemed un-interviewable. During an interview with CNA C on 7/7/2023 at 2:00 PM she indicated there were several things not in the witness statement she gave dated 6/15/2023 at 5:10 PM. CNA C said she asked LVN A to help her change resident #2 during the early morning of July 15, 2023, and LVN A put her whole-body weight on resident #2 to hold her down. CNA C said resident #2 seemed upset by being restrained. CNA C also indicated she asked LVN A for assistance changing resident #3 on the night of June 14 and 15, 2023. CNA C said LVN A took resident #3's hands and held them above her head and LVN A held her hand over Resident #3's mouth when Resident #3 screamed. CNA C said after she completed her rounds, she exited the secured unit and told LVN B about LVN A's actions towards Resident's #2 and #3. Further interview with CNA C revealed at approximately 3:30 AM, she and LVN B found Resident #1 sitting in a chair with a lab jacket tied around her and the chair with a tight knot at Resident #1's stomach area. CNA C said at first Resident #1 was calm but then she began to scream for help and was attempting to get up and out of the restraint. CNA C said she observed LVN A cover Resident #1's mouth with LVN A's hand when she started to scream. CNA C said she and LVN B attempted to remove the knot, but both were unsuccessful since the knot was too tight. CNA C said LVN B was going to cut the lab coat to get Resident #1 free, but LVN A protested saying it was an expensive jacket. CNA C said LVN A just stood there and watched while CNA C and LVN B attempted to free Resident #1. CNA C said LVN B had to tilt the chair back on its two back legs as CNA C slid Resident #1 out of the chair from under the jacket. CNA C said she was not aware how to report the things that happened but was aware that abuse should be reported to the administrator or DON immediately after the incident. She stated We weren't taught those things in my class. CNA C said she was made aware of the protocol after it happened. She said she was trained to call the cops if she saw someone hitting a resident. CNA C said she was going to come in the next day and leave a note under the DONs door. Interview with LVN B on 07/09/23 at 5:35 PM revealed she was working the 6:00 PM- 6:00 AM shift on 07/14/23-07/15/23 on the 200 Hall. LVN B stated she was a pool nurse for the facility's parent company as was LVN A. LVN B said she worked with LVN A on a couple of other occasions and had not had any issues with her. LVN B said at approximately between 2:00 AM - 3:00 AM, CNA C walked out of the 100 Hall (secured unit) into the 200 Hall and approached LVN B as CNA C was crying and appeared upset. LVN B said CNA C told LVN B that she was upset and frustrated because LVN A was being rough with the residents, further saying LVN A was rough handling the residents, pinning them down. LVN B said CNA C took a few minutes to calm down and then went back to the 100 hall to finish her rounds. LVN B said she heard yelling coming from the 100 hall and when she went to check, she saw both LVN A and CNA C changing Resident #2 and was told by LVN A We got this, we got it. LVN B said she did not see anything wrong, so she went back to her hall. LVN B said later on (unsure of time lapse) CNA C again came out of the 100 hall looking upset with a flushed red face saying she could not take this. LVN B said she was dealing with two residents arguing on the 200 hall but she told CNA C she would go to the 100 Hall as soon as she could. LVN B said approximately 30-45 minutes later she opened the 100 hall locked doors, entered the 100 hall, and walked toward the dining area, hearing someone crying. LVN B said she saw Resident #1 sitting in a dining room chair with her arms down to her sides. A lab jacket was tied around the chair and tied into a tight knot in front of Resident #1's stomach. LVN B said Resident #1 was crying, screaming, and attempting to get loose from the tied lab jacket. LVN B said LVN A was standing by her medication cart approximately 3-4 feet away from Resident #1 and CNA C stood behind Resident #1 trying to remove the lab jacket. LVN B said she asked LVN A what was going on and LVN A said she was frustrated and tired that Resident #1 was agitated and was waking everyone else up. LVN B said she told LVN A This cannot happen, you're trippin, untie her now. LVN B said LVN A refused so LVN B attempted to remove the knot but was unable. LVN B said CNA C tried to undo the knot but was also unsuccessful. LVN B said she told LVN A that she was going to cut her jacket and that LVN A began to argue that her jacket was expensive, and it was not going to be cut. LVN B said Resident #1 was getting more agitated and her screaming was getting louder, Resident #1 was attempting to stand up with the chair on her back and LVN A began laughing at her. LVN B said she and CNA C leaned the chair back on the back to legs and slid Resident #1 out from under the jacket. LVN A said she did not do a head-to-toe assessment on Resident #1, but that Resident #1 did not seem to have any injuries or to be hurt. LVN B said