**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible and each resident received adequate supervision to prevent accidents for 2 of 4 residents (Resident #1 and #2) reviewed for accidents and supervision. 1. Resident #1 was transferred without a mechanical lift on 10/25/24 and experienced pain to her right leg/sustained a distal fracture 2. Resident #2 was transferred by a single staff member instead of the required two during a mechanical lift on 09/25/2024 and the mechanical lift tipped over, dropping the resident, and resulting in a bump and laceration to her nose. The noncompliance was identified as PNC. The IJ began on 9/24/2024 and ended on 11/27/2024. The facility had corrected the noncompliance before the investigation began. This deficient practice could place residents at-risk of harm, serious injury, or death. The findings included: 1. Record review of Resident #1's admission record, dated 03/26/25, reflected a [AGE] year-old female initially admitted [DATE] and re-admitted [DATE] with diagnoses to include hemiplegia and hemiparesis (paralysis and partial weakness of one side), age-related physical debility, lack of coordination, and acquired absence of left leg below knee. Record review of Resident #1's MDS assessment, dated 10/16/24, reflected Resident #1 was dependent (helper does ALL of the effort) for chair/bed-to-chair transfers and had a BIMS of 15 (indicating she was cognitively intact). Record review of Resident #1's care plan, last reviewed 02/19/25, revealed that mechanical lift transfer was not listed. Resident #1's care plan reflected Transfer: I require supervision, limited to extensive assistance in self-performance with 1-person physical assistance for all transfers. I may require more help on days I feel weak. Record review of Facility Provider Investigation Report, dated 11/12/24, reflected . On 10/25/24 at approx. [8:48 PM] Resident was lowered to ground during transfer from chair to bed by [LVN B] and [CNA A]. [LVN B] reported to DON that during transfer x2 resident became unable to bear weight and was lowered to ground by her and [CNA A]. Resident did not hit head during incident . [Resident #1] not on therapy PT/OT services due to pending insurance claim. [Resident #1] assist x2 with transfers. [Mechanical lift] may be used prn after HD treatments when resident is weaker. Resident stated she did not think she needed [mechanical lift] at this time due to feeling ok after HD and M-F regular staff being present. Record review of Resident #1's nurse's progress note, dated 10/25/24 at 08:48 PM, reflected staff was attempting to assist resident out of bed when due to residents non weight bearing status, more staff was needed to assist resident. Resident was then placed in a sitting position and when more staff arrived she was transferred to a geri chair using the [mechanical lift]. Patient did complain of pain to her right knee due to sitting up with her legs out in front of her. Head to toe assessment performed and resident is injury free and has been medicated with prn norco, md and don notified Record review of Resident #1's October 2024 MAR, accessed on 03/28/25, reflected Resident #1 received HYDROcodone-Acetaminophen Oral Tablet 5-325 MG . for moderate to severe pain from 10/26/24 through 10/29/24. Record review of Resident #1's Tibia/Fibula (two long bones located in lower leg) X-ray, dated 10/26/24, reflected no fracture or dislocation. Record review of Resident #1's November 2024 MAR, accessed on 03/28/25, reflected Resident #1 received HYDROcodone-Acetaminophen Oral Tablet 5-325 MG . for moderate to severe pain 11/04/24-11/07/24, 11/09/24, and 11/11/24. Record review of Resident #1's radiology results report for a knee X-ray, dated 11/11/24, reflected an acute distal femoral diametaphyseal fracture. Record review of Resident #1's hospital documents, dated 11/12/24, reflected orthopedic surgery spoke with patient and recommended no surgical intervention as patient is nonambulatory and has advance osteoporosis has no foot function and recommended nonoperative treatment with immobilizer on the right knee for 4 to 6 weeks with follow-up with orthopedic surgery as an outpatient in 3 weeks for repeat imaging . Interview on 03/28/25 at 10:50AM, CNA A revealed Resident #1 was supposed to be transferred via mechanical lift on 10/25/24, but LVN B decided to transfer resident with 2 people and no mechanical lift. Interview on 03/28/25 at 11:00AM, LVN B revealed Resident #1 was transferred via mechanical lift, however on this day (10/25/24) they did not use the mechanical lift because all of the mechanical lifts were taken. Interview on 03/28/25 at 11:10 AM, Resident #1 revealed she had been transferred via mechanical lift for 3 years and she had told CNA A and LVN B to transfer her via mechanical lift during the incident on 10/25/24. Resident #1 revealed she felt weak during this transfer because she had been to dialysis earlier that day. She revealed she felt scared and upset when the staff did not transfer her via mechanical lift. Interview on 03/28/25 at 11:15AM, the DOR revealed Resident #1 was not seen by physical therapy until after her fall in October (10/25/24) due to insurance coverage so they did not assess how Resident #1 should be transferred. Interview on 03/28/25 at 11:25AM, LVN C and CNA D revealed Resident #1 had been a mechanical transfer since she had been at this facility. 2. Record review of Resident #2's Face Sheet, dated 03/28/2025, reflected a [AGE] year-old female resident initially admitted to the facility on [DATE] with diagnoses of diabetes mellitus (a group of diseases that result in too much sugar in the blood), dementia (a group of thinking and social symptoms that interferes with daily functioning), and quadriplegia (paralysis of all 4 limbs). Record review of Resident #2's Comprehensive Person-Centered Care Plan, undated, reflected I require assistance with my ADL's because I [sic] Diagnosis of: Quadriplegia with interventions to include, Transfer: I require total assistance in self performance with 2 person physical assistance staff support using a mechanical Hoyer lift. Record review of Resident #2's Quarterly MDS Assessment, dated 12/23/2024, reflected that Resident #2 required assistance with chair/bed-to-chair transfer and was Dependent on staff, meaning Helper does ALL the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity. Record review of the Facility Provider Investigation Report, dated 10/01/2024, reflected, On 9/25/24 at approx. 930 am: Resident was transferred to gerichair from bed via hoyer by [CNA E] for breakfast. [CNA E] states that she transferred the resident to gerichair and as resident was lowered into gerichair hoyer lift tipped over. [CNA E] states she was able to catch resident to assist to floor. [LVN K went] in room and assessed resident. MD notified. Resident noted with abrasion to bridge of nose and head. [RT L and RT M] in room and evaluated, suctioned resident. [LVN K] called EMS to transport resident to ER for further eval. Resident positioned safely on floor until EMS arrived. [LVN K] informed family of incident and transfer for ER. [CNA E] suspended pending investigation. Record review of Resident #2's progress note, dated 09/25/2024 at 2:02 pm, reflected Resident returned from hospital. Abrasion to nose. CT and scans at hospital were negative. Continue neuros. MD notified. No new orders. Record review of Resident #2's Skin Assessment, dated 09/25/2024, reflected that Resident #2 had 1cm x 0.1cm x MD well approximated laceration to bridge of nose. No discernable drainage. No odor. Interview on 03/26/2025 at 11:56 AM, the DON stated that CNA E performed an unauthorized 1-person mechanical lift on Resident #2. The DON stated it is explicitly against policy to perform a 1-person transfer with a mechanical lift, and that any employees who are observed performing a 1-person mechanical lift are terminated. The DON stated that the only injury to Resident #2 was a bump and laceration on her nose, and that tests at the hospital did not reveal further injury. Interview on 03/27/2025 at 3:30 PM, LVN K stated she remembered the incident and was there after the resident had fallen. LVN K stated the only injury observed was the laceration on the residents nose. LVN K stated that after the incident occurred, the Director of Rehabilitation at the facility assisted in ensuring all staff had mechanical lift-trainings and that all staff were observed to ensure they passed competency tests on the use of a mechanical lift. Record review of staff competencies reflected that all nursing staff (CNA's, LVN's, and Respiratory Therapists) had a competency test on mechanical lifts between 09/25/2024 and 10/28/2024. Interview on 03/28/25 at 02:00PM, Maintenance worker J revealed the facility checked mechanical lifts quarterly and they all currently work. The facility implemented the following interventions: Interview with DON on 03/26/2024 at 11;56 AM revealed CNA E was not allowed to return to the facility due to not following facility policy regarding mechanical lifts. The DON further revealed that the mechanical lift had been replaced as a whole to