**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure that the resident's environment remained as free of accident hazards as possible for 1 of 23 residents (Resident #1) reviewed for accidents and supervision. The facility failed to provide that Resident # 1's environment remained as free of accident hazards as is possible when Resident #1 swallowed wet wipes, choked and expired. An IJ was identified on 03/14/25. The IJ template was provided to the facility on [DATE] at 4:11 p.m. While the IJ was removed on 03/21/25, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm because the facility needed to monitor the implementation of the plan of removal. The failure placed all residents at risk for serious injury, harm, and/or death. Finding include: Record review of Resident #1's admission Record dated 03/18/25 documented a [AGE] year-old male admitted to the facility 12/23/24 with diagnoses that included dementia in other diseases classified elsewhere, moderate, with other behavioral disturbance (a mental disorder in which a person loses the ability to think, remember, learn, make decisions and solve problems), schizophrenia (a serious mental condition of a type involving a breakdown in the relation between thought, emotion, and behavior, leading to faulty perception, inappropriate actions and feelings and withdrawal from reality), depression (a mental condition characterized by feelings of severe despondency and dejection), neuromuscular dysfunction of bladder (a condition that occurs when the nerved controlling the bladder are damaged), and benign prostatic hyperplasia (enlarged prostate potentially squeezing the urethra and causing urinary problems). Record review of Resident #1's PPS Discharge Assessment MDS dated [DATE] revealed a BIMS score of 13 indicating he was cognitively intact. The PHQ9 score evaluating mood was 0 indicating no evidence of depression. Under Functional Abilities, Resident #1 was able to walk unassisted, transfer himself in and out of bed and to the toilet, and only required setup or clean-up assistance with ADLs. Record review of Resident #1's Care Plan dated 12/24/24 revealed Focus that included: - that he required a catheter and interventions were in place to provide catheter care - at risk for psycho-social issues, emotional distress or behaviors related to schizophrenia with interventions that noted behavior triggers: mood disorder, delusion and hallucinations and to keep environment calm, quiet and avoid loud noises as much as possible - Required anti-psychotic medication related to schizophrenia which included the need to monitor/document/report to MD signs and symptoms of psychotropic drug complications, altered mental status, decline in mood or behavior, hallucinations, delusions, social isolation and withdrawal . Record review of Nurses Progress Notes dated 03/14/25 by RN B documented that Resident #1 was last seen at approximately 6:00 pm sitting on the side of his bed alert and oriented. CNA called for this nurse at approximately 7:10 pm. Resident lying in bed not responding to verbal stimuli, pale in color, and no pulse noted. Code Blue called. Resident was assisted to the floor by this nurse and two CNAs and CPR was initiated. 911 called by CNA at approximately 7:13 pm. CPR continued until EMS arrived .Time of death called by EMS MD at 7:48 pm. Record review of the EMS Report dated 03/14/25 revealed that during attempts to intubate Resident #1, EMS discovered a stack of wet wipes lodged in esophagus, wet wipes continued to be removed, approximately 15 wet wipes were removed . During an interview with LVN A on 03/18/25 at 1:12 pm, nurse reported that Resident #1 appeared to be in a good mood, participated in activities and had talked with a family member who was coming to visit. LVN A stated Resident #1 accidentally pulled out his foley so she easily reinserted it. LVN A stated Resident #1 was not complaining of pain. LVN A stated she had seen Resident #1 in the hall after that and there were no apparent signs of suicide. When asked if she had ever seen Resident #1 writing notes, LVN A stated he had asked for paper before but she had never seen him writing. LVN A was asked about the availability of wipes and she stated residents used to have access to wipes but they don't now. LVN A stated that getting rid of wipes was a plan of correction for a variety of reasons. During an interview with CNA D on 03/18/25 at 1:52 pm, she stated they were getting residents ready for bed. CNA D stated Resident #1 and his roommate would remind each other about going to the dining room to get their medications from the nurse. His roommate reported that he couldn't wake up Resident #1. CNA E went to check on Resident #1 and discovered he was non-responsive and got the nurse. CNA D stated she and the other CNA and the nurse got Resident #1 off the bed and onto the floor so CPR could be started until EMS arrived. CNA D stated she didn't see anything in Resident #1's mouth but later saw EMS pull something out of his mouth. CNA D stated she was in shock and never thought he would do anything like that. CNA D stated the wipes and gloves were always stored in the resident's bathrooms but now everything is either on the cart or will be locked up in a storage closet. CNA D stated staff was given an inservice by the DON about where these items will be kept. CNA D noted there are other things with which residents can hurt themselves like call light cords, miniblind cords and phones with cords - why not take those away? CNA D stated she always checked on her residents about every 30-40 minutes and makes sure the doors are open so I can see if they have fallen and they are OK. During a phone interview with CNA E on 03/18/25 at 2:11 pm, CNA E stated she had just seen Resident #1 earlier drinking some water. CNA E was present when EMS took the wipes out of Resident #1's throat but the wipes could not be seen prior to EMS taking them out. CNA E stated the DON inservices staff about abuse and neglect and keeping everything away from residents that are not safe. CNA E stated she worked in another facility before coming here and everything was locked up. CNA E stated that one of the girls told me Resident #1 had been seen with the bed remote cord around his neck one time. CNA E stated Resident #1 seemed fine the night before and he came out for a snack and water and was watching a movie. During an interview with RN B on 03/18/25 at 2:20 pm, the nurse stated she had seen Resident #1 sitting on the side of his bed when she arrived at 6:00 pm for her shift. RN B stated that when she was getting ready to give out medications, his roommate told staff Resident #1 was not waking up. RN B stated, After CNA E notified me that resident was unresponsive we lowered him to the floor and began CPR. RN B stated she first tried a sternal rub and then began compressions. Another staff member used the ambu bag and it appeared that air was going in. RN B stated the EMT showed her what he had taken from Resident #1's mouth which appeared to be multiple wipes. RN B stated Resident #1 was the most alert resident in the unit and was fully aware of what was going on. RN B stated she never saw Resident #1 do anything outside the norm. RN B stated she did know that Resident #1 wrote everything down but he never showed her what he was writing. RN B stated that the DCO, DON, ADM, SW, MDS Nurse and Treatment Nurse all were present during this incident and did an inservice with staff on abuse and neglect and maintaining the safety of residents. During an interview with the ADM, DON and DCO on 03/18/25 at 2:41 pm, the ADM explained why they had not reported the death. The ADM stated that Resident #1 never had a history with anything out of the ordinary. The ADM stated Resident #1 was in the Memory Care unit since this had been recommended by the hospital since Resident #1 had been found wandering around his neighborhood naked. The ADM and DON discussed the fact that wipes have always been available on the unit and that Resident #1 and his roommate were able to use them. The ADM stated that we have removed all the wipes and paper towels in the building and at mealtimes we have changed to cloth napkins. We did a full sweep of all the rooms. We also removed all the toiletries in the unit and they are now in a supply closet. The DCO stated they had also done a 4 Step Assessment as part of their QAPI to review any safety concerns for residents in the Memory Care Unit. Environmental rounds were made with Maintenance Dir on 03/19/25 between 8:30 - 9:00 am in the Memory Care unit. All drawers and cabinets in the resident rooms were observed for wipes and gloves and all rooms had been cleared of these items. A couple of rooms were found with items that were immediately removed including 1 silicone cream tube in the bathroom and 1 small body lotion tube in a dresser drawer. During a phone interview with Dr H, psychiatrist, on 03/19/25 at 11:43 pm, Dr H stated he was treating Resident #1 with antidepressants. Dr H stated that when he had seen Resident #1 earlier in March, he was a little withdrawn but denied sad mood or suicidal ideations. So I treated him with a mood stabilizer. Dr H stated he had a few sessions with Resident #1 and although he was found to have cognitive impairment it was not severe enough that he would confuse wipes and snacks but added it would be hard to say for sure. Dr. H stated he did see the psychologist at quarterly meetings they held with staff and he felt if she had a concern about Resident #1 she would have informed him. During an interview with SW on 03/19/25 at 3:26 pm, SW stated his last BIMS score was 13 and his PHQ-9 score was 0. SW stated she was not aware that resident heard voices. SW called LVN C to her office since LVN C was over the Memory Care Unit. LVN C stated the psychologist had mentioned Resident #1 hearing voices but that the psychologist was not