she asked LVN A since she was frustrated, for her to take the 200 hall and she would cover the 100 hall but LVN A refused. LVN B said she went back to the 200 hall to continue her duties and check on the residents. LVN B said she did not go back to check any resident in the 100 hall after that. LVN B said she did not call any management at any time during her shift to report the incidents because she was overwhelmed and was also dealing with two residents fighting and trying to remove televisions from the walls. LVN B said she dealt with the two agitated residents for approximately two hours which led to her being behind with her other duties such as passing medications, collecting lab draws, and making the schedule for the next shift. LVN B said she got so behind that she did not finish her shift until 9 AM that morning. LVN B stated she did not know how long Resident #1 was restrained but estimated it was at least 30 minutes. LVN B said she left the facility without reporting any incident that happened. LVN B said she was tired and said she had worked her fifth 16-hour shift and had to return to the facility at 2:00 PM for another double shift. LVN B said she realized she had not reported the incident until she returned to the facility at 2:00 PM. LVN B said she immediately told the DON and then called the ADON with the DON present and LVN B's supervisor on the phone listening to her statement of the incident. LVN B said she was asked why she did not report the incident immediately or before the end of her shift, and she said she knew she should have reported the situation immediately but was so busy and tired and distraught that she simply forgot to report it before she left the building. LVN B said she did not remember to report the incident until she arrived back at the facility later that day at 2:00 PM and saw she was assigned to the secured unit and that was when she remembered the incident and to report it. During an interview with the ADON on 7/10/2023 at 10:25 AM she said no one had complained about LVN A before this event. The ADON said LVN A worked at the facility quite a bit, for the company. She said that none of the other nurses had reported any previous complaints about LVN A. The ADON said she wrote CNA C's statement of witnessed incident during her interview and CNA C did not mention there were other things that happened besides Resident #1 being tied up. During an interview with the Administrator on 7/10/2023 at 12:45 PM he said no one had complained to him about LVN A before this incident. On 07/11/23 at 2:10 PM, an Immediate Jeopardy (IJ) was identified. The Administrator and DON were notified. Specific to this citation, the severity was changed after administrative review, on 08/10/23 at 2:30 PM, the Administrator was provided with the IJ template, and a Plan of Removal (POR) was explained and requested at that time. Due to no change in deficiency after re-entering the facility on 08/10/23, the facility's original plan of removal was accepted. On 7/12/2023 at 5:37 PM, the facility was notified of the acceptance of the Plan of Removal (POR). The facility's Plan of Removal documented: PLAN OF REMOVAL 7/12/2023 LETTER OF CREDIBLE ALLEGATION FOR REMOVAL OF IMMEDIATE JEOPARDY On July 11, 2023, at approximately 2:30pm the Administrator was notified by the surveyor that an Immediate Jeopardy had been called for Resident #1. The Facility respectfully submits this Letter for Plan of Removal pursuant to Federal and State regulatory requirements. The immediate jeopardy allegations are as follows: Issue: F-Tag: 604 Right to be free from physical restraints Done for those affected: Head to toe assessment was completed on 6/15/23 for Resident #1 with no negative outcome. The Medical Director and the attending physician were notified on 6/15/23. Social Services completed a psychosocial assessment on Resident #1 on 6/16/23 with no ill effects. Head to toe assessment was completed by Licensed Nurse on Resident #2 on 7/11/23 with no negative outcome. Social Service completed a psychosocial assessment on Resident #2 on 7/11/23 with no ill effects. Head to toe assessment was completed on 07/12/2023 for Resident #3 with no negative outcome. The Medical Director and the attending physician were notified on 07/12/2023. Regional Clinical Nurse completed a psychosocial assessment on Resident #3 on 07/12/2023 with no ill effects. Identify residents who could be affected: Director of Nursing and/ or designee reviewed the last 30 days of incident reports to evaluate if anyone else could have been affected. No other residents were identified. Action Taken: Effective immediately on 7/11/2023, the Administrator/ DON and/ or designee began education to all staff on the new process. This process includes defining of restraints, demonstration of said restraints, and what the observer/employee should do if they observe behavior issues or catastrophic behaviors from residents. This should include providing safety of the resident and contacting abuse coordinator. The education will also include the different types of Abuse including restraints, timely reporting, and reporting to the Abuse Prevention Coordinator. The facility Administrator and/or Director of Nursing will be responsible for monitoring the implementation of the new process. This will be conducted by utilization of designated check list to be completed three times a week for four weeks. 