prevent further injuries to residents. Observation on 03/28/25 at 01:45PM revealed there were 5 mechanical lifts in the building in working condition. Record review of Maintenance log 2024 reflected one mechanical lift was broken but fixed on 02/03/25. Record review of in-service training, dated 11/26-27/24, reflected all staff were in serviced on Abuse and Neglect. Record review of in-service training, dated 09/25/24, revealed all staff were trained on abuse neglect policy and procedure, resident assist x (0, 1, 2) status, [mechanical lift] policy and procedure, and reporting and removing of non-functioning equipment. Record review of Nursing Competency Evaluations was completed. Mechanical Lift Transfer competencies were completed between 09/25/2024 and 10/28/2024, with all direct care staff having completed a competency evaluation. Record review on 03/28/2025 of CNA Roster dated 03/28/2025 reflected Resident #1 was a 2 person transfer via mechanical lift. Interview on 03/27/2025 at 10:18 AM, CNA U stated she typically works from 6:00 AM until 2:00 PM, and that mechanical lifts always have to do 2 people. CNA U stated she regularly gets mechanical lift training, and has had one as recently as about a month ago. CNA U stated she has never seen anyone become injured during a mechanical lift, and if she ever saw another staff member doing a mechanical lift by herself she would contact her nurse, ADON, and DON. Interview on 03/27/2025 at 3:30 PM, LVN K stated she typically works from 8:00 AM until 5:00 PM, and the director of rehabilitation had trained staff on mechanical lifts after the incidents. LVN K stated she feels comfortable on how to use a mechanical lift and that training and competencies on mechanical lifts are done frequently. Interview on 03/27/2025 at 6:11 PM, CNA S stated he typically worked 10 PM until 6 AM and he recieved training on how to perform a mechanical lift last month. CNA S stated mechanical lifts must be done with 2 staff members and had never seen a 1 person mechanical lift. Interview on 03/27/2025 at 6:14 PM, CNA T stated they typically work 6:00 AM until 2:00 PM and had a mechanical lift training within the last month and that they have never seen a 1 person mechanical lift, as all mechanical lifts were completed with 2 people. Interview on 03/28/2025 at 8:33 AM, CNA V stated they typically work 2:00 PM until 10:00 PM and had a mechanical lift training last month. CNA V was able to describe the different duties for each person during a mechanical lift, why it was imperative that the mechanical lift was done by 2 people, and that they had never seen a resident become injured during a mechanical lift. Interview on 03/28/25 at 09:30 AM, CNA Z, typically worked 2PM-10PM, revealed she was trained on transferring residents via mechanical lift and knew how to find out if a resident was transferred via mechanical lift, to include following therapy recommendations for residents. Interview on 03/28/25 at 02:15PM LVN C, typically worked 2PM-10PM, revealed she had been trained on how to do mechanical lifts and what residents were transferred via mechanical lifts. Interview on 03/28/2025 at 2:19 PM, CNA X stated she typically worked 6:00 AM until 2:00 PM, but will regularly pick up shifts at other times. CNA X stated that it is explicitly against policy to do a 1 person mechanical lift and that they had never seen a person become injured during a mechanical lift. Interview on 03/28/2025 at 2:22 PM, CNA Y stated that she works as needed and has worked all shifts, but primarily works between 6:00 AM until 2:00 PM, or 2:00 PM until 10:00 PM. CNA Y stated that she has extensive training on mechanical lifts and has been trained by the facility within the last few months. CNA Y stated she had never seen a person do a 1 person mechanical lift transfer at the present facility or at any facility she has worked at. CNA Y stated if she saw a staff member attempting to do a 1 person mechanical lift, she would step in to assist to ensure it became a 2 person mechanical lift transfer, and then report it to the DON. Interview on 03/28/25 on 02:33 PM, RN P revealed he worked all shifts and he was trained on how to use the mechanical lifts properly and knew where to look to identify if a resident required a mechanical lift for transfer. He also got this information from report from the previous nursing staff. Interview on 03/28/25 on 02:37 PM, CNA Q, typically worked 2PM-10PM, revealed she was trained on how to properly transfer residents with mechanical lifts (to include needing 2 people to transfer) and what residents needed to be transferred via mechanical lift. She was trained frequently about mechanical lifts with the last training being last month. Interview on 03/28/25 at 02:38PM, LVN R, typically worked the 8AM to 5PM shift, revealed she knew what residents were to be transferred via mechanical lift by looking at the [NAME] or using CNA sheets at the nursing station. LVN R further revealed they needed 2 staff members to transfer residents via mechanical lift and she was trained frequently on using mechanical lifts. Facility policy titled, Safe Lifting and Movement of Residents, revised July 2017, reflected 1. Resident safety, dignity, comfort, and medical condition will be incorporated into goals and decisions regard the safe lifting and moving of residents . 3. Nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents' needs for transfer assistance on an ongoing basis .8. Mechanical lifts shall be made readily available and accessible to staff 24 hours a day. 10. Maintenance staff shall perform routine checks and maintenance of equipment used for lifting to ensure that it remains in good working order. Facility policy titled, [Mechanical Lift] Policy, undated, reflected Every [mechanical lift] transfer requires 2 PERSON ASSIST for the safety of the resident and the staff members. The noncompliance was identified as PNC. The IJ began on 09/25/2024 and ended on 11/27/2024. The facility had corrected the noncompliance before the investigation began. The Administrator and the DON were notified on 03/28/2025 at 09:00 PM, a past non-compliance IJ situation had been identified due to the above failure.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure the resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for one (Resident #2) of four residents reviewed for abuse. The facility failed to keep Resident #2 free from abuse when CNA A roughly provided bed mobility assistance and incontinent care on 02/11/2025 and 02/13/2025. The noncompliance was identified as past non-compliance IJ. The noncompliance began on 02/15/2025 and ended on 02/19/2025. The facility corrected the non-compliance before the investigation began. This deficient practice could affect any resident and result in emotional and physical abuse. The findings include: Record review of Resident #2's admission Record, dated 02/20/2025, reflected a [AGE] year-old male. He was initially admitted to the facility on [DATE] and re-admitted on [DATE]. He was noted to have a responsible party (RP) identified that was other than himself. Record review of Resident #2's Medical Diagnosis list, undated but accessed on 02/21/2025, reflected Resident #2 had diagnoses which included other specified trisomies and partial trisomies of autosomes (a genetic condition that results in abnormalities of the person's chromosomes which often cause severe physical and intellectual disabilities) and cerebral cysts (a fluid-filled sac in the brain that can be cancerous or noncancerous and may cause headaches, vision problems, or nausea). Record review of Resident #2's Quarterly MDS, signed as completed on 01/29/2025 by the DON, reflected Resident #2 had a BIMS score of 15, which indicated he was cognitively intact. His mood was documented as having never felt lonely or isolated over the last 2 weeks and he did not have any documented behavioral symptoms. He was documented as having had upper extremity (shoulder, elbow, wrist, hand) impairment on one side and lower extremity (hip, knee, ankle, foot) impairment on both sides. He used a wheelchair and was dependent (requiring a helper for all of the effort) for toileting hygiene and lower body dressing. He was always incontinent of urine and bowel. During an observation on 02/19/2025 at 04:30 p.m. revealed 2 pictures, with no date stamp and was submitted by Resident #2's RP on 02/18/2025, the first picture with deep purple bruising noted in multiple sites of upper right arm, ranging from mid upper interior side of right arm to the interior of the elbow. The second picture with deep purple bruising on the right hand, palm side of hand, extending from the little finger and ring finger to the palm of the hand. Source of bruising was not evident from pictures. During an observation on 02/20/2025 at 04:30 p.m. revealed 3 videos, with no date stamp and submitted by Resident #2's RP on 02/18/2025, CNA A was observed changing Resident #2's incontinence brief while in his bed. Due to the same clothing and positioning of CNA A, Resident #2, and Resident #3 visible on the videos, two of the three videos appeared to have been recorded on the same day and to have been recorded back-to-back. On one video, CNA A was observed to roughly grab Resident #2's left foot and with force push his foot against the right side of the bed, causing a visible bend in his foot and a compression of the mattress under his foot, and then she proceeded to grab Resident #2's right wrist, and roughly [NAME] Resident #2 onto his left side using only her handholds of the resident's right wrist and the pad of his left foot. On a separate video, which appeared to have occurred on a separate day, CNA A was observed to flick Resident #2's left leg, from a position of him turned onto his right side with both of his knees together, and then she abruptly pushed his left leg, still bent at the knee to the left side, which resulted in his legs to become fully opened at the hip. Audio on the videos was able to be heard but not sufficiently distinguished. Prior observation of images of Resident #2's bruises was not found to match possible injuries noted during video observation. During an interview on 02/20/2025 at 12:20 p.m., Resident #2's RP stated the videos she submitted were from Tuesday (02/11/2025) and Thursday (02/13/2025) at around 06:30 p.m.