**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure residents had the right to be free from physical abuse by staff for 1 of 3 (Resident #1) residents reviewed for abuse. The facility failed to ensure Resident #1 was not physically abused by CNA A after Resident#1 suffered pain and fear after incontinent care was provided roughly by CNA A, using a dry towel and a healing labial skin tear was identified on 06/03/25. CNA A provided incontinent care to Resident #1 again with a dry towel and Resident #1 told CNA A not to come into her room. CNA A continued to provide care to Resident #1 until the day before her discharge on [DATE]. The facility failed to implement protective measures as CNA A continued to provide care to Resident #1 until the day before her discharge on [DATE]. An Immediate Jeopardy (IJ) was identified on 09/11/25 at 6:52 PM and an IJ template was provided. While the IJ was removed on 09/12/25 at 7:00 PM, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy due to the facility need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk for abuse, neglect, and exploitation.Findings included: Review of Resident #1's face sheet, dated 09/11/25, reflected a [AGE] year-old female originally admitted to the facility on [DATE], readmitted on [DATE], and discharged on 06/17/25. Her diagnoses included sequelae of cerebral infarction (complications that occur after a stroke), sepsis (a response to an infection that can cause organ damages), diabetes (a disease that affects how the body uses glucose), depression, anxiety, and osteomyelitis of sacral region (an infection of the tailbone). Review of Resident #1's 5-day MDS assessment, dated 05/15/25, Section C (Cognitive Patterns) reflected a BIMS score of 15, reflecting intact cognition. Section GG (Functional Abilities) reflected she was dependent on staff for toileting hygiene. Section H (Bladder and Bowel) reflected she was incontinent of bowel and bladder. Section M (Skin Conditions) reflected the resident had no pressure injuries/ulcers and no venous or arterial ulcers present and that she received pressure ulcer/injury care. Review of Resident #1's comprehensive care plan, revised 05/18/25, reflected in part as follows:Problem: Resident #1 experiences bowel incontinence. Goal: Resident #1 will not exhibit skin breakdown, constipation/impaction, impaired social interaction, secondary to bowel incontinence. Approach: .Report signs of skin breakdown or perianal excoriation (skin issues around the anus) . Use appropriate incontinence management products to promote hygiene and dignity. Use skin barrier after incontinent episodes. The care plan did not address a skin tear on the labia. Review of Resident #1's active physician's orders as of 06/16/25, printed on 09/11/25, reflected: Apply zinc barrier cream or Triad paste(an ointment used to protect the skin and promote wound healing) to wound on right posterior thigh, cover with xeroform BID. The order was dated 04/09/25. The physician orders did not address any treatment for a skin tear on the labia. Review of Resident #1's progress notes from 03/21/25 through 06/17/25 reflected a note written 06/03/25 at 10:09 PM by LVN C, Skin assessment performed. No new skin injuries were observed. Old skin tear to right labia appears 90% healed. No more redness present. Can barely see where the skin tear was. Healing well. Continuing to put barrier cream on skin tear during brief changes. There was no other documentation of a labial skin tear in the progress notes. There was no documentation of Resident #1 complaining of rough treatment by a CNA. There was no documentation that a head-to-toe assessment was completed. Review of Resident #1's progress notes provided by the ADM, reflected a note written,04/05/25 at 3:14 PM by LVN P, reflected in part, Resident has a small open area to the right gluteal cleft. A note written 04/16/25 at 9:55 PM by LVN Q, reflected in part, Resident #1 is incontinent of B/B, treatment apply to open area to perineum area, and open area to buttock[sic]. Review of the readmission Skin assessment dated [DATE], reflected in part, R arm PICC (a line used for administering long term medications into a vein) ecchymosis peri (bruises around) exit site, no s/s infection. Max assist ADL. Redness to groin, skin moist, res obese. Reactive when touched, states painful to move skin to examen [sic], starts to cry. Review of the Skilled Nurses note dated 05/21/25 and written by LVN C, the skin section of the assessment reflected none of the questions were answered, no comments were documented, and there was no documentation of a labial skin tear. Review of the Skilled Nurses note dated 05/31/25 and written by LVN E reflected, the daily wound treatments were not completed, no comments were documented, and there was no documentation of a labial skin tear. Review of the Skilled Nurses noted dated 06/08/25 and written by LVN E, reflected the daily wound treatments were not completed, no comments were documented, and there was no documentation of a labial skin tear. Review of the NP notes for Resident #1 dated 05/23/25, 06/02/25, and 06/06/25 all reflected, Concern for rt thigh fistula (an opening or passageway between two areas that normally do not connect), has h/o rectal abscess (a pocket of pus near the rectum). There was no documentation regarding a labial tear. Review of Resident #1's observation list from 04/22/25 through 06/11/25 reflected a Re-admit Social Service Review dated 05/15/25 written by the SW. No other observation assessments were documented by the SW since 05/15/25. Review of Resident #1's Point of Care History from 06/01/25 through 06/17/25, reflected CNA A documented limited assist of one person for bed mobility on 06/02/25, 06/03/25, 06/05/25, 06/06/25, 06/10/25, 06/11/25, 06/14/25, and 06/16/25. CNA A documented no swallowing difficulties and transfers to the toilet did not occur on the same dates. Review of CNA A's personnel file reflected he was hired on 04/17/25 and terminated effective 07/15/25. The termination form reflected a voluntary termination and the Job Abandonment box was checked. The file reflected a pericare competency checklist and test, both dated 06/04/25, completed and signed by CNA A. There was no documentation in the personnel file that reflected CNA A was ever suspended around the time of the allegation. Review of the grievance summary forms from 03/27/25 through 07/24/25 reflected no grievance related to Resident #1. Review of the incident reports from 06/01/25 through 09/10/25 reflected no incident reports regarding Resident #1's report of rough treatment nor a report for a labial tear. During an interview on 09/11/25 at 1:17 PM, the SW stated a female resident told her a male CNA provided rough incontinent care and that it hurt. The SW identified Resident #1 and CNA A. The SW stated CNA A quit working with Resident #1 after that report. The SW stated she mentioned the incident in the morning meeting, but other staff were aware and already investigating the incident because Resident #1 had told more than one person. The SW stated she did not remember the day of the complaint or the day of the morning meeting. The SW stated she did not remember which other staff was investigating the incident. The SW stated she talked with a state investigator about the incident in early June. The SW stated she met a couple times with Resident #1 after the complaint to ensure she was okay but did not remember if her interactions were documented. She stated when there was an allegation of abuse, she conducted an emotional distress evaluation and checked in with the resident several times after the evaluation. The SW stated she had been trained on abuse and neglect but did not remember the date of the training. Documentation of the interaction with Resident #1 requested from the SW. No documentation was provided prior to exit from the facility. During an interview on 09/11/25 at 1:32 PM, the DON stated she was not aware of any complaints of rough care concerning CNA A. She stated her concerns with CNA A were more about time and attendance. The DON stated she did not remember CNA A ever being suspended in the time he was working at the facility. The DON stated ADON D, who completed CNA A's Corrective Action Form on 06/04/25, was on vacation until 06/15/25. The DON stated if there was an allegation of abuse against an employee, that person was suspended during the investigation. She stated she worked with the ADM to investigate abuse allegations and sometimes they would send it up to corporate for further guidance. She stated allegations of abuse needed to be reported immediately to the ADM who was the abuse coordinator. During an interview on 09/11/25 at 1:55 PM, ADON B stated she was not involved in the investigation of the complaint Resident #1 made against CNA A because Resident #1 was on a hall covered by the other ADON. She stated she knew that CNA A could not work with Resident #1 after the investigation that happened early in June. ADON B stated she did not know if CNA A had been suspended during the investigation. ADON B stated any suspicion of abuse was reported to the ADM immediately. She stated the ADM's phone number was posted in multiple places for easy access to call if the ADM was not in the building. She stated if abuse was observed, the alleged perpetrator was removed, the resident assessed, and the abuse coordinator notified. During an interview on 09/11/25 at 2:27 PM, the ADM stated Resident #1 reported CNA A used a dry towel while providing incontinent care. The ADM stated Resident #1 stated the pericare was rough and it hurt but she did not say she was afraid of CNA A. She stated she asked Resident #1 if she had any injuries from the event and Resident #1 denied injury. The ADM stated she did not follow up with the nurse to confirm. The ADM stated she spoke with CNA A, and he denied using a dry towel when providing pericare to Resident #1. She stated using a towel was old-school and now they used wet wipes to provide pericare. The ADM stated she did not investigate further because she felt it was not abuse. The ADM stated the progress notes dated 04/05/25 and 04/16/25, may have shown why the resident had discomfort during pericare. The ADM stated she did not have any documentation about the allegation made or the conversations she had. The ADM stated CNA A did not work with Resident #1 after that complaint and it was a one-time event. The ADM did not remember what day she talked to Resident #1 or CNA A about the complaint. The ADM stated it was around the same time a state investigator was in the facility in early June. After reviewing CNA A's personnel file, she stated she did not see that he was ever suspended. She stated when there was an allegation of abuse, it was their policy to suspend the alleged