24 Hour Report and Incident Reports will be reviewed in the morning clinical meeting attended by the Administrator and Director of Nursing to review for any inappropriate use of restraints. Re-education of all staff will be completed by 07/12/2023. Those that are PRN and/ or out on FMLA/ LOA will have the education completed prior to accepting assignment for their next scheduled shift. Involvement of Medical Director: The Medical Director was notified about the immediate jeopardy on 7/11/2023. Involvement of QA: On 7/11/2023 an Ad Hoc QAPI meeting was held with the Administrator, Director of Nursing, Regional Clinical Specialist, Medical Director, Regional [NAME] President of Operations, to review the plan of removal. Who is responsible for the implementation of the process? The Director of Nursing and Administrator will be responsible for the implementation of the new process. The new process/system was started on 7/11/2023. Who is responsible for the monitoring of the process? The Facility Administrator will be responsible for monitoring the implementation of this new process. Please accept this letter as our plan of removal for the determination of Immediate Jeopardy issued on 7/11/2023. Sincerely, Administrator The surveyor confirmed the Plan of Removal had been implemented sufficiently to remove the Immediate Jeopardy by: Record reviews of In-services included: In-Service training report for nursing, therapy, dietary, housekeeping, maintenance, managers (7/11/2023) abuse/neglect and restraint management. The in-service included definitions of abuse and restraints, and instructions on procedures to follow if abuse is witnessed, i.e. stopping the abuse, calling the abuse Coordinator immediately and not going home. Other tools used for training included the [company] Restraints Policy (8/15/2022) and Abuse/Neglect Policy (8/15/2022). A staff roster was used to ensure training was received by all staff. 92 staff were identified, and 9 PRN staff were pending in-service as of 7/14/2023 at 12:00 PM. Provisions were made to in-service untrained staff upon entrance to facility. A staff education tracking list was created to review in-service retention for staff with 100% success for ten out of ten staff on 7/13/2023. During in-person and telephone interviews with day, evening, and night facility staff on 7/13/2023 and 7/14/2023 it was determined 14 out of 14 staff interviewed were able to define types of restraints, identify restraints as a form of abuse, and describe steps to be taken in the event of witnessing such an occurrence. The following 14 staff were interviewed: CNA G LVN H Nursing assistant in training I CNA J LVN K CNA L LVN M CNA N LVN O CNA P CNA Q LVN R Med Aid S LVN T Record review of the facility's Abuse Policy dated 8/15/2022 indicated the facility will implement policies and procedures to prevent and prohibit all types of abuse that achieves: Assigning responsibility for the supervision of staff on all shifts for identifying inappropriate staff behaviors . Reporting/Response: the facility will have written procedures that include reporting to the state nurse aide registry or licensing authorities any knowledge it has of any actions by a court of law which would indicate an employee is unfit for service. The Administrator will follow up with government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within 5 working days of the incident, as required by state agencies. During an interview with the DON on 7/13/2023 at 2:50 PM revealed she knew why notification to the BON was important and stated it was important To remove their license and to protect the patients. Record review of facility's policy on abuse (Revised December 2017) indicated Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Record review of facility's policy on restraints (Implemented 8/15/2022) indicated that it is the policy of the facility that each resident shall attain and maintain his/her highest practicable well-being in an environment that prohibits the use of restraints for discipline or convenience and limits restraint use to circumstances in which the resident has medical symptoms that warrant the use of restraints. On 7/14/2023 at 12:00 PM, the Administrator and DON were informed the IJ was lifted. However, 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 after the IJ immediacy was removed due to the facility's need to monitor and evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that all alleged violations involving abuse 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 to the administrator of the facility and to other officials (including to the State Survey Agency where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures, for 3 of 3 residents (Residents #1, #2, and #3) reviewed for abuse. Resident #1 was placed in a chair and tied to it with a lab coat by LVN A. Resident #2 was held down with the full force of LVN A's body. Resident #3 had her hands held above her head and her mouth covered when she protested by LVN A. LVN B and CNA C had knowledge and/or witnessed LVN A abuse Residents #1, #2, and #3 and failed to notify the Abuse Prevention Coordinator/Administrator immediately. The Abuse Prevention Coordinator did not notify the licensing agent (Board of Nursing - BON) of abuse committed by LVN A after an investigation was completed and until the surveyor's inquiry. This failure could place residents at risk of abuse and injury. The staff failing to immediately report the incidents to the administrator/other officials could have led to the further abuse from LVN A. If the administrator/other officials were immediately notified, actions could have been taken to remove LVN A from the facility therefor preventing further abuse. On 7/11/2023 at 2:10 PM, the facility Administrator, DON, and the Corporate HR were notified that an Immediate Jeopardy situation had been identified due to the above failures. The Administrator was provided with an Immediate Jeopardy Template at that time, with a revised Template on 7/13/2023 at 2:47 PM. These failures resulted in the identification of Immediate Jeopardy (IJ) on 07/11/23 at 2:10 PM. While the immediacy was removed on 7/14/2023 at 12:00 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 after the IJ immediacy was removed due to the facility's need to monitor the implementation of the plan of removal. The findings were: A review of Resident #1's face sheet accessed on 7/7/2023 indicated a [AGE] year-old female with a diagnosis included dementia, senile degeneration (of older individuals who suffered from cognitive decline, memory loss), epilepsy, anxiety, and age-related osteoporosis. A review of Resident #1's Annual Minimum Data Set assessment for Cognitive Patterns dated 5/26/2023 and accessed on 7/7/2023 revealed a BIMS score of 00, which indicated severe cognitive impairment. A review of Resident #1's care plan initiated on 5/25/2023 indicated she was unable to sit still for any length of time and will sit herself down on the floor from chair, wheelchair and bed and crawl around on the floor. Interventions included, among other things, to approach/speak in a calm manner. Divert attention. Monitor for restlessness and assist resident to sit on the floor in a safe space. A review of Resident #2's face sheet accessed on 7/7/2023 revealed an [AGE] year-old female with a diagnosis of dementia with other behavioral disturbance and major depressive disorder. A review of Resident #2's Quarterly Minimum Data Set assessment for Cognitive Pattern dated 4/13/2023 and accessed 7/7/2023 revealed a BIMS score of 6, which indicated severe cognitive impairment. A review of Resident #2's care plan initiated on 3/1/2023 revealed she was an elopement risk/wanderer and had behavioral problems with episodes of aggression. Interventions included diverting attention and speaking to resident in a calm manner. A review of Resident #3's face sheet accessed on 7/7/2023 indicated an [AGE] year-old female with a diagnosis of Alzheimer's disease, dementia, osteoporosis and anxiety disorder. A review of Resident #3's Annual Minimum Data Set assessment for Cognitive Pattern dated 4/3/2023 and accessed 7/7/2023 indicated a BIMS score of 1, which indicates severe cognitive impairment. A review of Resident #3's care plan initiated on 11/4/2022 indicates resident becomes physically aggressive with staff during resident care with interventions that include redirection, provide physical and verbal cues to alleviate anxiety, and 1:1 supervision until calm. Record review of a witness statement dated 6/15/2023 at 5:10 PM authored by CNA C documented that LVN A was aggressive with residents and that CNA C saw Resident #1 tied up. Record review of a witness statement dated 6/15/2023 authored by LVN B documented she untied Resident #1 with the help of CNA C. LVN B said she asked LVN A why she tied the resident up and LVN A said she was exhausted by resident #1 wandering up and down the halls. Interview with the DON on 6/23/2023 at 4:40 PM she said she knew the nurse that tied up Resident #1. The DON said she did not report it to the BON. The DON said she called the agency the next day, as soon as she found out. The DON said LVN A worked for the rest of her shift the night of the incidents after it was discovered she had tied up Resident #1 because no one immediately reported the incidents. The DON said LVN B was not allowed to work again for the facility because she did not report the abuse in a timely manner. The DON did not notify the BON about LVN B not reporting witnessed abuse. The DON said LVN B called her the next day to report the incident. The DON said she did call the police, but the police decided to not come out. The DON said the facility social worker assessed Resident #1 to make sure there were no effects they would have noticed. The DON said they have a lot of agency nurses, and she said she