- 07:30 p.m. She stated she was unable to provide the videos with date and time stamps. She stated she last saw Resident #2 on Monday, 02/10/2025 and he did not have the bruises noted in the pictures at that time. She stated Resident #2 could not provide a lot of information regarding the incident, but he could give her the person's name. He named CNA A. She stated when she asked Resident #2 about the bruises, he mostly replied it happened during his showers, on Tuesdays and Thursdays. She stated the source or cause of the bruising on Resident #2's arm was still unknown. She stated Resident #2 was not aggressive, and he did not like to complain or accuse anyone of hitting him. During an interview on 2/20/25 at 11:40 a.m., the DON revealed that CNA A was terminated. During an observation and interview on 02/21/2025 at 11:07 p.m., revealed Resident #2 was observed to be sitting in his wheelchair in the hallway. His arms were noted to be covered up to his wrist, but light, dark purple bruising was noted on his right hand. Resident #2 stated he was pinched by CNA A in the shower hard and indicated an injury to his upper right arm. He stated the facility staff were nice except for CNA A. He stated, she hurt me, and I don't feel safe with CNA A. When asked about the bruise on his hand, Resident #2 stated he had blood taken last month and pointed toward the area in the facility where bloodwork would have been taken. During an interview on 02/24/2025 at 12:21 p.m., CNA A stated she worked the 2:00 p.m. to 10:00 p.m. shift, Monday to Friday, the week of Valentine's Day (02/10/2025- 02/14/2025). She stated she was assigned to work with the residents on 300-hall for those shifts. She stated Resident #2 was one of her patients for the week of 02/10/2025 to 02/14/2025. She stated after she assisted Resident #2 with a shower on Thursday, 02/13/2025, she put him on his bed to change his brief. She stated Resident #2's behaviors would start when he was taken back to his room following the shower. She stated he could be difficult if you didn't do what he said. She stated, he didn't want to go back into bed, and he didn't want to turn. She stated he tried to hit her, and she had stopped him by putting her arm up to block him. She stated any bruising or scratches he had was not from her. She stated she did see bruising on Resident #2 on Friday, 02/14/2025 but was under the impression they had already been reported. She stated she completed facility training documentation which indicated she was trained on incontinent care, resident rights, and abuse/neglect. She stated she knew the procedures. During an interview on 02/24/2025 at 12:36 p.m., the LSW stated she was familiar with Resident #2, since he had a tendency to come visit her during the day. She stated she had not observed any changes in his behaviors following the incident reported on 02/15/2025. She stated he had not expressed any concerns or fears of other staff members. She stated following the incident, she came into the facility and completed safe surveys with other residents and spoke with Resident #2. She stated no other residents reported concerns during the safe surveys. She stated she completed a trauma assessment on Resident #2 on 02/15/2025. She stated she documented that he reported to have had nightmares because that was the closest way to document on that specific form that he reported to her that the incident still bothered him, but he didn't want to think about it. She stated the nursing department had already started abuse and neglect training with staff by the time of her response to the incident. During an interview on 02/24/2025 at 05:11 p.m., LPN E stated he worked on the 300-hall, Monday to Friday during the 02:00 p.m. to 10:00 p.m. shift. He stated he recalled observing Resident #2's bruises but thought they were due to Resident #2's recent lab draw. He stated Resident #2 was upset with CNA A and CNA A did tell him Resident #2 was aggressive; however, he stated he did not observe Resident #2 having been aggressive. He stated CNA A told him Resident #2 did not want his shower and when he spoke with Resident #2, Resident #2 said he wanted his shower later. LPN E stated CNA A did shower Resident #2 later that shift. LPN E stated when he gave Resident #2 his 08:00 p.m. medications, Resident #2 did not say anything to him. LPN E stated he believed he first saw Resident #2's bruises on Thursday and asked Resident #2 what had happened. He stated Resident #2 reported to him that it was CNA A, but this report occurred after the facility had started an investigation. LPN E did not provide a date for when he observed Resident #2's bruises or a date for when he had a conversation with Resident #2 regarding CNA A. During an interview on 02/24/2025 at 08:47 p.m., LPN F stated she worked double weekends on the 300-hall. She stated the only prior behaviors she observed from Resident #2 was his preference to hang around in the hallways and he liked to talk and be social. She stated she was present at the time CNA B first reported Resident #2's allegation of abuse from another CNA. She stated CNA B told her of Resident #2's allegation and she went to assess and speak with Resident #2. She stated she noted quite a few bruises of differing size that were purple to brownish in color on his arm. She stated Resident #2 initially wouldn't tell her what happened but then he told her the same report he had given CNA B, that CNA A hit him. She stated she was unable to get a straight answer on when the incident occurred, but Resident #2 repeatedly stated it happened on his shower day and CNA A was mean, she hit him, and he was trying to fight back. LPN F stated Resident #2 did not appear to be scared or apprehensive of other CNAs. She stated following her assessment, she identified around 5 scattered bruises on Resident #2's arm and hand and 3 tiny bruises on his abdomen, which she stated Resident #2 identified as resulting from where CNA A pinched him. She identified a bruise on his ear, which Resident #2 stated was where CNA A pinched and pulled his ear. She stated an abuse allegation had to be reported within 2 hours and she immediately reported the allegation to the weekend supervisor, RNJ, who reported it to the administrator, who was the abuse coordinator. She stated the facility staff were in-serviced on abuse that same day she initially reported the allegation. During an interview on 02/24/2025 at 09:16 p.m., CNA B stated he worked weekends and primarily on 300-hall. He stated Resident #2 was typically talkative, happy, and wanted to say hi to everyone. He stated Resident #2 liked to get up in the morning, be in his wheelchair, and go to all the activities. He stated Resident #2 never refused care from him and always wanted his showers. CNA B stated he was the one to initially report Resident #2's allegation of abuse. He stated he noticed the bruising on Resident #2's right arm and even though Resident #2 tended to bruise easily when the facility did bloodwork, he asked Resident #2 what had happened because there were more bruises than normal. He stated Resident #2 replied that CNA A did it. CNA B stated he had never heard Resident #2 have hate towards anyone, but Resident #2 told him he hated CNA A. CNA B stated he noticed the additional bruising on Resident #2's right arm, bicep, ear cartilage, and right hand, but was more concerned about Resident #2 having stated he hated CNA A and she had hit him. CNA B stated following Resident #2 reporting what occurred, he finished Resident #2's shower, got him into his wheelchair, and then reported the allegation to LPN F. He stated following his report to LPN F, he observed LPN F reported the incident to the weekend supervisor and then the report escalated from there. He stated he felt as if the facility responded to the allegation appropriately, they immediately took action, which included having assessed Resident #2. He stated the staff had an in-service on abuse and