perpetrator immediately then begin an investigation. The ADM stated she was the Abuse Coordinator, and staff knew to report to her immediately. The ADM stated she, along with the SW, DON, and ADONs all provided in-services on Abuse and Neglect. During an interview on 09/11/25 at 3:15 PM, the DON stated CNA A was still documenting he provided care to Resident #1 up until the day before she discharged , because sometimes the nurses provided the care, but the CNAs documented it. She stated the CNAs had to have their charting done by the end of the shift, so it was a group effort to provide care and document. The DON stated she was not sure what day Resident #1 had made the complaint so the Corrective Action form in CNA A's personnel file could have been about something else and that was why CNA A still documented care on Resident #1. A telephone interview was attempted with CNA A on 09/11/25 at 3:20 PM. A return call was not received prior to exit. During a telephone interview on 09/11/25 at 3:46 PM, Resident #1 stated she remembered an incident of rough treatment she reported while she was at the facility. She stated she remembered the incident and she stated it was CNA A that hurt her so bad she was in tears. Resident #1 stated she had been incontinent of bowel and CNA A came in to clean her. She began crying as she described CNA A using a dry towel to clean her and the pain and fear it caused. Resident #1 stated she asked CNA A to use the wet wipes because the towel was too painful. She stated she asked him to stop because of the pain but he responded, No, I got to you clean. She stated she was in tears when CNA A left the room. Resident #1 stated LVN C came into the room and found her in tears just after CNA A left the room. Resident #1 stated she reported to LVN C what had happened. She stated she reported to another nurse and to the SW and nothing was ever done. Resident #1 denied that the ADM ever spoke to her about the incident. Resident #1 stated CNA A came in to provide incontinent care another time, maybe the next day, and she was afraid to say anything because she needed to be cleaned so she would not get another infection. Resident #1stated after she was roughly cleaned a second time by CNA A, she told him to not come into her room anymore. Resident #1 stated CNA A provided care other times but, I didn't have a BM, so it wasn't as terrifying. Resident #1 cried multiple times during the telephone interview. Resident #1 stated, That place terrorized me. I have never felt that way in my entire life. I was afraid I was going to die. A telephone interview was attempted with LVN C on 09/11/25 at 4:20 PM. A return call was not received prior to exit. During a telephone interview on 09/12/25 at 3:43 PM, the MD stated he last saw Resident #1 on 06/17/25. He stated he did not remember notified of a skin tear on Resident #1's labia. He stated even if he had been notified, he may not have written it in his notes. He stated there was no treatment for a labial skin tear per chart review. He stated he did not remember being notified that Resident #1 complained about rough treatment during pericare. The MD stated the resident was obese, bed bound, and often complained of pain. The MD stated he did not believe it was standard of care to use a dry towel to provide pericare, They shouldn't be doing that. He stated he expected documentation about anything that happened was completed the same day and the MD should have been notified if anything major happened. He stated skin assessments should have been documented and everything should have been documented if there were concerns. The MD stated if a resident complained about rough treatment, It should not be brushed off and if anything, should absolutely be looked into. I think it should be documented if investigating a complaint. The MD stated if anyone heard or saw something about rough treatment, it should be documented and have a follow through to get to the bottom of it. Review of the in-service record dated 06/03/25 presented by ADON B reflected title Abuse and Neglect. The objectives of the in-service reflected, Review of Abuse, Neglect, Exploitation, or Mistreatment with staff and Policy and Procedures. The abuse and neglect policy were attached. Forty-nine staff members signed as being in-serviced. Review of the in-service record dated 06/04/25 presented by ADON B reflected title, Resident Rights. The objectives of the in-service reflected, Review of patient/resident rights policy and procedure. The Patient/Resident Rights policy was attached. Forty staff members signed as being in-serviced. Review of the policy and procedure, Abuse, Neglect, Exploitation, or Mistreatment revised 10/23/19 reflected in part, III: Prevention Abuse Prohibition Handout which includes information on how to and to whom concerns are reported without fear of retribution .B. Displayed in a prominent place in the facility . 4. Adequate supervision of staff is maintained in order to identify and prevent inappropriate behaviors, such as: B. Rough handling: and C. Ignoring the patient's/residents needs requests. Component V: Reporting/Response 1. All alleged violations concerning abuse, neglect, or misappropriation of property are reported verbally immediately to the Facility Abuse Coordinator, the Administrator and to other officials in accordance with state law including the State Survey and Certification Agency (nurse aide registry or licensing authorities). Component VI: Investigation 1. The facility maintains that all allegations of abuse, neglect, misappropriation of property, etc. are thoroughly investigated and appropriate actions are taken. In the event another patient/resident, a family member or visitor, etc. is accused of abuse/neglect against a patient/resident, the facility will intervene and take appropriate steps to safeguard the patient/resident during and after the investigation. 4. Investigations are prompt, comprehensive and responsive to the situation and contain founded conclusions. 5. The investigation may include but is not limited to the following: A. Identification and removal of the alleged perpetrator(s). D. Where and when the incident occurred. E. Written summaries of interviews with individuals having first-hand knowledge of the incident. NOTE: Employees/witnesses are not to write out statements. Employees/witnesses will be interviewed by designated facility staff and the interviewer will record all witness accounts in a document, written, dated, and signed by the interviewer. F. Resolution/outcome. G. Measures taken to prevent future incidents. H. All documents pertaining to the investigation must be complied and stored in the administrator's office. 6. In the event an employee is accused of abuse/neglect, that employee will be suspended during the investigation process. 7. Guidelines for Investigation: A. Immediately assess the resident/patient at the time of discovery of alleged abuse. B. Document assessment in the medical record. C. Maintain the resident's/patient's protection during the investigation. D. Notify the attending physician and the resident's/patient's legally responsible party. E. Notify the Administrator, Director of Nursing, and Social Worker regardless of the time of day. This was determined to be an Immediate Jeopardy (IJ) on 09/11/25 at 6:52 PM. The ADM was notified and provided with the IJ Template on 09/11/25 at 6:52 PM. The following POR submitted by the facility was approved on 09/12/25 at 3:55 PM: F600The facility failed to ensure Resident #1 was not abused by CNA A after she complained of rough treatment during peri care.The facility failed to investigate and report abuse of Resident #1 after she reported rough treatment during peri care by CNA A.Resident #1 no longer resides at the facility.Certified Nursing Assistant A no longer employed at facility. Last day of employment was 7/14/25A review of 24hour reports and facility activity reports will be completed begin 9/11/25 and completed by 9/12/25 by the Director of Nursing for the prior 14 days to identify possible allegations of abuse or neglect. A review of progress noted from 6/1/25 -7/25/25 will be reviewed by the Administrator or Director of Nursing to identify possible allegations of abuse or neglect, this review will be completed on 9/12/25. Any identified will be reported per policy and investigated by the Director of Nursing and Administrator. No issues identified.The Facility Leadership Staff will be re-educated by the Clinical Consultant on 9/11/25 on the Abuse, Neglect and Misappropriation policy and Grievance policy including: Identification of abuse or neglect, by observable and objective evidence, witness reports of unusual occurrence or patterns or trends of potential abuse or neglect Abuse is the willful infliction of injury unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual of goods or services that are necessary to maintain physical, mental and psychosocial wellbeing. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse Immediate identification and removal of the alleged perpetrator Identification and assessment of the alleged victim The Facility will report immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involved abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not result in serious bodily injury to the State Survey agency and other in accordance with state law Conducting a prompt, thorough investigation of any allegation of abuse or neglect and grievances and appropriate actions taken to protect the resident Investigations should be prompt, comprehensive and responsive to the situation and contain founded conclusionsThis reeducation will be explained back to the Clinical Consultant by the Leadership staff and a written post test will be given to validate this reeducation is comprehended and staff are able to apply the information.Facility Staff will be re-educated by the Administrator/Designee on 9/11/25 on the Abuse, Neglect and Misappropriation policy and Grievance Policy including: Identification of abuse or neglect, by observable and objective evidence, witness reports of unusual occurrence or patterns or trends of potential abuse or neglect Abuse is the willful infliction of injury unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual of goods or services that are necessary to maintain physical, mental and psychosocial wellbeing. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse Immediate identification and removal of the alleged perpetrator Identification and assessment of the alleged victim Reporting immediately to State Survey Agency and others in accordance with state law Immediate identification and removal of the alleged perpetrator Identification and assessment of the alleged victim Reporting immediately to Facility Abuse Coordinator, Director of Nursing, and social worker regardless of time of dayThis will be explained back to the administrator/designee by the learner and a written post test given to validate this reeducation is comprehended and staff are able to apply the information.This reeducation began immediately and will be completed by 9/12/25. Any, including PRN, staff not receiving this education prior to this date will receive prior to next scheduled shift. This education will be presented in New Hire orientation. Facility does not use agency staff.Administrator and Director of Nursing will review incident reports and grievance reports in morning meeting daily beginning 9/12/25 for 7 days then Monday - Friday ongoing for identification of possible allegations of abuse. The weekend supervisor will review the incident reports and grievances on the weekends to identify possible allegations of abuse. The weekend supervisor will notify the Administrator and Director of Nursing if any identified for further direction.The Administrator/Designee and the Director of Nursing/Designee will each interview 4 random residents daily beginning 9/12/25 for one week validating residents feel safe and have no care concerns.Human Resources will interview 3 random employees daily beginning 9/12/25 for one week to validate transfer of knowledge of education and document results of interviews.Ad Hoc QAPI was held on 9/11/25.The Medical Director was notified of the Immediate Jeopardy and the contents of this plan on 9/11/25 The POR was monitored on 09/12/25 as followed: Review of Resident #1's face sheet reflected she was discharged from the facility on 06/17/25. Review of CNA A's personnel file reflected a Termination Form. The form reflected 07/14/25 was the last day worked. The form reflected the termination was voluntary. Review of the Facility Activity Report, a review of the progress notes, from 08/28/25 through 09/11/25 were reviewed by the DON and signed by the DON and ADM on 09/12/25. No adverse events identified. Review of an in-service dated 09/11/25 at 7:30 PM, provided by the regional clinical nurse, reflected the topic, Abuse/Neglect and Reporting Guidelines. Points covered included identification of abuse, definition of abuse, immediate identification and removal of the alleged perpetrator, identification, and assessment of the alleged victim, reporting immediately, and conducting a prompt and thorough investigation. The ADM, DON, ADON B, and twelve other administrative staff signed the attendance section of the document. Review of 34 undated Grievance and Abuse Neglect Tests, reflected the tests were completed by multiple staff from various disciplines including the ADM, DON, and ADON B. All tests reflected the ADM was the abuse coordinator. No concerns with the tests identified. Review of an in-service record dated 09/11/25, provided by leadership, titled, Grievances reflected, Any resident complaints need to be on a grievances. [sic]. 34 staff from nursing, administration, activities, therapy, dietary, and maintenance signed the document. A copy of the Complaint/Grievance policy was attached. Review of an in-service dated 09/11/25, provided by ADON B, titled, Abuse & Neglected reflected a review of the abuse and neglect policies and procedures. 69 staff from nursing, dietary, rehab, laundry, administration, and maintenance signed the document. A copy of the Abuse and Neglect policy was attached. Review of in-service sign in sheet dated 09/11/2025 reflected peri care was reviewed with 35 nursing staff (nurses and CNAs) Review of a Daily Review of Incident Reports and Grievances log was initiated for September 2025. The DON signed 09/12/25 as completed with no concerns identified. Review of an Admin/DON Resident Interviews log was initiated for September 2025. The DON signed 09/12/25 as completed with no concerns identified. Review of Safety Interviews conducted 09/12/25 reflected eight residents were interviewed. All eight residents reported feeling safe. No adverse findings were documented. Review of the Human Resource Employee Interviews log was initiated for September 2025. The HRD documented the three staff interviewed all answered correctly. Review of the Ad Hoc QAPI meeting document dated 9/11/25 at 7:32 PM, reflected the meeting was attended by the ADM, ADON B, and the DON. The Medical Director participated by telephone. During an interview on 09/12/25 at 4:06 PM, the SW stated she received in-service on abuse, neglect, and grievances from the DON. She stated she learned who to report to, when to report, what ANE looks like, and the importance of taking concerns seriously. She was able to define abuse and name the ADM as the abuse coordinator. She learned once the allegation was reported, she would follow up with the resident and complete an emotional distress assessment and safety surveys with other residents. She stated she, as the SW, was responsible to ensure grievances were given to the person responsible the area of concern. She stated she learned all grievances should be written on the form and follow up completed. During an interview on 09/12/25 at 4:18 PM, RN F stated she received in-service provided by the DON on 09/12/25. She stated the in-service included abuse, neglect, and grievances. She was able to define abuse and give examples of how to recognize abuse. She learned an investigation was documented as an observation, progress note, or a grievance form. She stated the ADM was the abuse coordinator and she would investigate. She stated she learned if an allegation of abuse was made against staff, they ensured the resident was safe, removed the alleged perpetrator and notified the abuse coordinator. She learned the investigation included speaking with the resident involved and other staff members. She stated the charge nurse was responsible for conducting a head-to-toe assessment and assessing for pain. She was able to speak to the grievance policy. During an interview on 09/12/25 at 4:30 PM, the HRD stated she had received in-service on abuse, neglect, and grievances on 09/12/25. She stated the in-services were provided by the DON, ADM, and consultant. She stated she learned what was considered abuse, neglect, and exploitation. She learned a grievance is any complaint or feeling of mistreatment. She stated she learned the SW and ADM reviewed the grievances. She was able to define abuse and state how it could be identified. She named the ADM as the abuse coordinator and stated all allegations of abuse had to be reported to the ADM immediately. She stated she learned if a staff were suspected of abuse, they would be suspended during the investigation. She stated she was to interview at least three employees a day to ensure they have an understanding and know the expectations and procedures regarding abuse, neglect, and grievances. She stated she completed the first three interviews today with no adverse findings. She stated there is a designated staff to conduct interviews when she is out of the building. During interviews on 09/12/25 from 4:00 PM to 6:30 PM, staff from all shifts were interviewed, which included RN G, CNA H, CNA I (night shift), MA J, LVN K, LVN L, LA M, LVN N (night shift), and [NAME] O (evening shift). They all stated they had been in-serviced, prior to their shifts, on abuse, neglect, and grievances. They all stated they learned the ADM was the abuse coordinate and all suspected abuse was reported to her immediately. Staff stated the ADMs phone number was readily available and posted at the nursing stations. All staff were able to define types of abuse and neglect and state how to identify it. The staff gave examples of abuse and were able to name different types of abuse. They all stated they learned all complaints were documented on a grievance report to be given to the ADM or SW. Staff stated all reports of abuse should be investigated and the resident assessed for injuries. Staff stated they learned the alleged perpetrator was suspended during the investigation. During an interview on 09/12/25 at 6:13 PM, the DON stated CNA A had been terminated. She stated before the termination, he had issues with being late and not following directions. She stated she was not aware of an ANE allegations against him. She stated notes were reviewed and no resident issues were identified. The DON stated she received ANE and grievance in-service from the clinical consultant on 09/12/25. She stated she learned ANE can be identified when it is seen or reported by a resident, found during an assessment, or witnessed. She was able to define abuse and give examples of different types of abuse. The DON stated if an alleged perpetrator is identified, they were immediately suspended and had to leave immediately. She stated the ADM would be notified and provide further direction. She stated abuse was reported if it was valid and met the state criteria. The DON stated the resident was assessed and the findings documented in the progress notes. She stated all allegations were investigated. The DON stated the documentation was kept in a soft file as the investigation was conducted. In the EMR a physical assessment was documented in the progress notes and depending on what it was, document for three days. She stated staff and residents and whoever worked that shift were interviewed. The DON stated staff were in-serviced on ANE and grievances and a test was completed, and a copy was provided to the staff. She stated new staff were trained during orientation. The DON stated everyone who had come into the building had been educated and sent a test message with the information then the test completed and returned. She stated the 10:00 PM staff were to be educated prior to the start of their shift. The DON stated incident reports and grievances would be reviewed daily at the morning meeting. She stated the DON was responsible for the incident reports and the SW responsible for the grievance reports. The weekend supervisor was responsible for both on the weekend. The results will be documented on the tracking form. The DON stated the SW would interview four residents per day and HRD would interview three staff a day. The DON stated the QAPI meeting was conducted on 09/11/25. During an interview on 09/11/25 at 6:29 PM, the ADM stated CNA A had been terminated related to a violation on the code of conduct and he had som

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure in response to allegations of abuse, neglect, exploitation, or mistreatment the facility had evidence that all alleged violations were thoroughly investigated and prevent further abuse, neglect, exploitation, or mistreatment while the investigation was in progress for 1 of 3 residents (Residents #1) reviewed for abuse and neglect. The facility failed to investigate and report abuse when Resident #1 suffered pain and fear after incontinent care was