concerned he would be a harm to himself or others. LVN C stated his only change in behavior was that he seemed to forget he could walk and would take other residents' wheelchairs. LVN C said she reminded Resident #1 he could walk on his own so he would readily give up the wheelchair. On 03/19/25 at 6:22 pm, the complainant returned my call and I informed him about our investigation. The complainant stated he could not say whether or not there was foul play involved so suggested I call the detective investigating the case. During an interview on 03/20/25 at 9:47 am, EMT HH reported that when EMS arrived staff were doing chest compressions and using an AED. EMT HH stated EMS took over with their life pack. EMT HH stated the EMTs noticed they were unable to get Resident #1's oxygen level so made the decision to intubate him. EMT HH said he then noticed vomit in the airway so started suctioning him. EMT HH stated he then used a scope to investigate the airway and he noticed a film. EMT HH then said he had to use his fingers to pull out a group of bath wipes. EMT HH stated the wipes were in 2 wads and did not appear to have been chewed but were rolled up and appear to have been shoved in there. EMT HH stated he looked at Resident #1's medications and didn't see anything unusual. Due to the unusual circumstances, the Crime Scene Investigator unit was called out. During a phone interview with Dr. I, psychologist, she stated the last time she saw Resident #1 he was not having suicidal ideations. Resident #1 did say he had audio hallucinations and they were critical voices like God but they were not telling him to hurt himself. Dr I said she last saw Resident #1 on February 12 and he was seated at a table and did not appear to be more depressed. Dr I stated Resident #1 would refer to himself in the third person. When surveyor asked Dr I about the fact that he frequently wrote about clouds on his papers, she said this was a delusion but not an indicator of depression. Surveyor interviewed LE L at the police department where he opened the evidence bag that had gathered about 25 pages of 81/2 x 11 paper found in Resident #1's room. On one paper he had written Resident #1 swallowed a napkin. On another paper he had written that [family member] was coming to see him. Most of the notes were very disjointed and since there were no dates on any of the papers it is unknown when they were written. LE L stated an autopsy was being done and if the solution from the wet wipes was found under Resident #1's fingernails then the conclusion would be suicide or at least self-harm. A phone interview on 03/21/25 at 12:40 pm with NP II revealed he had not been informed about Resident #1's death although he did see Resident #1 on behalf of the primary care physician who is also the facility Medical Director. NP II stated he would try to get a message to Dr J. During a phone interview with Dr. J on 03/21/25 at 2:11 pm, Dr. J stated he was aware of the death and the circumstances after being informed by the DON. Dr J stated Resident #1 was a walking and talking patient. He was in a locked unit so couldn't elope. Dr. J stated that the wipes should be in a designated area. Dr J also stated that this is very rare and he was being followed by a psychiatrist and was on medication including an anti-psychotic. Dr. J added people with schizophrenia used to be in State Hospitals but now they are in nursing homes so the psychotic behaviors have to be managed. Personnel records were reviewed for staff involved in administration of CPR including RN B, CNA D, CNA E and CNA JJ. CPR certifications and all other personnel records were current and in order. Interviews conducted with 25 staff members out of 96 regular staff and 31 contracted staff by surveyors on 03/21/25 between 8:35 am and 10:30 am and from 4:55 pm to 7:55 pm to verify they had received inservices on Abuse and Neglect, Preventing Accidents, Plan of Care/[NAME], and to ensure all wipes, gloves or personal items were locked in storage closet until use by staff with residents. The Administrator and DON were notified on 03/21/25 at 4:11 pm that an Immediate Jeopardy situation had been identified on 03/14/25 due to the above failures and were presented with an Immediate Jeopardy Template. A Plan of Removal (POR) was requested. The facility's Plan of Removal for the Immediate Jeopardy was accepted on 03/21/25 at 8:34 pm and reflected the following: Immediate Response: Director of Nursing Services/Assistant Director of Nursing Services/Charge Nurse immediately assessed the identified resident and initiated emergency response care. Outcome: Resident pronounced deceased post EMS emergency response care provided. Date completed: 3/14/2025 Notifications: PCP notified Responsible party notified DNS and Admin notified Director of Clinical Operations /Director of Nursing Services/Assistant Director of Nursing Services/IDT conducted an assessment of current residents in order