understood the nurses she got from agencies were the responsibility of the facility. During an observation and interview of Resident #1 on 7/6/2023 at 10:50 AM Resident #1 was found in her room, resting. Fall mat was in place. She was in no obvious distress. She was easily aroused and smiling upon hearing her name. Resident #1 was deemed un-interviewable. During an interview with CNA C on 7/7/2023 at 2:00 PM she indicated there were several things not in the witness statement she gave dated 6/15/2023 at 5:10 PM. CNA C said she asked LVN A to help her change resident #2 during the early morning of July 15, 2023, and LVN A put her whole-body weight on resident #2 to hold her down. CNA C said resident #2 seemed upset by being restrained. CNA C also indicated she asked LVN A for assistance changing resident #3 on the night of June 14 and 15, 2023. CNA C said LVN A took resident #3's hands and held them above her head and LVN A held her hand over Resident #3's mouth when Resident #3 screamed. CNA C said after she completed her rounds, she exited the secured unit and told LVN B about LVN A's actions towards Resident's #2 and #3. Further interview with CNA C revealed at approximately 3:30 AM, she and LVN B found Resident #1 sitting in a chair with a lab jacket tied around her and the chair with a tight knot at Resident #1's stomach area. CNA C said at first Resident #1 was calm but then she began to scream for help and was attempting to get up and out of the restraint. CNA C said she observed LVN A cover Resident #1's mouth with LVN A's hand when she started to scream. CNA C said she and LVN B attempted to remove the knot, but both were unsuccessful since the knot was too tight. CNA C said LVN B was going to cut the lab coat to get Resident #1 free, but LVN A protested saying it was an expensive jacket. CNA C said LVN A just stood there and watched while CNA C and LVN B attempted to free Resident #1. CNA C said LVN B had to tilt the chair back on its two back legs as CNA C slid Resident #1 out of the chair from under the jacket. CNA C said she was not aware how to report the things that happened but was aware that abuse should be reported to the administrator or DON immediately after the incident. She stated We weren't taught those things in my class. CNA C said she was made aware of the protocol after it happened. She said she was trained to call the cops if she saw someone hitting a resident. CNA C said she was going to come in the next day and leave a note under the DONs door. Interview with LVN B on 07/09/23 at 5:35 PM revealed she was working the 6:00 PM- 6:00 AM shift on 07/14/23-07/15/23 on the 200 Hall. LVN B stated she was a pool nurse for the facility's parent company as was LVN A. LVN B said she worked with LVN A on a couple of other occasions and had not had any issues with her. LVN B said at approximately between 2:00 AM - 3:00 AM, CNA C walked out of the 100 Hall (secured unit) into the 200 Hall and approached LVN B as CNA C was crying and appeared upset. LVN B said CNA C told LVN B that she was upset and frustrated because LVN A was being rough with the residents, further saying LVN A was rough handling the residents, pinning them down. LVN B said CNA C took a few minutes to calm down and then went back to the 100 hall to finish her rounds. LVN B said she heard yelling coming from the 100 hall and when she went to check, she saw both LVN A and CNA C changing Resident #2 and was told by LVN A We got this, we got it. LVN B said she did not see anything wrong, so she went back to her hall. LVN B said later on (unsure of time lapse) CNA C again came out of the 100 hall looking upset with a flushed red face saying she could not take this. LVN B said she was dealing with two residents arguing on the 200 hall but she told CNA C she would go to the 100 Hall as soon as she could. LVN B said approximately 30-45 minutes later she opened the 100 hall locked doors, entered the 100 hall, and walked toward the dining area, hearing someone crying. LVN B said she saw Resident #1 sitting in a dining room chair with her arms down to her sides. A lab jacket was tied around the chair and tied into a tight knot in front of Resident #1's stomach. LVN B said Resident #1 was crying, screaming, and attempting to get loose from the tied lab jacket. LVN B said LVN A was standing by her medication cart approximately 3-4 feet away from Resident #1 and CNA C stood behind Resident #1 trying to remove the lab jacket. LVN B said she asked LVN A what was going on and LVN A said she was frustrated and tired that Resident #1 was agitated and was waking everyone else up. LVN B said she told LVN A This cannot happen, you're trippin, untie her now. LVN B said LVN A refused so LVN B attempted to remove the knot but was unable. LVN B said CNA C tried to undo the knot but was also unsuccessful. LVN B said she told LVN A that she was going to cut her jacket and that LVN A began to argue that her jacket was expensive, and it was not going to be cut. LVN B said Resident #1 was getting more agitated and her screaming was getting louder, Resident #1 was attempting to stand up with the chair on her back and LVN A began laughing at her. LVN B said she and CNA C leaned the chair back on the back to legs and slid Resident #1 out from under the jacket. LVN A said she did not do a head-to-toe assessment on Resident #1, but that Resident #1 did not seem to have any injuries or to be hurt. LVN B said she asked LVN A since she was frustrated, for her to take the 200 hall and she would cover the 100 hall but LVN A refused. LVN B said she went back to the 200 hall to continue her duties and check on the residents. LVN B said she did not go back to check any resident in the 100 hall after that. LVN B said she did not call any management at any time during her shift to report the incidents because she was overwhelmed and was also dealing with two residents fighting and trying to remove televisions from the walls. LVN B said she dealt with the two agitated residents for approximately two hours which led to her being behind with her other duties such as passing medications, collecting lab draws, and making the schedule for the next shift. LVN B said she got so behind that she did not finish her shift until 9 AM that morning. LVN B stated she did not know how long Resident #1 was restrained but estimated it was at least 30 minutes. LVN B said she left the facility without reporting any incident that happened. LVN B said she was tired and said she had worked her fifth 16-hour shift and had to return to the facility at 2:00 PM for another double shift. LVN B said she realized she had not reported the incident until she returned to the facility at 2:00 PM. LVN B said she immediately told the DON and then called the ADON with the DON present and LVN B's supervisor on the phone listening to her statement of the incident. LVN B said she was asked why she did not report the incident immediately or before the end of her shift, and she said she knew she should have reported the situation immediately but was so busy and tired and distraught that she simply forgot to report it before she left the building. LVN B said she did not remember to report the incident until she arrived back at the facility later that day at 2:00 PM and saw she was assigned to the secured unit and that was when she remembered the incident and to report it. During an interview with the ADON on 7/10/2023 at 10:25 AM she said no one had complained about LVN A before this event. The ADON said LVN A worked at the facility quite a bit, for the company. She said that none of the other nurses had reported any previous complaints about LVN A. The ADON said she wrote CNA C's statement of witnessed incident during her interview and CNA C did not mention there were other things that happened besides Resident #1 being tied up. During an interview with the Administrator on 7/10/2023 at 12:45 PM he said no one had complained to him about LVN A before this incident. On 07/11/23 at 2:10 PM, an Immediate Jeopardy (IJ) was identified. The Administrator and DON were notified. Specific to this citation, the severity was changed after administrative review, on 08/10/23 at 2:30 PM, the Administrator was provided with the IJ template, and a Plan of Removal (POR) was explained and requested at that time. Due to no change in deficiency after re-entering the facility on 08/10/23, the facility's original plan of removal was accepted. On 7/12/2023 at 5:37 PM, the facility was notified of the acceptance of the Plan of Removal (POR). The facility's Plan of Removal documented: PLAN OF REMOVAL 7/12/2023 LETTER OF CREDIBLE ALLEGATION FOR REMOVAL OF IMMEDIATE JEOPARDY On July 11, 2023, at approximately 2:30pm the Administrator was notified by the surveyor that an Immediate Jeopardy had been called for Resident #1. The Facility respectfully submits this Letter for Plan of Removal pursuant to Federal and State regulatory requirements. The immediate jeopardy allegations are as follows: Issue: F-Tag: 604 Right to be free from physical restraints Done for those affected: Head to toe assessment was completed on 6/15/23 for Resident #1 with no negative outcome. The Medical Director and the attending physician were notified on 6/15/23. Social Services completed a psychosocial assessment on Resident #1 on 6/16/23 with no ill effects. Head to toe assessment was completed by Licensed Nurse on Resident #2 on 7/11/23 with no negative outcome. Social Service completed a psychosocial assessment on Resident #2 on 7/11/23 with no ill effects. Head to toe assessment was completed on 07/12/2023 for Resident #3 with no negative outcome. The Medical Director and the attending physician were notified on 07/12/2023. Regional Clinical Nurse completed a psychosocial assessment on Resident #3 on 07/12/2023 with no ill effects. Identify residents who could be affected: Director of Nursing and/ or designee reviewed the last 30 days of incident reports to evaluate if anyone else could have been affected. No other residents were identified. Action Taken: Effective immediately on 7/11/2023, the Administrator/ DON and/ or designee began education to all staff on the new process. This process includes defining of restraints, demonstration of said restraints, and what the observer/employee should do if they observe behavior issues or catastrophic behaviors from residents. This should include providing safety of the resident and contacting abuse coordinator. The education will also include the different types of Abuse including restraints, timely reporting, and reporting to the Abuse Prevention Coordinator. The facility Administrator and/or Director of Nursing will be responsible for monitoring the implementation of the new process. This will be conducted by utilization of designated check list to be completed three times a week for four weeks. 