provided roughly by CNA A, using a dry towel and a healing labial tear was identified on 06/03/25. CNA continued to provide incontinent care to Resident #1 until the day before her discharge on [DATE]. An Immediate Jeopardy (IJ) was identified on 09/11/25 at 6:52 PM and an IJ template was provided. While the IJ was removed on 09/12/25 at 7:00 PM, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy due to the facility need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk for abuse, neglect, and exploitation.Findings included: Review of Resident #1's face sheet, dated 09/11/25, reflected a [AGE] year-old female originally admitted to the facility on [DATE], readmitted on [DATE], and discharged on 06/17/25. Her diagnoses included sequelae of cerebral infarction (complications that occur after a stroke), sepsis (a response to an infection that can cause organ damages), diabetes (a disease that affects how the body uses glucose), depression, anxiety, and osteomyelitis of sacral region (an infection of the tailbone). Review of Resident #1's 5-day MDS assessment, dated 05/15/25, Section C (Cognitive Patterns) reflected a BIMS score of 15, reflecting intact cognition. Section GG (Functional Abilities) reflected she was dependent on staff for toileting hygiene. Section H (Bladder and Bowel) reflected she was incontinent of bowel and bladder. Section M (Skin Conditions) reflected the resident had no pressure injuries/ulcers and no venous or arterial ulcers present and that she received pressure ulcer/injury care. Review of Resident #1's comprehensive care plan, revised 05/18/25, reflected in part:Problem: Resident #1 experiences bowel incontinence. Goal: Resident #1 will not exhibit skin breakdown, constipation/impaction, impaired social interaction, secondary to bowel incontinence. Approach: .Report signs of skin breakdown or perianal excoriation (skin issues around the anus) . Use appropriate incontinence management products to promote hygiene and dignity. Use skin barrier after incontinent episodes. The care plan did not address a skin tear on the labia. Review of Resident #1's active physician's orders as of 06/16/25, printed on 09/11/25, reflected: Apply zinc barrier cream or Triad paste (an ointment used to protect the skin and promote wound healing) to wound on right posterior thigh, cover with xeroform BID. The order was dated 04/09/25. The physician orders did not address any treatment for a skin tear on the labia. Review of Resident #1's progress notes from 03/21/25 through 06/17/25 reflected a note written 06/03/25 at 10:09 PM by LVN C, Skin assessment performed. No new skin injuries were observed. Old skin tear to right labia appears 90% healed. No more redness present. Can barely see where the skin tear was. Healing well. Continuing to put barrier cream on skin tear during brief changes. There was no other documentation of a labial skin tear in the progress notes. There was no documentation of Resident #1 complaining of rough treatment by a CNA. There was no documentation that a head-to-toe assessment was completed around the time of the allegation. Review of Resident #1's progress notes provided by the ADM, reflected a note written,04/05/25 at 3:14 PM by LVN P, reflected in part, Resident has a small open area to the right gluteal cleft. A note written 04/16/25 at 9:55 PM by LVN Q, reflected in part, Resident #1was incontinent of B/B, treatment apply to open area to perineum area, and open area to buttock[sic]. Review of the readmission Skin assessment dated [DATE], reflected in part, R arm PICC (a line used for administering long term medications into a vein) ecchymosis peri (bruises around) exit site, no s/s infection. Max assist ADL. Redness to groin, skin moist, res obese. Reactive when touched, states painful to move skin to examen [sic], starts to cry. Review of the Skilled Nurses note dated 05/21/25 and written by LVN C, the skin section of the assessment reflected none of the questions were answered, no comments were documented, and there was no documentation of a labial skin tear. Review of the Skilled Nurses note dated 05/31/25 and written by LVN E reflected, the daily wound treatments were not completed, no comments were documented, and there was no documentation of a labial skin tear. Review of the Skilled Nurses noted dated 06/08/25 and written by LVN E, reflected the daily wound treatments were not completed, no comments were documented, and there was no documentation of a labial skin tear. Review of the NP notes for Resident #1 dated 05/23/25, 06/02/25, and 06/06/25 all reflected, Concern for rt thigh fistula (an opening or passageway between two areas that normally do not connect), has h/o rectal abscess (a pocket of pus near the rectum). There was no documentation regarding a labial tear. Review of Resident #1's observation list from 04/22/25 through 06/11/25 reflected a Re-admit Social Service Review dated 05/15/25 written by the SW. No other observation assessments were documented by the SW since 05/15/25. Review of Resident #1's Point of Care History from 06/01/25 through 06/17/25, reflected CNA A documented limited assist of one person for bed mobility on 06/02/25, 06/03/25, 06/05/25, 06/06/25, 06/10/25, 06/11/25, 06/14/25, and 06/16/25. CNA A documented no swallowing difficulties and transfers to the toilet did not occur on the same dates. Review of CNA A's personnel file reflected he was hired on 04/17/25 and terminated effective 07/15/25. The termination form reflected a voluntary termination and the Job Abandonment box was checked. The file reflected a pericare competency checklist and test, both dated 06/04/25, completed and signed by CNA A. There was no documentation in the personnel file that reflected CNA A was ever suspended around the time of the allegation. Review of the grievance summary forms from 03/27/25 through 07/24/25 reflected no grievance related to Resident #1. Review of the incident reports from 06/01/25 through 09/10/25 reflected no incident reports regarding Resident #1's report of rough treatment nor a report for a labial tear. During an interview on 09/11/25 at 1:17 PM, the SW stated a female resident told her a male CNA provided rough incontinent care and that it hurt. The SW identified Resident #1 and CNA A. The SW stated CNA A quit working with Resident #1 after that report. The SW stated she mentioned the incident in the morning meeting, but other staff were aware and already investigating the incident because Resident #1 had told more than one person. The SW stated she did not remember the day of the complaint or the day of the morning meeting. The SW stated she did not remember which other staff was investigating the incident. The SW stated she talked with a state investigator about the incident in early June. The SW stated she met a couple times with Resident #1 after the complaint to ensure she was okay but did not remember if her interactions were documented. She stated when there was an allegation of abuse, she conducted an emotional distress evaluation and checked in with the resident several times after the evaluation. The SW stated she had been trained on abuse and neglect but did not remember the date of the training. Documentation of the interaction with Resident #1 requested from the SW. No documentation was provided prior to exit from the facility. During an interview on 09/11/25 at 1:32 PM, the DON stated she was not aware of any complaints of rough care concerning CNA A. She stated her concerns with CNA A were more about time and attendance. The DON stated she did not remember CNA A ever being suspended in the time he was working at the facility. The DON stated ADON D, who completed CNA A's Corrective Action Form on 06/04/25, was on vacation until 06/15/25. The DON stated if there was an allegation of abuse against an employee, that person was suspended during the investigation. She stated she worked with the ADM to investigate abuse allegations and sometimes they would send it up to corporate for further guidance. She stated allegations of abuse needed to be reported immediately to the ADM who is the abuse coordinator. During an interview on 09/11/25 at 1:55 PM. ADON B stated she was not involved in the investigation of the complaint Resident #1 made against CNA A because Resident #1 was on a hall covered by the other ADON. She stated she knew that CNA A could not work with Resident #1 after the investigation that happened early in June. ADON B stated she did not know if CNA A had been suspended during the investigation. ADON B stated any suspicion of abuse was reported to the ADM immediately. She stated the ADMs phone number is posted in multiple places for easy access to call if the ADM was not in the building. She stated if abuse was observed, the alleged perpetrator was removed and the resident assessed, and the abuse coordinator notified. During an interview on 09/11/25 at 2:27 PM, the ADM stated Resident #1 reported CNA A used a dry towel while providing incontinent care. The ADM stated Resident #1 stated the pericare was rough and it hurt but she did not say she was afraid of CNA A. She stated she asked Resident #1 if she had any injuries from the event and Resident #1 denied injury. The ADM stated she did not follow up with the nurse to confirm. The ADM stated she spoke with CNA A, and he denied using a dry towel when providing pericare to Resident #1. She stated using a towel was old-school and now they used wet wipes to provide pericare. The ADM stated she did not investigate further because she felt it was not abuse. The ADM stated the progress notes dated 04/05/25 and 04/16/25, may have shown why the resident had discomfort during pericare. The ADM stated she did not have any documentation about the allegation made or the conversations she had. The ADM stated CNA A did not work with Resident #1 after that complaint and it was a one-time event. The ADM did not remember what day she talked to Resident #1 or CNA A about the complaint. The ADM stated it was around the same time a state investigator was in the facility in early June. After reviewing CNA A's personnel file, she stated she did not see that he was ever suspended. She stated when there was an allegation of abuse, it was their policy to suspend the alleged perpetrator immediately then begin an investigation. The ADM stated she was the Abuse Coordinator, and staff knew to report to her immediately. The ADM stated she, along with the SW, DON, and ADONs all provided in-services on Abuse and Neglect. During an interview on 09/11/25 at 3:15 PM the DON stated CNA A was still documenting he provided care to Resident #1 up until the day before she discharged , because sometimes the nurses provided the care, but the CNAs documented it. She stated the CNAs had to have their charting done by the end of the shift, so it was a group