to validate their safety and well-being. Outcome: No negative outcomes identified. Date Completed: 3/14/25 Risk: All residents with cognitive impairment especially those who currently reside on the memory care unit can be affected by the deficient practice. Out of an abundance of caution the IDT Director of Nursing Services/Assistant Director of Nursing Services/Charge Nurse/Designee immediately inspected all resident room to identify and removed any items such as patient care items for added safety. Outcome: There were no negative outcomes identified. Any briefs/wipes identified in bathrooms (cabinets) were immediate removed and disposed of. Date Completed: 3/14/25 The [NAME]/Director of Nursing Services/Assistant Director of Nursing Services conducted rounds and staff interviews to identify any residents with poor cognition and who is at risk for ingesting nonfood items. Outcome: No negative outcomes identified. Date Completed: 3/14/2025 The IDT /Director of Nursing Services/Assistant Director of Nursing Services commenced with an audit of all residents with cognitive impairment to review and update the plan of care as indicated in order to validate the plan of care for accuracy and will update as needed to ensure the appropriate intervention/interventions are noted on the plan of care/[NAME] as well as accurately identified. Outcome: No negative outcomes identified. Date completed: 3/14/25 IDT conducted an audit of all residents with a diagnosis of schizophrenia recent change of condition concerning new onset of behaviors, worsening behaviors, or s/s of being withdrawn within the last 30 days to ensure that appropriate plan of care. Completed: Initially completed on 3/14/2025 and on going IDT conducted an audit of all residents with a recent change of condition concerning new onset of behaviors, worsening behaviors, or s/s of being withdrawn within the last 30 days and reviewed/updated the identified residents' care plan. Completed: Initially Completed 3/14/2025 and on going IDT conducted a depression screen for all resident identified with behavioral concerns changes in condition and all positive screens to be to the mental health provider for evaluation and treatment in order to identify any potential risks for harm to self, specifically reviewing any concerns with potential safety issues such as ingesting non-edible food items. Outcome: No negative outcomes identified. Completed: 3/21/2025 System Response: DCO re-educated Admin/DNS/ADNS regarding: o Abuse & Neglect Preventing, Identifying, and Reporting all suspicions or allegations. o Preventing Accidents/Incidents & Fall Prevention. o Plan of Care/[NAME] should be reviewed by direct care team to ensure the staff member is aware of the necessary care to be provided. o IDT to ensure any safety concerns and appropriate interventions are noted on the plan of care and [NAME]. Date Completed:3/14/2025 Community will ensure all staff on leave/agency staff /PRN staff are in serviced prior to working their shift. No licensed nurse, certified medication aide or certified nurse aide will assume an assignment of patient care until they have passed skills validation of accessing the [NAME]. Community will ensure administrative nursing staff in the community to provide in-service/education prior team members working their assigned shift. These trainings will also be conducted with new hires. Administrator/Director of Nursing/Assistant Director of Nursing re-educated staff regarding: o Abuse & Neglect Preventing, Identifying, and Reporting all suspicions or allegations. o Preventing Accidents/Incidents & Fall Prevention. o Plan of Care/[NAME] should be reviewed by direct care team to ensure the staff member is aware of the necessary care to be provided. o IDT to ensure any safety concerns and appropriate interventions are noted on the plan of care and [NAME]. Going forward the identified trainings above will also be conducted with new hires accordingly. Community will ensure all staff on leave/agency/PRN staff are in serviced prior to working their shift. Community will ensure administrative nursing staff in the community to provide in-service/education prior team members working their assigned shift. These trainings will also be conducted with new hires. IDT will conduct interviews with family, review of health records and evaluate any newly admitted resident for consideration on the memory care unit in order to identify any behavioral concerns that would pose risk of harm to self by ingesting non-food items. Date implemented and ongoing: 3/21/2025 Monitoring: The Administrator/Director of Nursing/Assistant Director of Nursing/Social Worker will make weekly random audits/rounds to validate the safety and well-being of our residents and resident rooms at random times on random halls in order to identify any safety concerns. This audit will be conducted 1-7 days a week for the next 2 months. The findings will be reviewed and reported to