24 Hour Report and Incident Reports will be reviewed in the morning clinical meeting attended by the Administrator and Director of Nursing to review for any inappropriate use of restraints. Re-education of all staff will be completed by 07/12/2023. Those that are PRN and/ or out on FMLA/ LOA will have the education completed prior to accepting assignment for their next scheduled shift. Involvement of Medical Director: The Medical Director was notified about the immediate jeopardy on 7/11/2023. Involvement of QA: On 7/11/2023 an Ad Hoc QAPI meeting was held with the Administrator, Director of Nursing, Regional Clinical Specialist, Medical Director, Regional [NAME] President of Operations, to review the plan of removal. Who is responsible for the implementation of the process? The Director of Nursing and Administrator will be responsible for the implementation of the new process. The new process/system was started on 7/11/2023. Who is responsible for the monitoring of the process? The Facility Administrator will be responsible for monitoring the implementation of this new process. Please accept this letter as our plan of removal for the determination of Immediate Jeopardy issued on 7/11/2023. Sincerely, Administrator The surveyor confirmed the Plan of Removal had been implemented sufficiently to remove the Immediate Jeopardy by: Record reviews of In-services included: In-Service training report for nursing, therapy, dietary, housekeeping, maintenance, managers (7/11/2023) abuse/neglect and restraint management. The in-service included definitions of abuse and restraints, and instructions on procedures to follow if abuse is witnessed, i.e. stopping the abuse, calling the abuse Coordinator immediately and not going home. Other tools used for training included the [company] Restraints Policy (8/15/2022) and Abuse/Neglect Policy (8/15/2022). A staff roster was used to ensure training was received by all staff. 92 staff were identified, and 9 PRN staff were pending in-service as of 7/14/2023 at 12:00 PM. Provisions were made to in-service untrained staff upon entrance to facility. A staff education tracking list was created to review in-service retention for staff with 100% success for ten out of ten staff on 7/13/2023. During in-person and telephone interviews with day, evening, and night facility staff on 7/13/2023 and 7/14/2023 it was determined 14 out of 14 staff interviewed were able to define types of restraints, identify restraints as a form of abuse, and describe steps to be taken in the event of witnessing such an occurrence. The following 14 staff were interviewed: CNA G LVN H Nursing assistant in training I CNA J LVN K CNA L LVN M CNA N LVN O CNA P CNA Q LVN R Med Aid S LVN T Record review of the facility's Abuse Policy dated 8/15/2022 indicated the facility will implement policies and procedures to prevent and prohibit all types of abuse that achieves: Assigning responsibility for the supervision of staff on all shifts for identifying inappropriate staff behaviors . Reporting/Response: the facility will have written procedures that include reporting to the state nurse aide registry or licensing authorities any knowledge it has of any actions by a court of law which would indicate an employee is unfit for service. The Administrator will follow up with government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within 5 working days of the incident, as required by state agencies. During an interview with the DON on 7/13/2023 at 2:50 PM revealed she knew why notification to the BON was important and stated it was important To remove their license and to protect the patients. Record review of facility's policy on abuse (Revised December 2017) indicated Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Record review of facility's policy on restraints (Implemented 8/15/2022) indicated that it is the policy of the facility that each resident shall attain and maintain his/her highest practicable well-being in an environment that prohibits the use of restraints for discipline or convenience and limits restraint use to circumstances in which the resident has medical symptoms that warrant the use of restraints. On 7/14/2023 at 12:00 PM, the Administrator and DON were informed the IJ was lifted. However, 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 after the IJ immediacy was removed due to the facility's need to monitor and evaluate the effectiveness of the corrective systems.