neglect that same weekend of his initial report. During an interview on 02/25/2025 at 10:43 a.m., the DON stated Resident #2 attended bingo on 02/13/2025, which would have finished up around 03:00 p.m. She stated bingo was not scheduled on the activity calendar at that time, but the residents really loved bingo, so it was held more often. She stated CNA A had documented under Resident #2's Tasks his shower was taken at 02:49 p.m., but CNA A may have documented at that time because she was planning on going to get him for his shower at that time. The DON stated the Task screen was not visible under surveyor EMR access. During an interview on 02/25/2025 at 01:03 p.m., the DON stated the facility process for screening when hiring was human resources completed background, license, and reference checks upon hire and then background and license checks as scheduled. She stated CNA A had not had any noted concerns or complaints for possible abusive behaviors. She stated she was first notified of Resident #2's CNA A abuse allegation by the weekend supervisor. She stated the weekend supervisor had already called Resident #2's RP, his PCP, and taken CNA A's statement. She stated CNA A was put on leave at that time. She stated the weekend supervisor asked Resident #2's RP if she could review the camera footage from Resident #2's room. The DON stated the facility turned in a self-report of the incident and spoke to Resident #2's RP about wanting to do a police report. The DON stated the LSW ended up putting in the police report on Monday, 02/17/2025. The DON stated she came in on Saturday following the incident having been reported to her and the LSW and administrator also became involved in the investigation. The DON stated she believed the incident happened during the Thursday, 02/13/2025, 02:00 p.m. to 10:00 p.m. shift. She stated LPN E had gone into Resident #2's room that night and Resident #2 had told him he was okay. She stated LPN E did not report having had identified any indicators on Thursday night or Friday. She stated Resident #2 was not seen to have bruises on Friday, 02/14/2025 and he seemed fine during the facility Valentine's Day party, which he attended. She stated he did not report bruising or pain at that time. She stated the incident seemed to come back up for Resident #2 on Saturday, 02/15/2025 because it was another of his shower days and he really loved that CNA, CNA B. The DON stated it was her expectation the nurse would get involved when a resident refused a shower, to determine why they refused and to find out if there was a way to alleviate that reason. She stated for when a resident had behaviors, the CNA was supposed to separate themselves from the situation and go inform the nurse. She stated she would expect the nurse to intervene and possibly let her know if she needed to switch staffing assignments or follow up with the resident. The DON stated she did view the camera footage and would say that it was abuse, CNA A was rough with Resident #2. She stated that was not how she would want anyone to be treated. During an interview on 02/25/2025 at 01:31 p.m., the ADMIN stated staff were trained on abuse and neglect upon hire and as needed following every incident. The ADMIN stated she was notified of the incident involving Resident #2 and CNA A on Saturday, 02/15/2025 around 03:00 p.m. to 04:00 p.m. She stated the investigation, and the incident response was a group effort with the DON completing the investigation and interviews, and safe surveys were conducted. She stated with abuse allegations, the staff member would be immediately suspended with the primary goal to protect the resident until the investigation was completed. She stated CNA A had not had any previous complaints and as soon as they were notified of the abuse allegation, CNA A was put on suspension. The ADMIN stated the allegation of abuse was confirmed following their facility investigation and the facility was planning to refer CNA A. She stated Resident #2's RP did decide for a police report to be submitted for this incident. The ADMIN stated following this incident, Resident #2 did not require treatment other than responding to his emotional distress and his request for CNA A to not be back in his room. The ADMIN stated for any reason, if a resident was having behaviors, staff were trained and in-serviced to monitor for resistance to care and to let the nurse know. She stated her expectation was for staff to stop attempting the care and to notify the nurse. They may try to approach at a different time. The ADMIN stated CNA A's care did appear abusive on the camera footage, she [CNA A] was flopping his legs back and forth. The ADMIN stated following viewing of the camera footage it was pretty evident CNA A's behaviors were unprovoked by Resident #2. Record review of Resident #2's Progress Notes reflected the following entries: - Incident Note written by the DON, dated 02/15/2025 at 02:30 p.m., reflected On 2/15/25 Resident verbalized to [CNA B] and [LPN F] that [CNA A] made him leave bingo to take a shower. While in shower [CNA A] pulled his ear and pinched his stomach. Stated he tried to punch and kick her back. Then CNA put resident in bed after he stated he did not want to go to bed. Stated Employee [sic] punched him on arm in room. Resident has camera in room. [Resident #2 RP] notified of allegation and stated she would review footage. Resident with bruising to RUA [right upper arm], L [left] ear and abdomen. [Resident #2's PCP] notified. Skin and pain assessment completed. Employee suspended pending investigation. - Nursing note written by RN K, dated 02/15/2025 at 04:05 p.m. and noted as LATE ENTRY, reflected Resident's [Resident #2's RP] reviewed footage of personal camera that is in resident's room. Footage provided to this nurse by [Resident #2's RP]. 8 videos sent. In clips there are no obvious incidents of staff member hitting resident or of resident being combative. Noted resident pushed over to side, legs allowed to fall to bed instead of supporting through turns during peri care. [Resident #2's RP] states she will come by facility to visit resident tomorrow to see how he is doing. Informed RP resident is in good spirits and not complaining of pain or any other discomfort at this time. Staff continuing to monitor. - Nursing note written by RN K, dated 02/15/2025 at 04:11 p.m. and noted as LATE ENTRY, reflected Resident is up in power chair propelling self-down [sic] hall. Noted smiling and speaking to another resident at nurses [sic] station. No s/s of distress at this time. Will continue to monitor. - Incident Note written by LPN H, dated 02/15/2025 at 09:33 p.m. and noted as LATE ENTRY, reflected Patient presents with no behaviors at this time. Patients' [sic] vitals remain stable and states no pain to Rt arm. Received all nighttime medications. Will continue to monitor for changes. Patient is now in bed asleep. - Incident Note written by LPN H, dated 02/15/2025 at 10:21 p.m., reflected Patient presents with no behaviors at this time. Patients' [sic] vitals remain stable and states no pain to Rt arm. Received all nighttime medications. Will continue to monitor for changes. Patient is now in bed asleep. - Activities Note written by LPN H, dated 02/16/2025 at 05:39 a.m., reflected Patient slept through the night and presented with no behaviors. Vitals remain stable. - Incident Note written by LPN H, dated 02/16/2025 at 06:00 a.m., reflected Patient slept through the night and presented with no behaviors. Vitals remain stable. - Nursing Note written by RN K, dated 02/16/2025 at 03:14 p.m., reflected .Resident in a cheerful mood. No complaints verbalized to me or other staff members at this time. - Nursing Note written by LPN H, dated 02/16/2025 at 08:40 p.m., reflected Patient is in chair engaging in conversation with people. No signs of distress noted. Vitals are stable and no aggressive behavior observed. - Social Services Note written by the LSW, dated 02/18/2025 at 04:40 p.m., reflected This SW met with [officer name and badge number], with [county name] sheriff office. Case #[number documented]. He met with this resident to discuss the incident that occurred between himself and the CNA. [Officer M] also spoke with the DON and me, as well as this resident's [Resident's RP]. The officer is turning over his report to the Detective [sic] and he will follow up, after he reviews the case. - Social Services Note written by the LSW, dated 02/19/2025 at 08:29 a.m., reflected This SW spoke with this resident, about how he was doing and if he was feeling anxious or upset about the situation, that he had with his CNA. He said that he was fine and that he was happy. Record review of Resident #2's Care Plan, dated as last review completed 01/24/2025 and accessed 02/20/2025, reflected the following focuses with interventions: - Resident #2 required assistance with his ADLs because of his cerebral cysts. Interventions included: - Bed Mobility: I require limited to extensive assistance in self performance [sic] with 1 person [sic] physical assistance staff support. - Personal Hygiene: I require supervision, limited assistance in self performance [sic] with 1 person [sic] physical assistance staff support during my personal hygiene. - Toileting: I require limited to extensive assistance in self performance [sic] with 1 person [sic] physical assistance staff support. - Resident #2 is known to become upset very easily when I feel I am in trouble or done something wrong . Interventions included: - Approach in a calm and reassuring manner - Explain care procedures in simple terms - Staff to redirect resident in gentle manner when behaviors are noted. - 2/13/2025 Suspected physical abuse of resident by staff member as evidenced by: Resident report 2/15/25. Interventions included: - Arrange for psych consultation as ordered by primary MD. - Assess/record/report [sic] to MD prn noted s/sx of suspected abuse: Unexplained bruising, bleeding, swelling, other s/sx of trauma Unusual [sic] or unexplained behavioral symptoms (fearfulness, aggressiveness, acting out sexually) [sic] Vaginal bleeding or discharge Penile [sic] discharge Resident [sic], staff or family member reports of abusive behavior. - Discuss with resident/family concerns, fears or issues related to suspected abuse. - Document resident, family or staff member statements concerning the alleged abuse. - Immediately notify regulatory agencies of suspected abuse. Record review of facility investigation file for incident #564291, received 02/20/2025 upon entry for investigation, reflected the following documents: - an Employee Disciplinary Action Form, dated 02/15/2025 for counseling with CNA A. Notation of Decision on document included Suspension and Termination boxes checked with plan of correction written, Employee terminated due to investigation- intake #564261. - a document titled, Self-Reporting Protocol - Abuse and/or Neglect, dated 02/15/2025. The document reflected: - Notifications checked as completed included: abuse coordinator, the DON, Resident RP, Resident PCP, facility Medical Director, local law enforcement, and a report to THHS was completed within specified timeframe, - CNA A was suspended pending investigation on 02/15/2025, - Resident #2 was interviewed, a BIMS was conducted, and a head-to-toe skin assessment was completed on 02/15/2025, - Resident Safe Surveys were conducted, - incident reports in [EMR] were completed, and - abuse/neglect in-servicing was started for all staff. - a printed statement titled [CNA A] 2/15/2025. The statement included On Tuesday [02/11/2025] I did not have any issues with [Resident #2]. On Thursday [02/13/2025] when I was trying to transfer him [Resident #2] to the bed he started hitting everything, scratching his face. His friend from B bed [Resident #3] got up and was peeking through the curtain trying to talk to him and get his attention so I told him to go to the other side of the curtain. He was banging his arm on the rail. That's how he acts when I put him back to bed. I told the nurse he was acting out again. The nurse went in the room but by that time he was settled in bed and calm. I gave him a shower in the shower room and I didn't have any problems, it's when I try to put him in bed. I never hit [Resident #2], I put my arm up to keep him from hitting me. I did notice a healing bruise to his right shoulder area when I changed him. - a printed statement titled 8/15/2025 [Resident #2's] Statement. The statement included I don't like [CNA A] no more. I got mad with [CNA A] because she did not let me play games .I was trying to keep playing the games and [CNA A] don't let me play. She keeps punching me. Look, see? (shows bruising to right upper arm.) I hit [CNA A] and then she hit me on purpose. - Six Resident Safe Surveys, dated 02/15/2025, completed by RN K and the LSW on residents with rooms on 300-hall [hall Resident #2's room was located and CNA A's assigned hall]. All residents noted to select that they felt safe in the facility. - a copy of the self-report for incident #564291, sent by the ADMIN on 02/15/2025 at 03:32 p.m. - a copy of Resident #2's Trauma Informed Care Assessment, dated 02/15/2025 at 03:12 p.m. and signed by the DON. The assessment reflected Resident #2 had experienced an unusually or especially frightening, horrible, or traumatic event and he had nightmares about the event(s), but he did not need to try hard to not think about the event(s), was not on constant guard, did not feel detached from people or activities, or feel guilty or unable to stop blaming himself. - a copy of Resident #2's Pain Evaluation, dated 02/15/2025 at 03:12 p.m. and signed by the DON. The evaluation reflected, Resident #2 denied pain or hurting at any time in the last 5 days. Under Conclusion, NO pain, intervention is not necessary. Re-assess quarterly or with onset of pain. was selected and a documented note, assessment completed due to abuse allegation and bruising noted. Resident states he currently does not have pain. was included under Progress Notes. - a copy of Resident #2's Weekly Skin Assessment Report, dated 02/15/2025 at 03:14 p.m. and signed by the DON. The report reflected Resident #2 had three light yellow bruises on his abdomen, a purple bruise on his left ear, five yellow to purple bruises on his right upper arm. He did not have any open injuries and was not in pain. Resident #2's PCP and RP were noted to have been notified on 02/15/2025. Record review of the facility's document, Inservice Attendance Record, labeled with topic Abuse, Neglect, Self Report, Involuntary Exclusion, received 02/20/2025 but dated 02/25/2025, reflected 82 of 146 staff had completed the training. Of the clinical staff that completed the training, 16 of 34 were CNAs from multiple shifts, 13 of 22 were LPNs from multiple shifts, 2 were weekend RNS of 7 RNs, and 15 of 32 were therapy staff. 45 of the total facility staff were identified as not full-time staff with 10 staff labeled as part-time employees, 32 staff labeled as working PRN (as needed), and 3 staff labeled as LOA (on leave of absence). Record review of the police report, dated as reported 02/18/2025 at 03:24 p.m., reflected Resident #2's RP reported Resident #2 was assaulted by a staff member. The general report noted the officer spoke with the facility LSW, the DON, and Resident #2's RP at the facility. The report noted the officer was advised by his supervisor sergeant to notify the criminal investigation department. Record review of the facility's policy Abuse Prevention Program, dated as revised December 2016, reflected a policy statement which stated, Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. Policy Interpretation and Implementation stated As part of the resident abuse prevention, the administration will: 1. Protect our residents from abuse by anyone including, but not necessarily limited to: facility staff . 4. Implement measures to address factors that may lead to abusive situations, for example: a. Provide staff with opportunities to express challenges related to their job and work environment without reprimand or retaliation; . The noncompliance was identified as past non-compliance IJ. The noncompliance began on 02/15/2025 and ended on 02/19/2025. The facility corrected the non-compliance before the investigation began.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for 5 of 79 residents (Resident #5, #7, #10, #11, and #12) reviewed for elopement. 1. Resident #5 was admitted on [DATE] with diagnoses which included dementia and was assessed on 02/26/2024 as a wander risk at 9 out of a possible 11 for high risk. Resident #5 walked out of the facility on 03/16/2024 around 3:00 to 4:00 PM and was discovered 13 miles away on a public street and returned to the facility at 9:40 PM. 2. Residents #7, #10, #11, and #12 have been assessed as at risk for wandering while the facility has a front door which was unlocked and unmonitored from 6:00 AM to 8:00 AM and 5:00 PM to 10:00 PM on Monday through Friday and unlocked and unmonitored from 6:00 AM to 8:00 AM and 7:00 to 10:00 PM on Saturdays and Sundays. The facility receptionist's monitors the front door from 6:00 to 5:00 Monday through Friday and from 6:00 AM to 7:00 PM on Saturdays and Sundays but are unaware of which residents are at risk for wandering and or elopement. An IJ was identified on 04/19/2024. The IJ template was provided to the facility on [DATE] at 02:44 PM. While the IJ was removed on 04/20/2024, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with the potential for more than minimal harm that was not an Immediate Jeopardy due to the facility staff had not been trained on measures to identify and support residents needs for safe outdoor activities. These failures could place residents at risk of harm, severe injury, and possible death to residents who require supervision to prevent elopement. The findings included: 1. A record review of Resident #5's admission record dated 04/18/2024 revealed an admission date of 02/23/2024 with diagnoses which included dementia (the loss of cognitive functioning and thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities), altered mental status, restlessness and agitation, and noncompliance with medical treatment and regimen. A record review of Resident #5's admission MDS assessment, dated 