the QAPI committee, to validate compliance or to identify additional training needs. Date Initiated: 3/21/2025 Director of Nurses/Assistant Director of Nurses will review all admission/re-admission care plan and [NAME] to ensure any safety risks are accurately noted on the plan of care and [NAME] Will review progress notes and risk management reports to identify and safety risks / concerns. accordingly. This will take place 1-7 days a week for the next 2 months. Date Initiated: 3/21/2025 This corrective action plan will remain in place for the next 2 months to ensure compliance or to identify any further training needs. Findings of those observations will be reported to the QAPI committee during monthly meeting for the next 2 months to establish compliance or identify additional trainings and oversight is required. The Administrator/Director of Nursing/Assistant Director of Nursing/Social Worker will complete all audits and they will be placed in a binder and kept for review by HHSC for the revisit to validate for compliance. The Administrator/Director of Nursing and Medical Director conducted a Ad Hoc QAPI meeting to review this situation, and the immediate corrective action plan implemented. The facility's POR verification was as follows: Record review with ADM and DON conducted at 5:00 pm on 03/21/25 to ensure assessment of residents was conducted to assure their safety and well-being. No other residents identified as being in danger of self-harm. Surveyor and Maintenance Director had conducted search of Memory Care Unit rooms on 03/19/25 from 8:30 am to 9:00 am to ensure all patient care items such as wipes and gloves had been removed from rooms and were secured. Record review of Plan of Care review conducted on 03/21/25 at 8:30 pm to ensure anyone with cognitive impairment was not at risk of ingesting non-food items. Record review of Plan of Care with all residents with cognitive impairment conducted on 03/21/25 at 8:30 pm to ensure accuracy of care plans. Reviewed list of residents with schizophrenia and their plan of care on 03/21/25 at 8:35 pm. 5 residents were listed with this disorder. Record review of 4 Step Assessment was conducted by facility staff with each resident in the facility as of 03/14/25 is and ongoing. Review verified with DON on 03/21/25 at 8:40 pm. These steps included reviewing the care plan including diagnoses and related medications, monitoring behaviors and related documentation of any changes, and determining any safety concerns as each resident room was observed. Information will be discussed in the monthly QAPI meeting. Facility did chart review for residents with behavioral concerns who are already see by psychological services and no new changes were identified. Discussed procedures and outcomes with ADM and DON on 03/21/25 at 8:40 pm. Record review of inservice conducted by DCO with ADM, DON and ADON regarding Abuse and Neglect Preventing, Identifying and Reporting; Preventing Accidents and Incidents and Fall Prevention; and Plan of Care/[NAME] to be reviewed by direct care team to ensure the staff member is aware of the care to be provided and the need for the IDT to ensure any safety concerns and appropriate interventions are noted on the Plan of Care/[NAME]. The ADM, DON and ADON then re-educated staff on these topics and education acknowledged on 03/21/25 at 8:45 pm. Training reviewed for all staff and reviewed signatures on inservices. Verified 96 regular staff and 31 contracted staff for a total of 127 staff members. 25 staff interviews were conducted by surveyors on 03/21/25 between 8:35 am and 10:30 am and from 4:55 pm to 7:55 pm to verify that the above inservices were conducted and staff had an understanding of the contents of each inservice. The interviews, that covered all shifts, were as follows: 8:35 am - LVN A - was working on nights but moved to day shift; she did receive the in-services; is aware that the gloves and wipes can no longer be in the resident rooms; the Nurse stated that the foley was pulled out accidentally by the resident; the Nurse stated that resident Resident #1 was acting at his baseline and did not observe any unusual behavior 8:50 am - CNA G - she confirmed that she had received the in-services on abuse and [NAME] and that wipes and gloves cannot be in the resident rooms; she advised if she saw unusual behavior she would tell the nurse; 9:00 am - CNA O - he advised that he did receive the in-services on [NAME] and abuse; he was aware that wipes and gloves are not to be accessible to the residents; he stated that if he sees a resident acting unusually he would advise the nurse; 9:10 am - LVN C - she had received the in-services on abuse and [NAME] and aware of no gloves/wipes in resident rooms; she was working on the unit on 3/14/25 and stated resident Resident #1 acting at baseline; he sat in someone else's wheelchair, she advised if staff or she would observe unusual behavior she would report it; 9:40 am - LA CC - she did receive the in-services, is aware of no wipes/gloves in resident rooms on Memory Care Unit; was not on unit when resident expired; she would report unusual behavior. 