effort to provide care and document. The DON stated she was not sure what day Resident #1 had made the complaint so the Corrective Action form in CNA A's personnel file could have been about something else and that was why CNA A still documented care on Resident #1. A telephone interview was attempted with CNA A on 09/11/25 at 3:20 PM. A return call was not received prior to exit. During a telephone interview on 09/11/25 at 3:46 PM, Resident #1 stated she remembered an incident of rough treatment she reported while she was at the facility. She stated she remembered the incident and she stated it was CNA A that hurt her so bad she was in tears. Resident #1 stated she had been incontinent of bowel and CNA A came in to clean her. She began crying as she described CNA A using a dry towel to clean her and the pain and fear it caused. Resident #1 stated she asked CNA A to use the wet wipes because the towel was too painful. She stated she asked him to stop because of the pain but he responded, No, I got to you clean. She stated she was in tears when CNA A left the room. Resident #1 stated LVN C came into the room and found her in tears just after CNA A left the room. Resident #1 stated she reported to LVN C what had happened. She stated she reported to another nurse and to the SW and nothing was ever done. Resident #1 denied that the ADM ever spoke to her about the incident. Resident #1 stated CNA A came in to provide incontinent care another time, maybe the next day, and she was afraid to say anything because she needed to be cleaned so she would not get another infection. Resident #1stated after she was roughly cleaned a second time by CNA A, she told him to not come into her room anymore. Resident #1 stated CNA A provided care other times but, I didn't have a BM, so it wasn't as terrifying. Resident #1 cried multiple times during the telephone interview. Resident #1 stated, That place terrorized me. I have never felt that way in my entire life. I was afraid I was going to die. A telephone interview was attempted with LVN C on 09/11/25 at 4:20 PM. A return call was not received prior to exit. During a telephone interview on 09/12/25 at 3:43 PM, the MD stated he last saw Resident #1 on 06/17/25. He stated he did not remember notified of a skin tear on Resident #1's labia. He stated even if he had been notified, he may not have written it in his notes. He stated there was no treatment for a labial skin tear per chart review. He stated he did not remember being notified that Resident #1 had complained about rough treatment during pericare. The MD stated the resident was obese, bed bound, and often complained of pain. The MD stated he did not believe it was standard of care to use a dry towel to provide pericare, They shouldn't be doing that. He stated he expected documentation about anything that happened was completed the same day and the MD should have been notified if anything major happened. He stated skin assessments should have been documented and everything should have been documented if there were concerns. The MD stated if a resident complained about rough treatment, It should not be brushed off and if anything, should absolutely be looked into. I think it should be documented if investigating a complaint. The MD stated if anyone heard or saw something about rough treatment, it should be documented and have a follow through to get to the bottom of it. Review of the in-service record dated 06/03/25 presented by ADON B reflected title Abuse and Neglect. The objectives of the in-service reflected, Review of Abuse, Neglect, Exploitation, or Mistreatment with staff and Policy and Procedures. The abuse and neglect policy were attached. Forty-nine staff members signed as being in-serviced. Review of the in-service record dated 06/04/25 presented by ADON B reflected title, Resident Rights. The objectives of the in-service reflected, Review of patient/resident rights policy and procedure. The Patient/Resident Rights policy was attached. Forty staff members signed as being in-serviced. Review of the policy and procedure, Abuse, Neglect, Exploitation, or Mistreatment revised 10/23/19 reflected in part, Component V: Reporting/Response 1. All alleged violations concerning abuse, neglect, or misappropriation of property are reported verbally immediately to the Facility Abuse Coordinator, the Administrator and to other officials in accordance with state law including the State Survey and Certification Agency (nurse aide registry or licensing authorities). Component VI: Investigation 1. The facility maintains that all allegations of abuse, neglect, misappropriation of property, etc. are thoroughly investigated and appropriate actions are taken. In the event another patient/resident, a family member or visitor, etc. is accused of abuse/neglect against a patient/resident, the facility will intervene and take appropriate steps to safeguard the patient/resident during and after the investigation. 4. Investigations are prompt, comprehensive and responsive to the situation and contain founded conclusions. 5. The investigation may include but is not limited to the following: A. Identification and removal of the alleged perpetrator(s). D. Where and when the incident occurred. E. Written summaries of interviews with individuals having first-hand knowledge of the incident. NOTE: Employees/witnesses are not to write out statements. Employees/witnesses will be interviewed by designated facility staff and the interviewer will record all witness accounts in a document, written, dated, and signed by the interviewer. F. Resolution/outcome. G. Measures taken to prevent future incidents. H. All documents pertaining to the investigation must be complied and stored in the administrator's office. 6. In the event an employee is accused of abuse/neglect, that employee will be suspended during the investigation process. 7. Guidelines for Investigation: A. Immediately assess the resident/patient at the time of discovery of alleged abuse. B. Document assessment in the medical record. C. Maintain the resident's/patient's protection during the investigation. D. Notify the attending physician and the resident's/patient's legally responsible party. E. Notify the Administrator, Director of Nursing, and Social Worker regardless of the time of day. This was determined to be an Immediate Jeopardy (IJ) on 09/11/25 at 6:52 PM. The ADM was notified and provided with the IJ Template on 09/11/25 at 6:52 PM. The following POR submitted by the facility was approved on 09/12/25 at 3:55 PM: F610The facility failed to ensure Resident #1 was not abused by CNA A after she complained of rough treatment during peri care.The facility failed to investigate and report abuse of Resident #1 after she reported rough treatment during peri care by CNA A.Resident #1 no longer resides at the facility.Certified Nursing Assistant A no longer employed at facility. Last day of employment was 7/14/25.A review of 24hour reports and facility activity reports will be completed begin 9/11/25 and completed by 9/12/25 by the Director of Nursing for the prior 14 days to identify possible allegations of abuse or neglect. A review of progress noted from 6/1/25 -7/25/25 will be reviewed by the Administrator or Director of Nursing to identify possible allegations of abuse or neglect, this review will be completed on 9/12/25. Any identified will be reported per policy and investigated by the Director of Nursing and Administrator. No issues identified.The Facility Leadership Staff will be re-educated by the Clinical Consultant on 9/11/25 on the Abuse, Neglect and Misappropriation policy and Grievance policy including: Identification of abuse or neglect, by observable and objective evidence, witness reports of unusual occurrence or patterns or trends of potential abuse or neglect Abuse is the willful infliction of injury unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual of goods or services that are necessary to maintain physical, mental and psychosocial wellbeing. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse Immediate identification and removal of the alleged perpetrator Identification and assessment of the alleged victim The Facility will report immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involved abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not result in serious bodily injury to the State Survey agency and other in accordance with state law Conducting a prompt, thorough investigation of any allegation of abuse or neglect and grievances and appropriate actions taken to protect the resident Investigations should be prompt, comprehensive and responsive to the situation and contain founded conclusionsThis reeducation will be explained back to the Clinical Consultant by the Leadership staff and a written post test will be given to validate this reeducation is comprehended and staff are able to apply the information.Facility Staff will be re-educated by the Administrator/Designee on 9/11/25 on the Abuse, Neglect and Misappropriation policy and Grievance Policy including: Identification of abuse or neglect, by observable and objective evidence, witness reports of unusual occurrence or patterns or trends of potential abuse or neglect Abuse is the willful infliction of injury unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual of goods or services that are necessary to maintain physical, mental and psychosocial wellbeing. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse Immediate identification and removal of the alleged perpetrator Identification and assessment of the alleged victim Reporting immediately to State Survey Agency and others in accordance with state law Immediate identification and removal of the alleged perpetrator Identification and assessment of the alleged victim Reporting immediately to Facility Abuse Coordinator, Director of Nursing, and social worker regardless of time of dayThis will be explained back to the administrator/designee by the learner and a written post test given to validate this reeducation is comprehended and staff are able to apply the information.This reeducation began immediately and will be completed by 9/12/25. Any, including PRN, staff not receiving this education prior to this date will receive prior to next scheduled shift. This education will be presented in New Hire orientation. Facility does not use agency staff.Administrator and Director of Nursing will review incident reports and grievance reports in morning meeting daily beginning 9/12/25 for 7 days then Monday - Friday ongoing for identification of possible allegations of abuse. The weekend supervisor will review the incident reports and grievances on the weekends to identify possible allegations of abuse. The weekend supervisor will notify the Administrator and Director of Nursing if any identified for further direction.The Administrator/Designee and the Director of Nursing/Designee will each interview 4 random residents daily beginning 9/12/25 for one week validating residents feel safe and have no care concerns.Human Resources will interview 3 random employees daily beginning 9/12/25 for one week to validate transfer of knowledge of education and document results of interviews.Ad Hoc QAPI was held on 9/11/25.The Medical Director was notified of the Immediate Jeopardy and the contents of this plan on 9/11/25 The POR was monitored on 09/12/25 as followed: Review of Resident #1's face sheet reflected she was discharged from the facility on 06/17/25.Review of CNA A's personnel file reflected a Termination Form. The form reflected 07/14/25 was the last day worked. The form reflected the termination was voluntary. Review of the Facility Activity Report, a review of the progress notes from 08/28/25 through 09/11/25 were reviewed by the DON and signed by the DON and ADM on 09/12/25. No adverse events identified. Review of an in-service dated 09/11/25 at 7:30 PM, provided by the regional clinical nurse, reflected the topic, Abuse/Neglect and Reporting Guidelines. Points covered included identification of abuse, definition of abuse, immediate identification and removal of the alleged perpetrator, identification, and assessment of the alleged victim, reporting immediately, and conducting a prompt and thorough investigation. The ADM, DON, ADON B, and twelve other administrative staff signed the attendance section of the document. Review of 34 undated Grievance and Abuse Neglect Tests, reflected the tests were completed by multiple staff from various disciplines including the ADM, DON, and ADON B. All tests reflected the ADM was the abuse coordinator. No concerns with the tests identified. Review of an in-service record dated 09/11/25, provided by leadership, titled, Grievances reflected, Any resident complaints need to be on a grievances. [sic]. 34 staff from nursing, administration, activities, therapy, dietary, and maintenance signed the document. A copy of the Complaint/Grievance policy was attached. Review of an in-service dated 09/11/25, provided by ADON B, titled, Abuse & Neglected reflected a review of the abuse and neglect policies and procedures. 69 staff from nursing, dietary, rehab, laundry, administration, and maintenance signed the document. A copy of the Abuse and Neglect policy was attached. Review of in-service sign in sheet dated 09/11/2025 reflected peri care was reviewed with 35 nursing staff (nurses and CNAs) Review of a Daily Review of Incident Reports and Grievances log was initiated for September 2025. The DON signed 09/12/25 as completed with no concerns identified. Review of an Admin/DON Resident Interviews log was initiated for September 2025. The DON signed 09/12/25 as completed with no concerns identified. Review of Safety Interviews conducted 09/12/25 reflected eight residents were interviewed. All eight residents reported feeling safe. No adverse findings were documented. Review of the Human Resource Employee Interviews log was initiated for September 2025. The HRD documented the three staff interviewed all answered correctly. Review of the Ad Hoc QAPI meeting document dated 9/11/25 at 7:32 PM, reflected the meeting was attended by the ADM, ADON B, and the DON. The Medical Director participated by telephone. During an interview on 09/12/25 at 4:06 PM, the SW stated she received in-service on abuse, neglect, and grievances from the DON. She stated she learned who to report to, when to report, what ANE looks like, and the importance of taking concerns seriously. She was able to define abuse and name the ADM as the abuse coordinator. She learned once the allegation was reported, she would follow up with the resident and complete an emotional distress assessment and safety surveys with other residents. She stated she, as the SW, was responsible to ensure grievances were given to the person responsible the area of concern. She stated she learned all grievances should be written on the form and follow up completed. During an interview on 09/12/25 at 4:18 PM, RN F stated she received in-service provided by the DON on 09/12/25. She stated the in-service included abuse, neglect, and grievances. She was able to define abuse and give examples of how to recognize abuse. She learned an investigation was documented as an observation, progress note, or a grievance form. She stated the ADM was the abuse coordinator and she would investigate. She stated she learned if an allegation of abuse was made against staff, ensure the resident was safe, remove the alleged perpetrator and notify the abuse coordinator. She learned the investigation should include speaking with the resident involved and other staff members. She stated the charge nurse was responsible for conducting a head-to-toe assessment and assessing for pain. She was able to speak to the grievance policy. During an interview on 09/12/25 at 4:30 PM, the HRD stated she had received in-service on abuse, neglect, and grievances on 09/12/25. She stated the in-services were provided by the DON, ADM, and consultant. She stated she learned what is considered abuse, neglect, and exploitation. She learned a grievance is any complaint or feeling of mistreatment. She stated she learned the SW and ADM reviewed the grievances. She was able to define abuse and state how it could be identified. She named the ADM as the abuse coordinator and stated all allegations of abuse had to be reported to the ADM immediately. She stated she learned if a staff was suspected of abuse, they would be suspended during the investigation. She stated she was to interview at least three employees a day to ensure they have an understanding and know the expectations and procedures regarding abuse, neglect, and grievances. She stated she completed the first three interviews today with no adverse findings. She stated there is a designated staff to conduct interviews when she is out of the building. During interviews on 09/12/25 from 4:00 PM to 6:30 PM, staff from all shifts were interviewed, which included RN G, CNA H, CNA I (night shift), MA J, LVN K, LVN L, LA M, LVN N (night shift), and [NAME] O (evening shift). They all stated they had been in-serviced prior to their shifts on abuse, neglect, and grievances. They all stated they learned the ADM was the abuse coordinate and all suspected abuse was reported to her immediately. Staff stated the ADMs phone number was readily available and posted at the nursing stations. All staff were able to define types of abuse and neglect and state how to identify it. They all stated they learned all complaints were documented on a grievance report to be given to the ADM or SW. Staff stated all reports of abuse should be investigated and the resident assessed for injuries. Staff stated they learned the alleged perpetrator was suspended during the investigation. During an interview on 09/12/25 at 6:13 PM, the DON stated CNA A had been terminated. She stated before the termination, he had issues with being late and not following directions. She stated she was not aware of an ANE allegations against him. She stated notes were reviewed and no resident issues were identified. The DON stated she received ANE and grievance in-service from the clinical consultant on 09/12/25. She stated she learned ANE can be identified when it is seen or reported by a resident, found during an assessment, or witnessed. She was able to define abuse and give examples of different types of abuse. The DON stated if an alleged perpetrator is identified, they were immediately suspended and had to leave immediately. She stated the ADM would be notified and provide further direction. She stated abuse was reported if it was valid and met the state criteria. The DON stated the resident was assessed and the findings documented in the progress notes. She stated all allegations were investigated. The DON stated the documentation was kept in a soft file as the investigation was conducted. In the EMR a physical assessment was documented in the progress notes and depending on what it was, document for three days. She stated staff and residents and whoever worked that shift were interviewed. The DON stated staff were in-serviced on ANE and grievances and a test was completed, and a copy was provided to the staff. She stated new staff were trained during orientation. The DON stated everyone who had come into the building had been educated and sent a test message with the information then the test completed and returned. She stated the 10:00 PM staff were to be educated prior to the start of their shift. The DON stated incident reports and grievances would be reviewed daily at the morning meeting. She stated the DON was responsible for the incident reports and the SW responsible for the grievance reports. The weekend supervisor was responsible for both on the weekend. The results will be documented on the tracking form. The DON stated the SW would interview four residents per day and HRD would interview three staff a day. The DON stated the QAPI meeting was conducted on 09/11/25. During an interview on 09/11/25 at 6:29 PM, the ADM stated CNA A had been terminated related to a violation on the code of conduct and he had some write-up. She stated there were no previous allegations of abuse, more so attendance issues. She stated progress notes were reviewed from 06/01/25 through 07/25/25 and no issues were identified, and no reports were made. The ADM stated she received ANE and grievance training from the regional clinical nurse on 09/11/25. She stated Abuse was identified through observation, in writing, and it could be from watching trends in the residents. She defined abuse as the willful infliction of injury or unreasonable confin