03/01/2024, revealed Resident #5 was a [AGE] year-old male admitted for long term care with dementia safety needs and assessed with a BIMS score of 09 out of a possible 15 which indicated moderately impaired cognition. Further review revealed Resident #5 was assessed independent for indoor mobility (ambulation): code the resident's need for assistance with walking from room to room (with or without a device such as cane, crutch, or walker) prior to the current illness, exacerbation, or injury. Further review revealed Resident #5 was assessed as Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort when assessed for Walk 150 feet: Once standing, the ability to walk at least 150 feet in a corridor or similar space. A record review of Resident #5's base line care plan dated 02/23/2024 revealed Resident #5 was assessed as needing no assistance with locomotion, Locomotion on unit: support provided 0. No setup or physical help from staff. A record review of Resident #5's Wander Risk assessment dated [DATE] revealed LVN D assessed Resident #5 as at Risk to Wander, out of a possible, low risk to wander, at risk to wander, and high risk to wander. During an interview on 04/17/2024 at 9:00 AM the Administrator stated on 03/16/2024 Resident #5 eloped from the facility and was returned the same evening around 9:00 PM. The Administrator stated after the elopement Resident #5 was placed on a 1 to 1 level of supervision and was discharged to another facility with a secured memory care unit. The Administrator stated she reported the incident to the state survey agency and provided in-service education for the staff for elopement protocols and provided a practice drill for elopement protocols. The Administrator stated she was in the process of securing bids to have a secured front door and back door to include a back fenced area. A record review of the facility's investigation report, dated 3/22/2024, revealed Resident #5 eloped from the facility on Saturday 03/16/2024 around 03:00 PM to 4:00 PM and was returned to the facility by Resident #5's POA around 10:00 PM. A record review of Resident #5's nursing progress notes dated 03/16/2024 revealed LVN C documented at 7:23 PM, 1713 (5:13 PM) went to assess resident and obtain vital signs for 2-10 PM shift but resident not in room; looked in dining room where residents are gathering for evening meal; resident not in dining room; searched for resident in all rooms on 100 and 200 hall; unable to locate resident; 1726 (5:26 PM) paged for CODE PINK overhead and informed weekend supervisor; all rooms, closets, shower rooms, storage rooms searched but unable to find resident; searched outside grounds, as well as convenience stores across street and across open field from facility; weekend supervisor notified administrator, DON, and family; placed call to IT (representative) to review camera footage; (Local) Sheriff Office notified and deputy dispatched; 1850 (6:50 PM) administrator called and informed weekend supervisor that resident had been located at (local) ER (emergency room); informed deputy who left to go make contact with resident at ER; 1950 (7:50 PM) deputy returned to facility and informed this nurse that administrator had been given incorrect information and that resident is not at (local) ER; deputy had notified maintenance director and requested that he return to facility to review camera footage to verify that resident did, in fact, leave premises; informed weekend supervisor who, in turn, informed administrator. A record review of Resident #5's nursing progress notes dated 03/16/2024 revealed LVN C documented at 9:37 PM, 2030 (8:30 PM) Resident #5's POA came to facility to report that resident had called him; resident had left facility on foot and got a ride to an old address, and got the people that live there now to take him to the west side; Resident #5's POA states that he is going to go try and find him in the not so nice place that he's at, and try and get him to come back, I will call y'all when I find him; 2140 (9:40 PM) Resident #5's POA arrived back at facility with resident; resident smiling and laughing; no acute distress noted; denies pain or discomfort; resident will be placed on 1:1 monitoring. During an interview on 04/20/2024 at 4:20 PM LVN C stated she was the charge nurse on 03/16/2024 and recalled she saw Resident #5 around 3:00 PM and then could not locate Resident around 5:00 and announced Code Pink which alerted the staff a Resident was missing. LVN C stated the staff began searching the facility and then searched the immediate neighborhood. LVN C stated she alerted the local police, the doctor, and Resident #5's POA. LVN C stated Resident #5's POA called the facility, around 8:00 PM and reported he had discovered Resident #5 downtown and would return shortly. During an interview on 04/18/2024 at 3:25 PM the DON stated Resident #5 was admitted on [DATE] and assessed as a wander risk due to his diagnoses of dementia and did not have any history of elopements and or verbalizations of ideations for elopement. The DON stated Resident stated the front doors are not locked from 6:00 AM to 10:00 PM and the receptionist monitors the doors from 8:00 to 5:00 PM. The DON stated the 10:00 PM to 6:00 AM nurse locked the front doors at 10:00 PM and unlocked the doors at 6:00 AM. The DON stated on 03/16/2024 at around 5:00 PM LVN C attempted to assess Resident #5 and discovered she could not find him and alerted the weekend Supervisor RN who initiated the elopement protocol. The DON stated the police were alerted and Resident #5's POA was alerted. The DON stated Resident #5's POA called the facility and reported he had discovered Resident #5 had boarded a public bus and traveled to an apartment he used to rent, and the landlord identified Resident #5 and drove Resident #5 to the downtown homeless shelter. The DON stated she and multiple facility staff independently used their vehicles to search the downtown homeless shelter area and Resident #5 was discovered by the homeless shelter and rode back to the facility with Resident #5's POA. During an interview on 04/19/2024 at 12:07 PM Resident #5's POA stated he had met Resident #5 several years ago and recognized Resident #5 had no family and or friends to look after him and so I began to follow his well-being .and became his POA. Resident #5's POA stated over the years Resident #5 was diagnosed with dementia and Resident #5's moments of clarity were becoming less and less. Resident #5's POA stated after Resident #5's recent hospitalization it was determined a safe discharge from the hospital would require long term care at the facility. Resident #5's POA stated on 03/16/2024 early evening he received a call from the facility reporting Resident #5 was missing. Resident #5's POA stated he was immediately concerned and drove to the facility to assist in Resident #5's search. Resident #5's POA stated during his time searching the facility's surrounding area for Resident #5 he recalled Resident #5 had a recollection of his previous address, so he decided to call Resident #5's previous landlord and learned from the previous landlord that Resident #5 had presented at the home and attempted to reside there. Resident #5's POA stated the landlord reported he drove Resident #5 downtown to a local charity and dropped him off. Resident #5's POA asked for specific details of a location and the landlord identified an area by a highway bridge. Resident #5's POA drove to the area and located Resident #5 on a public street by the local charity and a highway bridge. Resident #5's POA stated Resident #5 stated he did not know how he got there and was hungry. Resident #5's POA stated he drove Resident #5 back to the facility to be assessed. Resident #5's POA provided the address to Resident #5's previous address and the area where he found Resident #5. Resident #5's POA stated he learned from Resident #5 that he more than likely rode the bus to his previous address. A record review of the city's public transport system revealed a bus route from the facility to Resident #5's previous residence which ran directly without a need to change buses. Further review revealed the trip required 20 miles in distance, 1.5 hrs. in duration, and a walk of 7/10ths of a mile. 2. A record review of Resident #7's admission record dated 04/19/2024, revealed an admission date of 10/24/2023 with diagnoses which included schizophrenia (a serious mental disorder in which people interpret reality abnormally.) A record review of Resident #7's quarterly MDS assessment dated [DATE] revealed Resident #7 was a [AGE] year-old-male admitted from the hospital for long term care with needs for wandering and schizophrenia safety supports and assessed with a BIMS score of 12 out of 15 which indicated moderate cognitive impairment. Further review revealed Resident #7 used a wheelchair. A review of the Functional Abilities and Goals assessment, dated 04/08/2024, revealed Resident #7 was assessed to an ability to use a wheelchair as: Wheel 50 feet with two turns: Once seated in wheelchair/scooter, the ability to wheel at least 50 feet and make two turns .Setup or clean-up assistance - Helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity and Wheel 150 feet: Once seated in wheelchair/scooter, the ability to wheel at least 150 feet in a corridor or similar space .Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as Resident completes activity. Assistance may be provided throughout the activity or intermittently. A record review of Resident #7's care plan dated 04/19/2024 revealed, Resident independent with ADLS (Activities of Daily Life). Maintain independence through review date: I may fluctuate on my ADL's Self-Performance score and fluctuate in my ADL. Support score because some days I may need more or less help due to my physical impairment and cognitive impairments .USES WALKER TO AMBULATE TRANSFERS-INDEPENDENT TO LIMITED ASSIST AT TIMES. A record review of Resident #7's Wandering Risk Scale dated 03/22/2024, revealed, Resident #7 was assessed by LVN D as At Risk for Wandering. A record review of Resident #10's admission record dated 04/19/2024 revealed an admission date of 04/19/2021 with diagnoses which included dementia (the loss of cognitive functioning and thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities) and schizophrenia (a serious mental disorder in which people interpret reality abnormally.) A record review of Resident #10's quarterly MDS assessment dated [DATE] revealed Resident #10 was a [AGE] year-old-male admitted from the hospital for long term care with needs for wandering, dementia and schizophrenia safety supports and assessed with a BIMS score of 9 out of 15 which indicated severe cognitive impairment. A review of the Functional Abilities and Goals assessment, dated 01/22/2024, revealed Resident #10 was assessed with the ability to, Walk 150 feet: Once standing, the ability to walk at least 150 feet in a corridor or similar space with, Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as Resident completes activity. Assistance may be provided throughout the activity or intermittently. A record review of Resident #10's care plan dated 04/19/2024 revealed Resident #10 was at risk for falls related to generalized weakness, impaired cognition, use of psychoactive meds and irregular gait, dementia, poor safety awareness, hearing and visual impairment, psychotropic med use, and prior falls with interventions: Monitor resident every shift or as needed and keep watch .I use a walker . ensure resident's safety at all times and keep watch . I am at risk of injury as I have impaired visual functioning due to Cataracts and macular degeneration A record review of Resident #10's Wandering Risk Scale dated 03/17/2024, revealed, Resident #10 was assessed by LVN D as At Risk for Wandering. A record review of Resident #11's admission record dated 04/19/2024 revealed an admission date of 04/16/2020 with diagnoses which included dementia (the loss of cognitive functioning and thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities), bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), and legal blindness (a person cannot attain 20/200 vision even with prescription eyewear.) A record review of Resident #11's quarterly MDS assessment dated [DATE] revealed Resident #11 was a [AGE] year-old-male admitted from another facility for long term care with needs for wandering, dementia and blindness. Resident #11 was assessed with a BIMS score of 14 out of a possible 15 which indicated intact cognition. A review of the Functional Abilities and Goals assessment, dated 10/24/2023, revealed Resident #11 was assessed with the ability to, Walk 150 feet: Once standing, the ability to walk at least 150 feet in a corridor or similar space with, Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as Resident completes activity. Assistance may be provided throughout the activity or intermittently. Resident #11 had a need for a walker (a device that gives support to maintain balance or stability while walking). A review of the Functional Abilities and Goals assessment, dated 10/24/2023, revealed Resident #11 was assessed with the ability to, Walk 150 feet: Once standing, the ability to walk at least 150 feet in a corridor or similar space with, Setup or clean-up assistance - Helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity. Assistance may be provided throughout the activity or intermittently. A record review of Resident #11's care plan dated 04/19/2024 revealed, I am at risk of injury as I have impaired visual functioning due to Blindness and cataracts . I am at risk for injuries or falls related to generalized weakness, use of psychoactive meds, dementia, and blindness . I require assistance with Activity Daily living due to due to impaired cognition related to diagnosis of Dementia, generalized weakness, blindness, depression . Pt requires INDEPENDENT WITH TRANSFERS AND LOCOMOTION/AMBULATION AT TIMES NEEDS supervision of one with Transfers, dressing, toileting, and walking in room. A record review of Resident #11's Wandering Risk Scale dated 03/17/2024, revealed, Resident #11 was assessed by LVN D as At Risk for Wandering. A record review of Resident #12's admission record revealed an admission date of 06/29/2020 with diagnoses which included dementia (the loss of cognitive functioning and thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities), bipolar II disorder (a mental health condition that involves periods of depression and periods of elevated mood), and unspecified psychosis (thoughts and perceptions are disrupted and they may have difficulty recognizing what is real and what is not). A record review of Resident #12's quarterly MDS assessment dated [DATE] revealed Resident #12 was a [AGE] year-old-male admitted from a nursing facility for long term care with support needs for wandering and dementia. Resident #12 was assessed with a BIMS score of 13 out of a possible 15 which indicated intact cognition. Further review revealed Resident #12 had a need for a walker (a device that gives support to maintain balance or stability while walking). A review of the Functional Abilities and Goals assessment, 12/29/2023, revealed Resident #12 was assessed with the ability to, Walk 150 feet: Once standing, the ability to walk at least 150 feet in a corridor or similar space with, Setup or clean-up assistance - Helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity. Assistance may be provided throughout the activity or intermittently. A record review of Resident #12's care plan dated 04/19/2024 revealed, I require assistance with activities of daily living due to lack of coordination, abnormal gait, muscle weakness which can impair my performance with mobility tasks (PMHx (past medical history): HTN (high blood pressure), Bipolar d/o (disorder), Neuropathy (nerve pain), Severe mood swing) .Ambulates with a walker .Encourage resident to perform as much of the activity as possible . I use walker for locomotion related to generalized weakness . Provide supervision at all times when resident is able to move around using his Walker . I am at risk for elopement related to wandering risk assessment score .Discuss with resident/family risks of elopement and wandering . A record review of Resident #12's Wandering Risk Scale dated 03/17/2024, revealed, Resident #12 was assessed by LVN D as At Risk for Wandering. During an interview on 04/20/2024 at 2:23 PM LVN D stated she used the facility's electronic program Wander Risk Scale for assessing residents for elopement risks. LVN D stated residents could be assessed as 1. Low risk, 2. at risk for wandering, and 3. high risk to wander. An observation on 04/18/2024 at 4:01 PM revealed Resident #7 use his wheelchair to ambulate out the facility's front automatic sliding front doors. Further observation revealed Resident #7 enjoying the outdoor weather and returning into the facility, several minutes later During an interview on 04/18/2024 at 4:10 PM Receptionist A stated she observed Resident #7 ambulate outside and return inside. Receptionist A stated residents are free to go outside and return when they choose. Receptionist A stated she had no list of residents who could and or could not go outdoors unsupervised. Receptionist A stated she worked from Monday through Friday from 08:00 AM to 5:00 PM and when she arrived the front doors were already opened, and the doors remained open when she left. During an interview on 04/18/2024 at 4:50 PM Receptionist B stated she was the receptionist on the weekends and was on duty from 8:00 AM to 7:00 PM. Receptionist B stated when she arrived the front doors were already opened, and the doors remained open when she left. Receptionist B stated she had worked at the facility 3 years and Resident #5 was new to her, but she was not concerned for his safety because he could walk and make his needs known. Receptionist B stated she had no list of residents who could and or could not go outdoors unsupervised. Receptionist B stated she worked on the day Resident #5 eloped and could not recall the exact time she saw Resident #5 outside of the facility but did recognize the time of day which was after lunch and before dinner . Receptionist B stated she recalled she heard the announcement Code Pink which indicated a Resident was missing and learned Resident #5 was missing. Receptionist B stated she and the staff began a search for Resident #5 to include the immediate neighborhood surrounding the facility. During an interview on 04/20/2024 at 1:55 PM the Director of Rehabilitation stated Residents #7, #10, #11, and #12 were not safe to ambulate out of the facility without supervision due they were all at risk for falls with severe injuries complicated by the various outdoor terrains and their inabilities to cope with those varied terrains. During an interview on 04/19/2024 at 2:40 PM the Administrator and the DON stated Resident #5 was not at risk for wandering due to a lack of elopement history, verbalizations of elopement, and his was alert and oriented to himself, his surroundings, and time. The Administrator and the DON stated Residents #7, #10, #11, and #12 were not at risk for wandering due to a lack of elopement histories, verbalizations of elopement, and were alert and oriented to themselves, their surroundings, and time. A record review of the facility's Elopements policy dated December 2007, revealed, staff shall investigate and report all cases of missing residents . staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the charge nurse or director of nursing. if an employee observes a resident leaving the premises, he or she should: attempt to prevent the departure in a courteous manner; get help from other staff members in the immediate vicinity, if necessary; and instruct another staff member to inform the charge nurse or director of nursing services that a resident has left the premises This was determined to be an Immediate Jeopardy (IJ) on 04/19/24 at 02:44 PM. The facility Administrator and the DON were notified. The Administrator was provided with the IJ template on 4/19/24 at 02:44 PM & a POR was requested. The following Plan of Removal submitted by the facilityApril 19, 2024, at 6:20pm as follows: The facility respectfully submits this plan of removal to abate the allegations of immediate jeopardy identified on April 19, 2024. Facility failed to have current interventions in place to monitor residents who are at risk for wandering out the front door as the front doors are not secured. Resident #5, with a BIMS of 8 and Wandering Risk Assessment score of 9 indicating Resident #5 was at risk to wander. Resident #5 ambulated outside to the facility front patio and from there left the premise to return to his previous home. Inservice completed on 3/17/24 - covering Elopement. Elopement drill completed on 3/21/24. Resident #5 was placed on 1:1 monitoring from the time of his return to the facility on 3/16/24 until his transfer to a secured unit on 4/5/24. Residents with the potential to be affected by the alleged deficient practice: The Facility immediately completed a 100% re-assessment of all residents' wander risk on 3/18/24. Any residents who were noted at risk for wandering at this time, were reviewed by the IDT Team and found not at risk for elopement . Each residents' care plan was updated to reflect this determination . Staff were in-serviced on Elopement , and an elopement drill was also subsequently completed. Bids were solicited and received for a keypad locking mechanism for the front entrance doors as well as the Hall 200 exit door. The incident was referred to the QAPI committee for review on the next scheduled QAPI meeting. Resident identified to have been affected by the alleged deficient practice: Resident #5 was located and returned to the facility on 3/16/24. Resident #5 was assessed for injury with none noted. Resident #5 was interviewed and stated he decided to go visit his previous home to inquire if it would be available for him to return to upon discharge from the Facility. The Facility launched an in-depth investigation to determine how and when Resident #5 left the premises. The Facility interviewed staff and residents to determine the details of Resident #5 leaving Facility property. The Facility interviewed Resident #5 to learn the reason why, and the way, Resident #5 left. Alternate placement was sought for security of Resident #5. The IDT team determined Resident #5 was aware of when he left premises and why (to visit his previous home). The IDT team felt Resident #5 had the potential to attempt to leave the premise again to visit and inquire about his previous home. As such, Resident #5 was placed on 1:1 monitoring in the Facility and alternate placement at a secured facility was obtained. Resident #5 transferred to the secure facility on 4/5/24. Systemic Measures: Receptionist Hours Extended: The Facility immediately extended the hours of Reception at the front entrance of the building. This will include the hours of 6am-8am and 5pm-8pm. Coverage of the front entrance will now include a total daily timeframe of 6am-8pm. The front entrance door will be locked between the hours of 8pm and 6am. Should the Receptionist need to leave the desk, he/she will either call for relief to step-in in his/her absence or lock the front door until returning to duty. Hall 200 Exit Door alarm/lock: The Facility immediately implemented a temporary door alarm that will sound when the door is opened. The bid for the keypad for this exit door was signed by the Administrator and will be placed by (contractor) Engineering on 4/23/24. Wander Risk Binder: The Facility immediately implemented a Wander Risk Binder that includes pictures of the five (5) residents whose Wander Risk Assessment currently scores each at risk for wandering, although all five (5) residents had previously been reviewed by the IDT Team at the time of the incident and deemed not at risk for elopement due to no documented attempts of exit seeking in the past. All five (5) residents' care plans were updated to reflect the wander risk assessment result, and the fact that the resident was not deemed an elopement risk by the IDT Team. The Wander Risk Binder will be placed at the front Receptionist desk and at the nurses' station. The binder will be updated by DON or designee. The binder will be reviewed daily. Locking Log: The Facility immediately implemented a locking log for staff to document the locking and unlocking of the front entrance door. Training: Will be completed by 4/20/24 as follows: a. Initiate staff in-servicing of the Wander Risk Binder located at front Reception and the nurses' station. b. Initiate staff in-servicing of Elopement protocol. c. Initiate staff in-servicing of new door alarm placed on 200 Hall exit door. d. Initiate staff in-servicing on Locking Log. Inservice sign in sheet will be cross reference with employee roster. Quality Assurance Performance Improvement: On 4/19/24 the Quality Assessment and Assurance Committee members to include the Medical Director, Administrator, and Director of Nursing, and the Regional Director of Clinical Services met to review and approve this plan. The Administrator and/or Designee will review the Locking Log daily for 3 months. The Administrator and/or Designee will review the Wander Risk Assessment Binders located at the reception and nurses' station daily for 3 months. The results of the Administrator and/or Designee reviews will be presented to the Quality Assessment and Assurance Committee for review of trends and/or negative findings and further recommendations during the scheduled meetings for 3 months. The committee will make recommendations for further education as warranted and develop further performance improvement plans as necessary. Date of Correction: April 19, 2024 Monitoring of the POR as follows: The facility respectfully submits this plan of removal to abate the allegations of immediate jeopardy identified on April 19, 2024. Plan submitted on April 19, 2024, at 6:20pm. Facility failed to have current interventions in place to monitor residents who are at risk for wandering out the front door as the front doors are not secured. Resident #5, with a BIMS of 8 and Wandering Risk Assessment score of 9 indicating Resident #5 was at risk to wander. Resident #5 ambulated outside to the facility front patio and from there left the premise to return to his previous home. Inservice completed on 3/17/24 - covering Elopement. Elopement drill completed on 3/21/24. Resident #5 was placed on 1:1 monitoring from the time of his return to the facility on 3/16/24 until his transfer to a secured unit on 4/5/24. Residents with the potential to be affected by the alleged deficient practice: The Facility immediately completed a 100% re-assessment of all residents' wander risk on 3/18/24. Any residents who were noted at risk for wandering at this time were reviewed by the IDT Team and found not at risk for elopement. Each residents' care plan was updated to reflect this determination. Staff were in-serviced on Elopement, and an elopement drill was also subsequently completed. Bids were solicited and received for a keypad locking mechanism for the front entrance doors as well as the Hall 200 exit door. The incident was referred to the QAPI committee for review on the next scheduled QAPI meeting. Resident identified to have been affected by the alleged deficient practice: &[TRUNCATED]