9:45 am - LA DD - she did receive the in-services, is aware of no wipes/gloves in resident rooms in Memory Care; She would report unusual behavior 9:50 am - Hsk Dir - she did receive the inservices, is aware of no wipes/gloves in resident rooms in Memory Care hall; she would report unusual behavior 10:10 am - [NAME] V - received and signed inservices and aware of no wipes/gloves in resident rooms in Memory Care; would report unusual behavior 10:10 am- DA W - received and signed inservices and aware of no wipes/gloves in resident rooms in Memory Care; would report unusual behavior 10:10 am - DA X - received and signed inservices and aware of no wipes/gloves in resident rooms in Memory Care; would report unusual behavior 10:10 am - DA Y - received and signed inservices and aware of no wipes/gloves in resident rooms in Memory Care; would report unusual behavior 10:25 am - FSD - received and signed inservices and aware of no wipes/gloves in resident rooms in Memory Care; would report unusual behavior 10:30 am - SW - did receive inservices on [NAME], falls/accidents, is aware of no wipes/gloves being allowed in Memory Care Unit resident rooms, had not observed unusual behavior for Resident #1 but would report if behaviors were noted. 4:55 pm - CNA M - has had inservices on abuse, [NAME], falls, safety; is aware of wipes/gloves protocol for Memory Care, discussed reporting changes of resident behavior and would report anything unusual 4:55 pm - CNA N - has had inservices on abuse, [NAME], falls, safety; is aware of wipes/gloves protocol for Memory Care, discussed reporting changes of resident behavior and would report anything unusual 6:10 pm - CNA T - has had inservices on abuse, [NAME], falls, safety; is aware of wipes/gloves protocol for Memory Care, discussed reporting changes of resident behavior and would report anything unusual 6:20 pm - CNA E - has had inservices on abuse, [NAME], falls, safety; is aware of wipes/gloves protocol for Memory Care, discussed reporting changes of resident behavior and would report anything unusual; she worked the night of the incident with Resident #1 but did not observe anything unusual in his behavior 6:35 pm - RN B - she received the inservices on abuse, [NAME], falls, safety and is aware of the protocol for no wipes/gloves allowed in the Memory Care Unit; she would report any changes in behavior; she did not see any unusual behavior for Resident #1 on the night of the incident 7:00 pm - LVN U - has had inservices on abuse, [NAME], falls, safety; is aware of wipes/gloves protocol for Memory Care, discussed reporting changes of resident behavior and would report anything unusual 7:05 pm - CNA P - has had inservices on abuse, [NAME], falls, safety; is aware of wipes/gloves protocol for Memory Care, discussed reporting changes of resident behavior and would report anything unusual 7:05 pm - CNA Q - has had inservices on abuse, [NAME], falls, safety; is aware of wipes/gloves protocol for Memory Care, discussed reporting changes of resident behavior and would report anything unusual 7:15 pm - LVN Z - has had inservices on abuse, [NAME], falls, safety; is aware of wipes/gloves protocol for Memory Care, discussed reporting changes of resident behavior and would report anything unusual 7:15 pm - CNA R - has had inservices on abuse, [NAME], falls, safety; is aware of wipes/gloves protocol for Memory Care, discussed reporting changes of resident behavior and would report anything unusual 7:20 pm - RN BB - has had inservices on abuse, [NAME], falls, safety; is aware of wipes/gloves protocol for Memory Care, discussed reporting changes of resident behavior and would report anything unusual 7:55 pm - CNA S - has had inservices on abuse, [NAME], falls, safety; is aware of wipes/gloves protocol for Memory Care, discussed reporting changes of resident behavior and would report anything unusual 3 new residents in the past week were evaluated and not appropriate for Memory Care Unit. This was verified with ADM on 03/21/25 at 8:57 pm. Monitoring form reviewed that will be used by ADM, DON, ADON and SW to make weekly random audits to validate the safety and well-being of residents on 03/21/25 at 8:54 pm. Monitoring tool reviewed for DON and ADON to review admission/readmissions' care plans and [NAME] to ensure safety risks are addressed. Tool reviewed on 03/21/25 at 8:54 pm. The binder in which all audits will be kept was reviewed on 03/21/25 at 9:00 pm. On 03/21/25 at 10:00 p.m., the Administrator was notified the IJ was removed. While the IJ was removed on 03/21/25 at 10:00 p.m. the facility remained out of compliance at a scope of isolated and a severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy because of the facility's need to monitor the implementation of the plan of removal.