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 (Resident #1) of 5 residents reviewed for accidents and hazards. The facility failed to ensure Resident #1 did not leave the facility without supervision and/or staff knowledge as she was found in the street in front of the facility by visitors of the facility on 02/23/2025. An Immediate Jeopardy (IJ) was identified on 03/17/2025. The IJ template was provided to the facility on [DATE] at 5:04 PM. While the IJ was removed on 03/18/2025 the facility remained out of compliance at a scope of isolated and a severity level of not actual harm because all staff had not been trained on elopement. This failure could place residents at risk of unsafe elopements, falls, injuries, hospitalization and/or death. Findings included: Review of Resident #1 face sheet reflected [AGE] year-old women admitted on [DATE] and discharged on 02/27/2025 with diagnoses of vascular dementia (a type of dementia caused by impaired blood flow to the brain, often due to strokes or other conditions that damage blood vessels, leading to problems with memory, thinking, and behavior), altered mental status (a change in a person's level of consciousness, alertness, and cognitive function), psychotic disorder with delusions (mental health condition characterized by persistent and false beliefs that are not based on reality), and anxiety disorder (a group of mental health conditions characterized by excessive and persistent feat, worry, and nervousness that can interfere with daily life). Review of Resident #1 care plan dated 02/26/2025 reflected Resident #1 had behavioral symptoms and Resident #1 wandered throughout the facility and was at risk for elopement and entering into others personal space. Approached included resident will be identified to staff through the facility alert system as an elopement risk. Review of Resident #1 care plan date 02/11/2025 reflected Resident #1 was rarely understood due to confusion. Further review of care plan dated 02/11/2025 reflected Resident #1 had impaired cognition and approached included to redirect Resident #1 when entering unsafe areas. Review of Resident #1 social service assessment dated [DATE] reflected resident was cognitively impaired. Resident #1 exhibited wandering behaviors and was exit seeking. Review of Resident #1 admission elopement assessment dated [DATE] reflected Resident #1 was an elopement risk. Review of Resident #1 elopement assessment dated [DATE] reflected Resident #1 got out the door on 400 hall. Interventions included to keep Resident #1 in common area and keep an eye on her. Resident #1 continued to be an elopement risk indicated by proceed selection on assessment. Review of Resident #1 progress note dated 12/04/2024 reflected Resident #1 had increased behavior and was exit seeking at side door of hallway. Review of Resident #1 progress note dated 01/15/2025 reflected Resident #1 attempted to go through the front door twice after visit from family. Review of Resident #1 progress note dated 02/06/2025 reflected resident tried to open hallway exit door. Review of Resident #1 progress note dated 02/23/2025 reflected Resident #1 followed visitors out the front door at 11:30 AM. Observation on 03/17/2025 at 9:30 AM, revealed a sign posted at the front door with a door code for outgoing and incoming visitors. During an interview on 03/17/2025 at 12:12 PM, LVN A stated she was familiar with Resident #1. LVN A stated that Resident #1 was confused and she would get up and walk without her wheelchair and she was not easily redirectable. LVN A stated that Resident #1 was going to do what she (Resident #1) wanted to do. LVN A stated she attempted to provide Resident #1 with a task throughout the day to try and take Resident #1's mind off wanting to leave. LVN A stated on 02/06/2025 Resident #1 tried to exit through the hallway door but she did not exit the building. LVN A stated that Resident #1 admitted with exit seeking behaviors and they increased the last month she was at the facility. LVN A stated that Resident #1 was put on 15 minute checks daily and this started on 02/06/2025. LVN A stated normally the checks would go for three days but continued until Resident #1 discharged due to her behavior. LVN A stated that she escorts the resident who sign out to the front desk and stated when they get to the front desk they go through a second sign-out process. LVN A stated there is a resident out on pass binder for each nurses station. LVN A stated she also documented all leave information on the 24-hour report. LVN A stated that all staff were trained on this process. LVN stated there was a binder kept at the nurses station that had residents who were at risk for elopement. During an interview on 03/17/2025 at 12:33 PM, RN B stated that she escorts residents who sign out of the facility for the day to the front desk to be released. She stated that there is a second sign-out process at the front as well. RN B state she documented residents who sign-out of the facility in the 24-hour report. RN B stated residents are required to sign out in the resident out on pass binder. During an interview 03/17/2025 at 12:55 PM, CNA C stated that she was not sure if there was a list that she could look at for residents who were at risk of elopement. CNA C stated she would look for the resident if she could not find them. CNA C stated she was not sure what else she would do if there was an elopement. During an interview on 03/17/2025 at 12:57 PM, CNA D stated that she was familiar with Resident #1. CNA D stated that sometimes Resident #1 did not make sense when she was speaking. CNA D stated that Resident #1 tried to leave the facility a couple of times and towards the end of her stay she had a sitter with her. CNA D stated that staff were able to get Resident #1 before she left the building during her attempts. CNA D stated that she remembered she got in-serviced on elopement. CNA D stated there was a binder at the nurses station on residents who were an elopement risk. CNA D stated if there was a resident who was missing, she would first look at the elopement binder, look in the building such as in the bathroom and other residents' rooms, nurses station and halls. She stated she would then let the nurse know before she started to search. CNA D stated that if residents were to go out on pass the family has to go the nurses station and sign the resident out when the leave and when they get back. CNA D stated there was only one resident on her hall who was considered an elopement risk. During an interview on 03/17/2025 at 1:11, LVN E stated that she was working when Resident #1 got out the front door. LVN E stated that there was a CNA clocking out for lunch and she told LVN E she was needed at the front door. LVN E stated when she got to the front door Resident #1 was back inside the building and was trying to get out again. LVN E stated Resident #1 was very agitated. LVN E stated that she placed Resident #1 in the vestibule between the door to the lobby area and outside door to help calm her down. LVN E stated that she believed on of the visitors called the police and a police officer came to the facility. LVN E stated that after a few minutes LVN E forgot what was going on and went back inside the building. LVN E stated that she went around the facility and asked staff to keep an eye on Resident #1 and call LVN E if Resident #1 went for the door. LVN E stated Resident #1 had 15 minutes checks. LVN E stated that usually facilities have a binder with residents who are at risk for elopement but she has not seen one at the facility and was unsure where it was. LVN E stated that she did receive an in-service on elopement. LVN E stated that the procedure for residents who go out on pass was that family walked them out and ensured they were signed out in the book at the nurses station. LVN E stated that it was not documented anywhere else if a resident went out on pass and the family notified the receptionist. LVN E stated she did not notify the receptionist if a resident left on pass. During an interview on 03/17/2025 at 1:41 PM, Receptionist F stated that when residents were leaving the facility they checked out with her on a kiosk. Receptionist F stated that they also have to sign out with the nurse before leaving the facility. Receptionist F stated that the nurses usually contacted her and let her know ahead of time who was leaving the facility. Receptionist F stated that if she saw a resident leaving she would double check with the nurse that they signed out. During an interview on 03/17/2025 at 2:30 PM, Receptionist G stated she worked at the facility on the weekends. Receptionist G stated that she was working when Resident #1 left the facility. Receptionist G stated that it was around 10:30 - 11:00 AM. Receptionist G stated that she was still getting to know the residents. Receptionist G stated that Resident #1 would wheel around the facility in her wheelchair. She stated that two couples came into the facility in the morning and when one couple was leaving, Resident #1 was behind them and left out the front door. Receptionist G stated that she assumed that it was Resident #1's family and that they checked out at the nurses station. She stated that one person from the couple came back in about five minutes later and stated that Resident #1 was in the middle of the road. Receptionist G stated that she went outside and attempted to reassure Resident #1 and stated that she needed to go back inside. Receptionist G stated that Resident #1 stated that she needed to go home. Receptionist G stated Resident #1 refused to go into the facility and stood up from her wheelchair in the middle of the road and started to wave down cars that passed. Receptionist G stated that a person stopped their car and Resident #1 pulled on their door handled and asked them to call 911. Receptionist G stated there were a lot of cars around. Receptionist G stated she did not recall getting trained on elopement prior to starting at the facility. Receptionist G stated that after the elopement the facility provided her a binder with all residents' pictures in it. She stated that she does not know if any list or any information where residents who were an elopement risk was located. Receptionist G stated she was not aware of any residents who were an elopement risk. Receptionist G stated that she was unsure if residents signed out of the facility unless she stopped them to ask or if she received a call from the family member ahead of time. Receptionist G stated that the nurses did not let her know ahead of time or before a resident signed out. Receptionist G stated she sometime called the nurse to ask but not every time. Reception G stated that she had not received an in-service to review an elopement binder. She stated she received a binder after the incident, but it was not reviewed with her and stated it contained all residents' pictures, names and room numbers. During an interview on 03/17/2025 at 3:26, the ADM stated that residents were supposed to sign out at the nurses station when they left the facility. The ADM stated the nurse was responsible for ensuring the resident had signed out. The ADM stated that the nurse does not typically let the receptionist know the resident was going out on pass because facility would not typically keep any residents at the facility that could not go out by themselves because they were not a locked facility. The ADM stated that the facility kept an elopement binder because there were residents who were confused. She stated they did not exit seek but they were confused. The ADM stated she was unable to say the level of confusion Resident #1 was prior to the elopement as she had started to deteriorate. The ADM stated that Receptionist G was educated on elopement and she was educated on the elopement binder and the policy and procedure. The ADM stated she [Receptionist G] did everything right. The ADM stated that Receptionist G just did not know the resident and the families. The ADM stated that BOM came in and educated Receptionist G on the day the elopement happened and believed it was documented. The ADM stated she was not sure it was documented on the elopement in-service. During an interview on 03/17/2025 at 3:40 PM, the BOM stated that she completed an in-service with Receptionist G and Receptionist E and this included to check the elopement binder and stated that they were to check with every resident going on if they checked out before the left the facility. The BOM stated Receptionist G and Receptionist E were supposed to ask the resident if they checked out with the nurse even if they were walking with family and stated they did double check with the nurse that the resident was signed out. The BOM stated that even if the family stated they checked out, they do have to double check. The BOM stated that residents should not go out the door alone and should be with someone. The BOM stated that the information reviewed with the receptionists included elopement procedure and explained that residents in the binder were at risk for leaving the facility. During an interview on 03/17/2025 3:57 PM, the MD stated that he was not under the impression that Resident #1 was approved to go out on pass on her own. He stated that the last time her personally saw Resident #1 was in December 2024 and he would not say Resident #1 had the capacity to leave the facility by herself based on what he documented at the point in time. The MD stated to the best of his knowledge it looked like that probably would not have been something he would have endorsed. During a telephone interview on 03/17/2025 at 4:22 PM, the DON stated that when Resident #1 attempted to elope on 02/06/2025 she was added to the elopement binder and she was placed on 15 minute checks daily until she discharged from the facility. The DON stated that Resident #1's hospice company assisted with providing a 1:1 sitter. The DON stated that Resident #1 was not exit-seeking when she first admitted to the facility. The DON stated that the purpose of the elopement binder was so that facility can see what the resident looks like and to know what residents may try to get out and to have extra eyes on those residents. The DON stated that normally residents who went on outings would tell the nurse and the nurse would take them out of the system and put them on therapeutic leave. The DON stated there was also a sign-out sheet at the front desk. The DON stated there is not a receptionist 24/7 but the receptionists were usually notified when they were there. The DON stated that the elopement binder was reviewed with Receptionist G and it was for her to have picture of resident who may try to elope and it was especially important because Receptionist G was new. The DON stated that anything could have happened to Resident #1 outside just like anyone else. The DON stated residents were currently in the elopement binder had exit seeking behaviors currently or may have been confused and tried to open a door to exit the facility. The DON stated they may not have tried to leave but just confused and try to go through the door. The DON stated residents were determined a risk for elopement if they wandered, pushed on exit doors. She stated Resident #1 pushed on an exit door and that is why she was considered an elopement risk. The DON stated that residents who wandered into other residents rooms were also considered an elopement risk. The DON stated if proceed was selected on the elopement assessment then the resident was considered and elopement risk. Review of the facility's policy titled Elopement with revision date of 11/01/2017 reflected that the policy is to safely and timely redirect patients/residents to safe environment. Review of facility in-service dated 02/23/2025 revealed covered topic of Elopements: All staff should review elopement binder and know what residents are in the binder When a door alarm goes off, it is the nurses responsible to verify all residents are in the building. Further review reflected Receptionist G did not sign the in-service. Review of the facility's policy titled Day Outings/Therapeutic Leaves of Absence with revision date of 11/01/2017 reflected residents may leave the facility for a day outing or therapeutic leave of absence with family or friends at any time with written permission from their physician. The ADM was notified on 03/17/2025 at 5:04 PM that an IJ had been identified. An IJ template was provided and a POR was requested. The following POR was approved on 03/18/2025 at 10:25 AM and indicated: Plan of Removal F689_ 3/17/25 Resident #1 no longer resides at the facility. Elopement Risk evaluations done in the past 90 days on current residents inhouse will be reviewed by Director of Nursing/Designee for accuracy by 3/18/25. Residents identified at risk will be reviewed for appropriate interventions including placement in the Elopement Binder and validated care plans have interventions listed. The Director of Nursing was reeducated by the Clinical Consultant on 3/17/25 on Accidents and Incidents including: elopement risk and the elopement binder when a resident is identified as an elopement risk, education will be provided to facility staff to alert them of a new resident listed in the elopement binder validating that when a resident is leaving the facility the nurse is aware and the resident and/or responsible party has signed the resident out for leave of absence elopement risk assessment process and putting interventions in place based on risks identified. All Facility Staff will be reeducated by 3/18/25 by the Director of Nursing/Designee on Accidents and Incidents including: elopement risk and the elopement binder when a resident is identified as an elopement risk, education will be provided to facility staff to alert them of a new resident listed in the elopement binder validating that when a resident is leaving the facility the nurse is aware and the resident and/or responsible party has signed the resident out for leave of absence Licensed Nurses will be reeducated by 3/18/25 by the Director of Nursing on the elopement risk assessment process and putting interventions in place based on risks identified. Any staff not receiving this education by 3/18/25 will receive prior to working the next scheduled shift. This will be presented in New Hire Orientation. The Director of Nursing will randomly interview a minimum of 2 staff daily to validate understanding of elopement risk and elopement binder. The Director of Nursing/Designee will review the facility activity report beginning 3/18/25 in clinical morning meeting to identify documentation and/or elopement risk assessments that may suggest a resident is exit seeking. If identified, the Director of Nursing/Designee will validate interventions are appropriate and care plan is updated. The Director of Nursing/Designee will review new admission elopement risk assessments in Clinical Morning Meeting beginning 3/18/25 for accuracy and interventions validated if indicated, including placement in the elopement binder and education to staff of new resident listed in the binder. The Medical Director was notified on 3/17/25 of the Immediate Jeopardy. An Ad Hoc Quality Assurance and Performance Improvement Meeting was held on 3/17/25 to discuss contents of this plan. Administrator will oversee compliance of this plan. Surveyor monitored the POR on 03/18/2025 as followed: During interviews on 03/18/2025 between 12:12 PM and 5:17 PM, with 1 DON, 2 RN (MDS Coordinators), 2 RNs, 7 LVNs, 1 Staffing Coordinator/CNA, 15 CNAs, 1 Social Worker, 1 admission Director, 1 Activity Director, 1 Activity Assistant, 1 Maintenance Director, 1 Dietary Manager, 3 Dietary Cooks, 2 Dietary Aides, 7 Housekeeping staff, and 1 Laundry Aide, it was revealed that staff received an in-service either 03/17/2025 or prior to their shift on 03/18/2025 on elopement risks led by the Clinical Services Director and DON. Staff interviewed stated that the in-serviced covered topics like the Elopement Policy and how to identify residents at high risk for eloping. Staff stated the training emphasized being vigilant about all residents who might try to elope, that each nurse's station had an updated elopement risk binder for tracking these residents at risk for elopement along with information available at the front desk. Staff stated they were encouraged to question any resident observed near exit doors as part of this awareness of elopement. Nursing staff stated during the in-service part of their training included understanding what steps needed to be taken when a resident was flagged as potentially high risk for elopement to ensure staff knew if there was a new entry in the elopement binder. Nursing staff stated that the assessment process was also discussed; and stated it involved determining whether a resident was high risk for elopement from behavior patterns documented during reviews of medical records. If residents were deemed not an elopement risk, staff checked do not proceed which meant no further action is needed. If a resident were deemed not an elopement risk, staff checked proceed and would notify charge nurse and it would be documented on the 24-hour report which was reviewed daily by the DON. Staff stated that a QAPI meeting was held, and staff discussed solutions regarding the plan of removal. The DON stated she reviewed past evaluations over 90 days concerning current residents identified as having high risk for elopement while confirming necessary interventions were incorporated into care plans- which included making sure those individuals were listed correctly within the Elopement Binder. DON stated she received training focused not only on accidents but also incidents of elopement and maintaining accurate documentation around residents at risk for elopement and nursing needs to ensure proper protocol was followed when resident left the facility temporarily. DON stated that staff was supposed to ensure responsible parties have signed out their loved ones properly upon departure. DON stated that going forward daily checks would involve random conversations between her and two other staff members who focused to reinforce knowledge about high-risk elopement residents and kept track through clinical morning reports highlighted existing documentation relevant towards identifying residents exhibiting exit seeking behaviors. The ADM was notified on 03/18/2025 at 6:09 PM that the IJ had been removed. While the IJ was removed, the facility remained out of compliance at a level of no actual harm that was not immediate jeopardy at a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems.