**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure each resident's environment remained free of accident hazards for 1 of 6 residents (Resident #31) reviewed for accident hazards.The facility failed to adequately supervise Resident #31 when she ingested plastic wrap from a container while being monitored by CMA H during dining.An IJ was identified on 07/03/35 at 1:22 PM. The IJ template was provided to the facility on [DATE] at 1:22 PM. While the IJ was removed on 07/04/25, 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 because all staff had not been trained on accidents and supervision.This failure could place residents at risk for injury, harm, and impairment. Findings included: Record review of Resident #1's face sheet revealed, the resident was a [AGE] year-old female admitted to the facility on [DATE] with a history of Dementia (group of symptoms affecting memory, thinking or language) anxiety (intense, excessive, and persistent worry and fear about everyday situations), altered mental status, and intellectual disabilities (condition that involves limitation on intelligence). Record review of Resident #31's Quarterly MDS Assessment, dated 05/07/25, indicated the resident's cognitive skills for daily decision making was severely impaired and required supervision when eating. Record review of Resident #31's care plan, updated 05/01/25, indicated the resident had a history of putting inedible things in her mouth, and was noted to have eaten paint off walls, Styrofoam cups, etc. The resident's goal was not to have adverse effects related to putting inedible things in her mouth. Interventions included observing the resident closely for presence of foreign matter in mouth. Providing limited assistance of one staff member with dining. Remove any foreign matter from mouth. Observe for presence during crafts or activities where she could pick up items and put them in her mouth. On 05/28/25 the care plan indicated Resident #31 was placed on 1:1 observation pending inpatient psych eval. The resident's goal was to not consume any plastic wrap through next review. Interventions included monitoring resident at meal times, staff to setup tray with each meal, and removing plastic wrap before meals were served. Record review of progress note entered by RN C and dated 05/25/25 at 5:57 PM, indicated the Resident ingested plastic wrap from desert cup. Resident @ baseline; no signs of distress, breathing even and unlabored. Behavior @ baseline; BP:132/88 HR 55 RR 18 O2: 97 T: 97.3. NP B notified; no n/o. Will continue to monitor.Record review of progress notes entered by the DON indicated the following: 05/28/25 at 5:43 PM, indicated the resident had an IDT review due to swallowing plastic wrap. Recommendations were to continue to monitor for adverse effects, KUB (Kidney, Ureter and Bladder imaging), dietary evaluation, and in-service on meal setup. IDT members were Administrator, DON, ADON, Unit Manager, MDS nurse and Social Worker.Further review of progress notes on 5/28/25 at 6:14 PM, indicated the resident's NP ordered follow up chest x-rays to rule out aspiration. Further review revealed the resident was sent for imaging.Further review of progress notes on 5/29/25 at 1:47 PM, indicated the resident's MD was notified of negative x-ray results. MD did not give new orders.During a telephone interview on 05/29/25 at 11:52 AM, CMA H said on 05/25/25 during lunch, Resident #31 took the plastic wrapping off the applesauce and swallowed it. She denied knowledge of the resident putting other inedible items in her mouth. She said she assisted the resident with eating lunch but could not get to her quickly enough before she swallowed the plastic. She said the resident never appeared to be in distress, did not have difficulty breathing, and did not choke after swallowing the wrap. She said the resident continued to eat her meal after swallowing the wrap. She said the resident was supposed to be closely monitored during meals. She said the resident was not on 1:1 supervision. She said she notified the nurse immediately after the incident, and the nurse performed a head-to-toe assessment on the resident. During an interview on 05/28/25 at 12:28 PM, RN C said on 05/25/25 a CNA informed her that Resident #31 ingested the plastic wrap from her dinner cup after the incident had occurred. RN C said she notified the NP and performed a head-to-toe assessment on the resident, who had normal vital signs and no changes in baseline. She said the NP did not give any new orders at that time. She said the facility continued to monitor the resident for adverse effects. She said the risk associated with the resident swallowing wrap was aspiration, choking, and/or bowel obstruction. During a telephone interview on 05/28/25 at 12:49 PM, NP B said the nurse had contacted him regarding the resident swallowing plastic wrap. He informed the staff to monitor the resident because her vital signs were stable and displayed no signs or symptoms of distress. He said Resident #31 was not having any issues, so no new orders were given. He said there was only risk to the resident if the resident could not pass the plastic wrap through a bowel movement. He said the risk associated with not passing the plastic wrap through a bowel movement was a small bowel obstruction. He said plastic wrap should not have been left out on the secure unit for a resident to ingest because it could have also been a choking hazard. He said the staff should monitor the resident's bowels to make sure she was passing stool, and document s/s of abdominal pain and distention. During an interview on 05/29/25, at 9:01 AM, the DON said during the lunch meal on 05/25/25, the resident took the plastic wrap off applesauce, and swallowed the plastic wrap before the staff could retrieve the plastic wrap. She said on 05/28/25, facility staff were in-serviced on the proper procedure for meal setup for safety before residents consume meals. She said staff were to take all items off the tray, set up the meal completely, open all containers and remove plastic from dishes. And place all plastics in the trash. The DON said she also spoke to the dietary manager, and to ensure different coverings were used for serving meals in the memory care unit. Interview on 05/29/25 at 10:15 AM, NP R said Resident #31 was non-verbal. He also said it was not unusual for the resident to have behaviors such as putting things in her mouth. He said the resident may have had [NAME] (compulsive eating of material that may or may not be food stuff). He said he would order labs for the resident. He said the resident needed increased supervision. He said he evaluated the resident since she ingested plastic wrap and would start with a non-pharmacological approach. He said the risk of a resident putting inedible items in their mouth could lead to choking or poisoning. Interview on 05/29/25 at 12:39 PM, Dr. N said he was aware of the incident involving Resident #31 and that it was not uncommon for a resident with dementia to ingest inedible items. He said all inedible items should be removed from the area of the resident to decrease the risk of placing the items in her mouth. He said the plastic was small and digestible. He said the resident had not shown any signs or symptoms of bowel obstruction. He said the resident also had not experienced signs and symptoms of stomach pain, nausea or vomiting. He said the small piece of plastic wrap had probably passed through her stool. He said a chest x-ray and KUB imaging were performed with negative results. He said he did not give any new orders. During an Interview on 05/29/25 at 2:21 PM, the Administrator said he learned of Resident #31 ingesting plastic but had no adverse reaction on 05/27/25. He said the facility followed physician's orders to monitor the resident closely and tailored the resident's care plan to meet her needs. During an interview on 06/15/25 at 11:43 AM, the Dietary Manager said Lids were only for desserts. He said cups were sent empty and filled from pitchers while on the unit. He said the residents did not have access to the plastic wrap. The staff were using plastic wrap on the hall trays (not secured unit), but the plastic wrap was removed by the staff before entering the room and was not left with the residents. Lunch observation on the secured unit on 06/15/25 at 11:45AM, all drinks had solid plastic covers. No plastic wraps were observed. Resident #31 was eating in her room with 1:1 assistance with CNA E.During an interview on 06/16/25 at 9:15 AM, the Dietary Manager said the secured unit staff were no longer using Styrofoam cups; instead, they were using hard plastic coffee cups and hard plastic lids. The surveyor observed breakfast trays from the secured unit with hard plastic coffee cups with hard lids visible. No plastic wrap noted.Main dining hall and secured unit dining area observation on 06/17/25 at 11:55 AM, revealed no plastic wraps and only hard cover plastic lids used by the facility. -Record review on 06/16/25 at approximately 9:18AM of Dietary Manager invoice for hard plastic cover lids on 05/21/25 and 06/04/25. Record review of the Risk Management- Incidents & Accidents policy, revised 01/2024, read in part . Policy: The facility will assess residents for risk factors of potential accidents/hazards. The facility will recognize signs of incidents/accidents and assist residents, staff members, and visitors as indicated. The facility will conduct thorough investigations as indicated to determine underlying causes and contributing factors to incidents and accidents; and will put interventions in place from the investigation .An immediate jeopardy was identified, and the Administrator was notified and provided the immediate jeopardy template on 07/03/25 at 1:22 PM and a plan of removal was requested. Th facility's Plan of Removal was accepted on 07/04/25 at 5:38 PM and included: Action: -Record review of Ad hoc QAPI meeting on 07/03/25 to evaluate the incident and monitor progress on corrective actions.-Record review of in-service on following meal and drink preparation and no plastic wrap for meal service and snack delivery and proper meal setup procedures conducted on 07/03/25:Dietary staff received an in-service on the immediate removal of plastic wrap in all resident-accessible areas.-Record review of in-service on understanding dementia and its impact on safety on 07/03/25: All staff received an in-service on understanding dementia and its impact on resident safety for residents on the secured unit. The training included emphasis on environmental risk factors, such as the removal of plastic wrap from all resident-accessible areas, and reinforced appropriate supervision and communication techniques. Any incidents and accidents will be reported to DON, Administrator, or designee immediately.-Record review of physician order to refer Resident #31 to inpatient psych on 05/29/25 and 06/15/25.-Record review of Resident #31 updated care plan on 07/04/25: Nurses, MDS Nurse, DON and Administrator ensured care plans were reviewed to prevent future accidents and hazards, based on the specific needs of resident. There were no negative findings.-Record review of completed behavior audits on 07/03/25 by the DON: The DON/designee will conduct a comprehensive review of other residents on the secured unit for similar behavioral risks, within the past 30 days. No other residents were identified with similar behaviors. For residents identified through this review, the following interventions will be implemented:Notification of physicianCare plan update/revisionReview the appropriateness of the resident's placement on the unit via the assessment -Record review of last 30-day chart audit/lookback with residents who had no behaviors of ingesting inedible items (meal audits): The DON/designee in-serviced licensed nursing staff on the supervision of meal services to include removal of clutter, snack wrappings, and non-food items that could be potentially ingested.-Record review of resident Transfer/ discharge summary: On Wednesday, July 2, 2025, Resident #31 was transferred to another nursing home -Record review of in-service on abuse and neglect completed on 07/03/25: The DON/designee initiated in-service training for all staff focused on resident abuse, neglect, exploitation. Staff will not be allowed to provide direct care until training has been completed.Monitoring: During an interview on 07/04/25 at 12:45pm, the DON and she stated that all facility staff had been in-serviced on not using any more plastic wrap. She stated that staff in the kitchen were told to use hard plastic tops to cover resident's meals, drinks, snacks, etc.Record review on 07/04/25 at 12:58pm of the facility in-service dated 7/3/25 reflected that the food service manager educated the food service department on not using plastic wrap for covering residents' food that goes out to the dining hall.During an interview on 07/04/25 at 1:09pm, the Food Service Manager stated that he educated staff that under no circumstances should plastic wrap be used when serving drinks, meals, snacks etc. when serving residents.During an interview on 07/04/25 at 1:12pm- with Tray Aide-A, Dietary Aide-B, Cook-A, and Dietary aide-C, they said they had been in-serviced on not using plastic on residents' food, and that hard plastic lids and coverings had to be used. During an interview on 07/04/25 at 1:35pm, the Social Worker and she stated that she had been in-service that no plastic wrap should be used in anyway when dealing with residents' food, drinks, snacks etc. And she stated that she was in-serviced on monitor resident trays when walking thru the facility. She was also able to give examples of abuse and neglect, and she was able to tell me who the abuse coordinator was.During an interview on 07/04/25 at 1:45pm, Housekeeping Staff-A stated that she had been in-service that no plastic wrap should be used in anyway when dealing with residents' food, drinks, snacks etc. And she stated that she was in-serviced on monitor resident trays when walking thru the facility. She was also able to give examples of abuse and neglect, and she was able to tell me who the abuse coordinator was. During an interview on 07/04/25 at 2:00pm with Nursing staff LVN-A, LVN-B, RN-C, and RN-B, they stated that they had been in-serviced that no plastic wrap should be used when dealing with residents' food, drinks, snacks etc. and they stated that they were in-serviced to monitor resident trays when walking through the facility. They were also able to give examples of abuse and neglect, and they were able to tell me who the abuse coordinator was. During an interview on 07/04/25 at 2:15pm with CNA-E, CNA-I, and CNA-C, they stated that they had been in-serviced that no plastic wrap should be used when dealing with residents' food, drinks, snacks, etc. and they stated that they were in-service to monitor resident trays when walking through the facility. They were also able to give examples of abuse and neglect, and she was able to tell me who the abuse coordinator was. During an interview on 07/04/25 at 2:30pm, the Assistant Activities Director stated she had been in-service that no plastic wrap should be used in anyway when dealing with residents' food, drinks, snacks etc. and she stated that she was in-serviced on monitoring resident trays when walking through the facility. She was also able to give examples of abuse and neglect, and she was able to tell me who the abuse coordinator was.Observation on 07/04/25 at 3:00pm of kitchen staff preparing a meal and there was no plastic wrap being used. The Food Service Manager demonstrated how hard plastic lids would be used to cover residents' drinks etc.During a telephone interview on 07/04/25 at 3:25pm, Dr. N. stated he participated in the QAPI meeting regarding the use of plastic wrap and other choking hazards.During an interview on 07/04/25 at 3:45pm, MDS Coordinator A stated that she along with the DON had reviewed residents for choking hazards.During an interview on 07/04/25 at 3:50pm, the Physical Therapist Assistant stated that he had been in-serviced that no plastic wrap should be used in anyway when dealing with residents' food, drinks, snacks etc. He stated that he was in-serviced on monitoring the residents' trays when walking through the facility. He was also able to give examples of abuse and neglect, and he was able to tell me who the abuse coordinator was.Observation on 07/04/25 at 4:15pm of meal service on the Dementia unit. All the residents' meals were covered in hard plastic tops, and food serving containers. There was no plastic used during this observation. Nursing staff checked to make sure that residents were getting the correct meal, and staff were communicating with residents.Observation on 07/04/25 at 4:30pm of CNA passing out trays in the hallways and there was not any plastic being used. Observation of meal service in the dining hall revealed that no plastic wrap was being used and nursing staff was making sure that residents were getting the correct trays.Record review at 5:00pm of care plans conducted by Nurses, MDS Nurse, DON and Administrator to prevent future accidents and hazards, based on the specific needs of resident was conducted and there were no concerns. The Administrator was informed the IJ was removed on 7/04/2025 at 5:38 PM; however, the facility remained out of compliance with a scope of isolated and a severity level of potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure two residents (Resident #59 and Resident #60) of five residents reviewed for abuse and neglect were free from abuse.The facility failed to address inappropriate sexual behavior between Resident #59 and Resident #60. Resident #59 had a diagnosis which included Dementia and Resident #60 had a diagnosis which included Alzheimers.The facility failed to immediately implement the Psychology NP's recommendation to move Resident #60 off of the unit. An Immediate Jeopardy (IJ) was identified on 6/14/2025. The IJ template was provided to the facility on 6/14/2025 at 3:35 p.m. While the IJ was removed on 6/17/2025, the facility remained out of compliance at a scope of pattern with the severity level at a potential for more than minimal harm that is not immediate jeopardy, because all staff had not been trained. This failure placed residents at risk of abuse/neglect. Findings included:Record review of the admission Record for Resident #59 revealed she did not have a person other than herself listed as Responsible Party (RP). Diagnoses included dementia (a group of symptoms that affect thinking, memory, and social abilities), schizoaffective disorder (a mix of hallucinations, delusions, and mood disorder), and generalized anxiety disorder. Her admission rate was 11/17/2023. She was [AGE] years old.Record review of the Minimum Data Set (MDS) assessment dated [DATE] for Resident #59 reflected she scored 10 of 15 on the Brief Interview for Mental Status (BIMS), indicative of moderately impaired cognition. The MDS reflected Resident #59 exhibited delusions and wandering. Record review of the admission Record for Resident #60 revealed he was [AGE] years old and was admitted to the facility on [DATE]. Diagnoses included Alzheimer's disease (progressive disease characterized by memory loss), dementia (a group of symptoms that affect thinking, memory, and social abilities), and unspecified psychosis (a mental state marked by loss of contact with reality). The admission Record reflected he was his own RP.Record review of the Quarterly MDS assessment for Resident #60 dated 05/07/25 revealed he scored 10 of 15 on the BIMS, indicative of moderate cognitive impairment. Record review of a Nurse's Note (NN) in Resident #59's electronic record, dated 03/25/25 at 12:15 p.m., reflected Resident #59 and Resident #60 were in Resident #59's room. They were both unclothed and in her bed. The NN reflected Resident #59 believed Resident #60 was her husband. Record review of a Social Services Note for Resident #60, dated 03/25/25 at 1:00 p.m., reflected the Social Worker and a clinical specialist from another service observed Resident #60 in Resident #59's room. The residents were engaged in sexual activity. Resident #60 was redirected. Record review of a Behavior Note for Resident #59, dated 03/29/25 at 9:40 p.m., reflected Resident #59 attempted to go to the men's side of the secured unit. She became combative with staff. She was redirected but attempted to return after ten minutes. She again said Resident #60 was her husband. Record review of an Orders-Administration Note for Resident #59, dated 04/05/25 at 6:34 p.m., reflected Resident #59 had her hand down a male resident's shirt. The nurse asked Resident #59 several times to stop. The male resident told the nurse 'You can't tell us what to do' and stuck his middle finger at the nurse. Resident #59 then stuck her middle finger up at the nurse. Both residents became aggressive with staff.In an interview on 05/28/25 at 3:15 p.m., the DON said Resident #59 and Resident #60 sat together in activities but were not allowed to go to each other's rooms. She said Resident #59 had delusions that she and Resident #60 were married. The DON said Resident #59 was not able to make consensual decisions. In an interview on 05/28/25 at 4:09 p.m., the MDS Coordinator said on 03/25/25 Resident #59 was found in bed with Resident #60. She confirmed there was no Care Plan to address sexual activity. She said the Care Plans should have been updated. She said the interventions needed to be changed.Record review of a Behavior Note for Resident #59, dated 06/03/25 at 5:43 p.m., reflected Resident #59 was in Resident #60's room, sitting next to Resident #60 on his bed. Resident #60 was lying on his back with his shirt raised. No sexual activity was noted. Resident #59 was redirected to her room.In an interview on 06/13/25 at 2:32 p.m., the Psychology Services NP said he was made aware of the incident soon after it occurred. He said he recommended separating the residents by moving Resident #60 out of the secure unit. He said both had dementia.In an interview on 06/13/25 at 1:05 p.m. with the DON, when asked what could the facility have done differently, the DON said the facility could have moved Resident #60 from the secured unit sooner.In an interview on 06/13/25 at 1:20 p.m. the Administrator said he wished both residents were not their own RP. He said that in hindsight, they should have moved Resident #60 out of the secured unit in March of 2025.An IJ was identified on 06/14/2025 at 3:35 p.m. The IJ Template and Plan of Removal guidance were provided to the facility on [DATE] at 3:35 p.m. The following Plan of Removal was submitted by the facility and was accepted on 06/15/2025 at 09:23 a.m. and indicated the following:Plan of Removal Name of facility: __________[facility]Date: 06/14/2025 According to the IJ template, the facility failed to address inappropriate sexual behavior between Resident #59 and Resident #60. Immediate ActionJune 14, 2025 - Resident TransferAction: Resident #59 was transferred to a female-only secured unit within a skilled nursing facility (SNF) in ______ County for long-term care.Responsible: AdministratorCompletion Date: 06/14/2025June 14, 2025 - In-service on Resident Abuse, Neglect, Exploitation, and Sexual MisconductAction: The DON/designee initiated in-service training to all staff focused on resident abuse, neglect, exploitation, and sexual misconduct to reinforce staff knowledge and compliance. Staff will not provide direct resident care until has been completed. Responsible: DON/designeeCompletion Date: 06/16/2025June 14, 2025 - Behavioral ReviewAction: The DON/ADON will conduct a comprehensive review of other residents on the secured unit for similar behavioral risks, within the past 30 to 60 days.For residents identified through this review, the following interventions will be implemented:Separation of residents from the unitOne-on-one staff monitoringNotification of responsible party (if applicable)Notification of physicianCare plan update or revisionTransfer to an appropriate setting (if applicable)The DON or designee will conduct a daily review of progress notes during the morning clinical meeting to promptly identify and address any documentation of inappropriate sexual behaviors or related concerns.Responsible: DON/designeeCompletion Date: 06/14/2025 Facilities Plan to Ensure ComplianceJune 14, 2025 - Ad hoc QAPI MeetingAction: An ad hoc QAPI meeting was held to evaluate the incident and monitor progress on corrective actions.Responsible: AdministratorCompletion Date: 06/14/2025June 14, 2025 - Notification of Medical DirectorAction: Medical Director was informed of immediate jeopardy.Responsible: AdministratorCompletion Date: 06/14/2025Yes, the Administrator and Director of Nursing reviewed the facility's policies on 06/14/2025 abuse, neglect, exploitation, and inappropriate sexual behavior and determined that no revisions were necessary. Completion Date: 06/14/2025In an interview on 06/15/2025 at 11:15 a.m. the Administrator said Resident #59 had been transferred from the facility. Observation on 06/15/2025 at 11:55 a.m. revealed Resident #60 had been relocated off of the secured unit. He was asleep when observed at that time.In an interview on 06/15/2025 at 12:06 p.m. the DON said she was reviewing the behaviors of the 24 residents on the secure unit. She said she would complete the audit that day.Record review on 06/16/2025 at 09:30 a.m. revealed all of the secured unit resident audits have been completed.The following interviews occurred on the Secured Unit:In an interview on 06/15/2025 at 12:00 p.m. RN D said she had a in-service that day. The focus was on sexual abuse and inappropriate behaviors. She would separate the residents, protect both, and inform the Administrator.In an interview on 06/15/2025 at 12:05 p.m. CNA N said he had in-service today on sexual abuse. He would separate, make sure they're safe, then tell the DON, Administrator.Secured UnitIn an interveiw on 06/15/2025 at 12:10 p.m. CNA E ( 6-2 ) said she had an in-service this morning. It was about sexual conduct and inappropriate behaviors. She would report to the Nurse, DON, and administrator immediately.In an interview on 06/15/2025 at 12:12 p.m. CNA G (6-2) said she had an in-service this morning about sexual abuse. If I see anything physically inappropriate report to the nurse. Then _____ [Administrator]. Write a statement.In an interveiw on 06/15/2025 at 12:15 p.m. CMA H said she had an in-service. The topic was sexual behaviors. If I see something stop them and report it to the nurse. DON. Administrator.In an interview on 06/15/2025 at 12:18 p.m. RN O said he had in-service yesterday (was interviewed yesterday).In an interview on 06/15/2025 at 12:27 p.m. CNA I said she had in-service yesterday. The topic was sexual abuse. She would tell the Administrator and the DON.In an interview on 06/15/2025 at 12:39 p.m, CNA J said she had an in-service today. The topic was physical and sexual abuse. If I see anything inappropriate notify the Adm and DON. In an interview on 06/16/2025 at 9:35 a.m. CMA K said she had a recent in-service on abuse/neglect. She was told to observe for residents crossing over to the other residents' side. She would redirect and inform the charge nurse and Administrator immediately.In an interview on 06/16/2025 at 9:37 a.m. on the Secured Unit RN C said she had an in-service via telephone with the DON yesterday. She said they discussed what to do if witness abuse/neglect, with focus on sexual abuse. She was told to be aware, observe for residents going to other side of unit. She would separate them, inform DON, Administrator, RP, Physician, and update the care plan.In an interview on 06/16/2025 at 9:50 a.m. HSKP L said she had an in-service yesterday on abuse/neglect. She was told to watch for inappropriate contact. She would notify the Administrator, DON, and the nurse.Observation on 06/17/2025 at 11:50 a.m. revealed Resident #70 relocated back to the Secured Unit.In an interview on 06/17/2025 at 1:55 p.m., The MDS Coordinator said the facility implemented the following changes:All incident/accident reports were reviewed in the morning meeting. Internal messaging for daily events were done via telephone or e-mail. There was a Standards of Care meeting conducted every Tuesday. She was reading Progress Notes every morning.She said she had received counselling from the Regional MDS Coordinator on 06/16/2025. In an interview on 06/17/2025 at 2:10 p.m. RN M (ADON) said information regarding care plans was discussed in the stand-up meeting in the mornings. She said the nurses could communicate concerns via email or telephone to the MDS Coordinator. In an interview on 06/17/2025 at 2:25 p.m. RN C said if there were incidents, accidents or changes in condition requiring Care Plan updates, she would notify the MDS Coordinator and DON via email or phone. The Administrator was informed the Immediate Jeopardy was removed on 06/17/2025 at 2:30 p.m. The facility remained out of compliance at a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put in place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care that included measurable objectives and timeframes to meet the residents' medical, nursing, and mental and psychological needs that are identified in the comprehensive assessment for 3 residents (Resident #31, Resident #59, and Resident #60) of 8 residents reviewed for care plans. -Resident #31's Care Plan did not include interventions and services to appropriately address the resident's behavior of placing inedible objects in her mouth.-Resident #59's Care Plan was not updated to include interventions and services to appropriately address inappropriate sexual behavior.-Resident #59 had delusional thoughts that Resident #60 was her husband.-Resident #60's Care Plan was not updated to include interventions and services to appropriately address inappropriate sexual behavior. An Immediate Jeopardy (IJ) was identified on 6/16/2025 The IJ template was provided to the facility on 8/16/2025 at 3:45 p.m. While the IJ was removed on 6/17/2025, the facility remained out of compliance at a scope of pattern with the severity level at a potential for more than minimal harm that is not immediate jeopardy, because all staff had not been trained. This failure placed residents at risk of not receiving the necessary care and services to meet their needs resulting in a decline in health or harm.Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care that included measurable objectives and timeframes to meet the residents' medical, nursing, and mental and psychological needs that are identified in the comprehensive assessment for 3 residents (Resident #31, Resident #59, and Resident #60) of 8 residents reviewed for care plans.-Resident #31's Care Plan did not include interventions and services to appropriately address the resident's behavior of placing inedible objects in her mouth.-Resident #59's Care Plan was not updated to include interventions and services to appropriately address inappropriate sexual behavior.-Resident #59 had delusional thoughts that Resident #60 was her husband.-Resident #60's Care Plan was not updated to include interventions and services to appropriately address inappropriate sexual behavior.An Immediate Jeopardy (IJ) was identified on 6/16/2025 The IJ template was provided to the facility on 8/16/2025 at 3:45 p.m. While the IJ was removed on 6/17/2025, the facility remained out of compliance at a scope of isolated with the severity level at a potential for more than minimal harm that is not immediate jeopardy, because all staff had not been trained. This failure placed residents at risk of not receiving the necessary care and services to meet their needs resulting in a decline in health or harm.Resident #31Review of Resident #31's face sheet revealed, the resident was a [AGE] year-old female admitted to the facility on [DATE] with a history of Dementia (group of symptoms affecting memory, thinking or language) anxiety (intense, excessive, and persistent worry and fear about everyday situations), altered mental status, and intellectual disabilities (condition that involves limitation on intelligence). Review of Resident #31's Quarterly MDS Assessment, dated 05/07/25, indicated the resident's cognitive skills for daily decision making was severely impaired. Review of progress notes, entered by RN C and dated 05/25/25 at 5:57 PM, indicated the following: Resident ingested plastic saran wrap from desert cup. Resident @ baseline; no signs of distress, breathing even and unlabored. Behavior @ baseline; BP:132/88 HR 55 RR 18 O2: 97 T: 97.3. NP B notified; no n/o. Will continue to monitor.Review of progress notes, entered by the DON and dated 05/28/25, indicated the resident had an IDT review due to swallowing plastic wrap. Recommendations were to continue to monitor for adverse effects, KUB (Kidney, Ureter and Bladder imaging), dietary evaluation, and in-service on meal setup. IDT members were Administrator, DON, ADON, Unit Manager, MDS nurse and Social Worker.Telephone interview with CMA H on 05/29/25 at 11:52 AM, who said on 05/25/25 during lunch, Resident #31 took the plastic wrapping off the applesauce and swallowed it. She denied knowledge of the resident putting other inedible items in her mouth. She said she assisted the resident with eating lunch but could not get to her quickly enough before she swallowed the plastic. She said the resident never appeared to be in distress, did not have difficulty breathing, and did not choke after swallowing the plastic wrap. She said the resident continued to eat her meal after swallowing the plastic wrap. She said the resident was supposed to be closely monitored during meals. She said the resident was not on 1:1 supervision. She said she notified the nurse immediately after the incident, and the nurse performed a head-to-toe assessment on the resident. Review of Resident #31's care plan, updated 05/01/25, indicated the resident had a history of putting inedible things in her mouth, and was noted to have eaten paint off walls, Styrofoam cups, etc. The resident's goal was not to have adverse effects related to putting inedible things in her mouth. Interventions included observing the resident closely for presence of foreign matter in mouth. Providing limited assistance of one staff member with dining. Remove any foreign matter from mouth. Observe for presence during crafts or activities where she could pick up items and put them in her mouth. Further review of Resident #31's care plan revealed documentation of past incidents of the putting inedible things in her mouth or ingesting inedible items and the incident on 05/25/25 was not addressed in the care plan.Interview with DON on 05/29/25 at 12:28 PM, who said the facility updated Resident #31's care plan on 05/28/25 to include 1:1 supervision/care at all times. She said she also emailed the dietitian to discuss interventions. She said the facility obtained a referral for an inpatient psychiatric evaluation for the resident. She said the facility also held an ad hoc QAPI meeting with the NP to provide additional interventions for the resident. She said the resident was at risk of an incident similar to ingesting plastic wrap reoccur.In an interview on 05/29/25 at 2:21 p.m. the Administrator said the facility tailored the resident's care plan to meet her needs.In an interview on 05/29/25 at 4:21 p.m. the MDS Coordinator said care plans were updated daily, or sometimes multiple times a day, to provide an accurate reflection of the care or services a resident required. She said the risk of not updating a care plan was resident's care needs not being met by facility staff. In an interview on 05/29/25 at 4:26 p.m. the DON said the MDS was supposed to update resident care plans as needed. She said a care plan should reflect goals and interventions based on a resident's specific needs to outline care to be provided to residents by facility staff. She said the risk of not updating the care plan to meet a resident's specific needs was failure to provide appropriate care to the resident. In an interview on 05/29/25 at 4:33 p.m., the Administrator said the MDS nurse was responsible developing care plans. He said the IDT team was also involved in developing comprehensive care plans. He said the risk associated with a resident not having an individualized care plan was facility staff may not have been meeting the resident's needs or may not have been aware of the resident's needs.Resident #59Record review of the admission Record (dated 05/28/25) for Resident #59 revealed she was [AGE] years old and was admitted to the facility on [DATE]. Diagnoses included dementia (a group of symptoms that affect thinking, memory, and social abilities), schizoaffective disorder (a mix of hallucinations, delusions, and mood disorder), and generalized anxiety disorder. The document did not have a RP listed.Record review of the Quarterly MDS assessment for Resident #59, dated 05/06/25, revealed she scored 11/15 on the BIMS, indicative of moderate cognitive impairment.Record review of a Psychosocial Evaluation dated 02/25/25 revealed Resident #59 scored 14/15 on the BIMS, indicative of intact cognition. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #59 reflected she scored 10 of 15 on the Brief Interview for Mental Status (BIMS), indicative of moderately impaired cognition. The MDS also reflected Resident #59 exhibited delusions and wandering.Record review of Resident #59's Care Plan, updated on 03/07/25, revealed she was found in her bed, naked with a male peer on 03/25/25. Resident #59 believed the male resident was her husband. Interventions included monitoring and charting behaviors as they occurred and reporting progress/declines to MD. Review of the care plan did not reveal goals or interventions to address the behavior of physical contact with peers.Record review of a Behavior Note for Resident #59, dated 03/29/25 at 9:40 p.m., reflected Resident #59 attempted to go to the men's side of the secured unit. She became combative with staff. She was redirected but attempted to return after ten minutes. She again said Resident #60 was her husband. Record review of an Orders-Administration Note for Resident #59, dated 04/05/25 at 6:34 p.m., reflected Resident #59 had her hand down a male resident's shirt. The nurse asked Resident #59 several times to stop. The male resident told the nurse 'You can't tell us what to do' and stuck his middle finger at the nurse. Resident #59 then stuck his middle finger up at the nurse. Both residents became aggressive with staff.Resident #60Record review of the admission Record for Resident #60 revealed he was [AGE] years old and was admitted to the facility on [DATE]. Diagnoses included Alzheimer's disease (progressive disease characterized by memory loss), dementia (a group of symptoms that affect thinking, memory, and social abilities), and unspecified psychosis (a mental state marked by loss of contact with reality). The admission Record reflected he was his own RP.Record review of Resident #60's Quarterly MDS assessment dated [DATE] revealed he scored 10/15 on the BIMS, indicative of moderate cognitive impairment. He was able to walk independently. The resident did not exhibit physical or verbal adverse behaviors during the seven-day lookback period.Record review of Resident #60's Care Plan, initiated 07/18/24, reflected he was found naked in bed in a female peer's room on 03/25/25. Review of the care plan did not reveal goals or interventions to address the behavior of physical contact with peers.In an interview on 05/28/25 at 3:15 p.m., the DON said Resident #59 and Resident #60 may sit together in activities but were not allowed to go to each other's rooms. She said Resident #59 had delusions that she and Resident #60 were married, she was not able to make consensual decisions.In an interview on 05/28/25 at 4:09 p.m., the MDS Coordinator said on 03/25/25 Resident #59 was found in bed with Resident #60. She confirmed there was no Care Plan to address sexual activity. She said the Care Plans should have been updated. She said the interventions needed to be changed.The facility policy Care plan Revisions (revised May 2022) read, in part, .1. The comprehensive care plan will be reviewed and revised every quarter, when a resident experiences a status change and as deemed necessary .c. The care plan will be updated with the new or modified interventions.An IJ was identified on 6/16/2025 at 3:45 p.m. The IJ template was provided to the Administrator via email at 3:45 p.m and a Plan of Removal was requested. The following Plan of Removal was submitted by the facility and was accepted on 6/16/2025 at 10:08 p.m. and indicated the following:Plan of Removal Name of facility: _______Date: 06/16/2025 According to the IJ Template, the facility failed to update care plans for Resident #59 and Resident #60 with measurable objectives and timeframes following a possible sexual encounter involving both residents. -Resident #31's care plan did not include interventions and services to appropriately address the resident's behavior of putting inedible items in her mouth. -Resident #59's Care Plan was not updated to include interventions and services to appropriately address inappropriate sexual behavior. -Resident #60's Care Plan was not updated to include interventions and services to appropriately address inappropriate sexual behavior.Immediate ActionJune 16, 2025 - 30-Day Incident ReviewAction: Regional Clinical Reimbursement Specialist will conduct full review of behavioral incidents from the past 30 days to ensure all related care plans were properly updated with measurable goals and appropriate interventions. There were not any negative findings. Responsible: Regional Clinical Reimbursement SpecialistCompletion Date: June 16, 2025June 16, 2025 - MDS Nurse EducationAction: Regional MDS Nurse will provide an in-service education to the facility's MDS Nurse on timely, individualized care plan updates in response to behavioral incidents.Responsible: Regional MDS Nurse/designee Completion Date: June 16, 2025June 16, 2025 - Facility Medical Director NotifiedAction: The facility's Medical Director was formally notified of the F-0656 deficiency. Responsible: AdministratorCompletion Date: June 16, 2025June 16, 2025 - Ad Hoc QAPI Meeting HeldAction: Meeting conducted with Medical Director, DON, MDS Nurse, Regional MDS Nurse, Regional Director of Operations, and Regional Nurse Consultant to review recent incidents and care planning deficiencies. Performance Improvement Plan created.Responsible: Administrator Completion Date: June 16, 2025June 16, 2025 - Daily Behavior Review and Care Plan Update MonitoringAction: The IDT team will review progress notes daily during the clinical morning meeting to identify behaviors, ensuring the care plans are updated with appropriate interventions. Responsible: DON June 16, 2025 - Care Plan Revision PolicyAction: The Administrator reviewed the care plan revision policy. Upon review, no changes were noted. Responsible: Administrator Completion Date: June 16, 2025Monitoring of the plan of removal included the following:In an interview on 06/15/2025 at 11:15 a.m. the Administrator said Resident #59 had been transferred from the facility. Observation on 06/15/2025 at 11:55 a.m. revealed Resident #60 had been relocated off of the secured unit. He was asleep when observed at that time.In an interview on 06/15/2025 at 12:06 p.m. the DON said she was reviewing the behaviors of the 24 residents on the secure unit. She said she would complete the audit that day.Record review on 06/16/2025 at 09:30 a.m. revealed all of the secured unit resident audits have been completed.The following interviews occurred on the Secured Unit:Observation on 06/17/2025 at 11:50 a.m. revealed Resident #70 relocated back to the Secured Unit.In an interview on 06/17/2025 at 1:55 p.m., The MDS Coordinator said the facility implemented the following changes:All incident/accident reports were reviewed in the morning meeting. Internal messaging for daily events were done via telephone or e-mail. There was a Standards of Care meeting conducted every Tuesday. She was reading Progress Notes every morning.She said she had received counselling from the Regional MDS Coordinator on 06/16/2025. In an interview on 06/17/2025 at 2:10 p.m. RN M (ADON) said information regarding care plans was discussed in the stand-up meeting in the mornings. She said the nurses could communicate concerns via email or telephone to the MDS Coordinator. In an interview on 06/17/2025 at 2:25 p.m. RN C said if there were incidents, accidents or changes in condition requiring Care Plan updates, she would notify the MDS Coordinator and DON via email or phone. The Administrator was informed the Immediate Jeopardy was removed on 06/17/2025 at 2:30 p.m. The facility remained out of compliance at a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put in place. Findings included: Resident #31 Review of Resident #31's face sheet revealed, the resident was a [AGE] year-old female admitted to the facility on [DATE] with a history of Dementia (group of symptoms affecting memory, thinking or language) anxiety (intense, excessive, and persistent worry and fear about everyday situations), altered mental status, and intellectual disabilities (condition that involves limitation on intelligence). Review of Resident #31's Quarterly MDS Assessment, dated 05/07/25, indicated the resident's cognitive skills for daily decision making was severely impaired. Review of progress notes, entered by RN C and dated 05/25/25 at 5:57 PM, indicated the following: Resident ingested plastic saran wrap from desert cup. Resident @ baseline; no signs of distress, breathing even and unlabored. Behavior @ baseline; BP:132/88 HR 55 RR 18 O2: 97 T: 97.3. NP B notified; no n/o. Will continue to monitor. Review of progress notes, entered by the DON and dated 05/28/25, indicated the resident had an IDT review due to swallowing plastic wrap. Recommendations were to continue to monitor for adverse effects, KUB (Kidney, Ureter and Bladder imaging), dietary evaluation, and in-service on meal setup. IDT members were Administrator, DON, ADON, Unit Manager, MDS nurse and Social Worker. Telephone interview with CMA H on 05/29/25 at 11:52 AM, who said on 05/25/25 during lunch, Resident #31 took the plastic wrapping off the applesauce and swallowed it. She denied knowledge of the resident putting other inedible items in her mouth. She said she assisted the resident with eating lunch but could not get to her quickly enough before she swallowed the plastic. She said the resident never appeared to be in distress, did not have difficulty breathing, and did not choke after swallowing the plastic wrap. She said the resident continued to eat her meal after swallowing the plastic wrap. She said the resident was supposed to be closely monitored during meals. She said the resident was not on 1:1 supervision. She said she notified the nurse immediately after the incident, and the nurse performed a head-to-toe assessment on the resident. Review of Resident #31's care plan, updated 05/01/25, indicated the resident had a history of putting inedible things in her mouth, and was noted to have eaten paint off walls, Styrofoam cups, etc. The resident's goal was not to have adverse effects related to putting inedible things in her mouth. Interventions included observing the resident closely for presence of foreign matter in mouth. Providing limited assistance of one staff member with dining. Remove any foreign matter from mouth. Observe for presence during crafts or activities where she could pick up items and put them in her mouth. Further review of Resident #31's care plan revealed documentation of past incidents of the putting inedible things in her mouth or ingesting inedible items and the incident on 05/25/25 was not addressed in the care plan. Interview with DON on 05/29/25 at 12:28 PM, who said the facility updated Resident #31's care plan on 05/28/25 to include 1:1 supervision/care at all times. She said she also emailed the dietitian to discuss interventions. She said the facility obtained a referral for an inpatient psychiatric evaluation for the resident. She said the facility also held an ad hoc QAPI meeting with the NP to provide additional interventions for the resident. She said the resident was at risk of an incident similar to ingesting plastic wrap reoccur. In an interview on 05/29/25 at 2:21 p.m. the Administrator said the facility tailored the resident's care plan to meet her needs. In an interview on 05/29/25 at 4:21 p.m. the MDS Coordinator said care plans were updated daily, or sometimes multiple times a day, to provide an accurate reflection of the care or services a resident required. She said the risk of not updating a care plan was resident's care needs not being met by facility staff. In an interview on 05/29/25 at 4:26 p.m. the DON said the MDS was supposed to update resident care plans as needed. She said a care plan should reflect goals and interventions based on a resident's specific needs to outline care to be provided to residents by facility staff. She said the risk of not updating the care plan to meet a resident's specific needs was failure to provide appropriate care to the resident. In an interview on 05/29/25 at 4:33 p.m., the Administrator said the MDS nurse was responsible developing care plans. He said the IDT team was also involved in developing comprehensive care plans. He said the risk associated with a resident not having an individualized care plan was facility staff may not have been meeting the resident's needs or may not have been aware of the resident's needs. Resident #59 Record review of the admission Record (dated 05/28/25) for Resident #59 revealed she was [AGE] years old and was admitted to the facility on [DATE]. Diagnoses included dementia (a group of symptoms that affect thinking, memory, and social abilities), schizoaffective disorder (a mix of hallucinations, delusions, and mood disorder), and generalized anxiety disorder. The document did not have a RP listed. Record review of the Quarterly MDS assessment for Resident #59, dated 05/06/25, revealed she scored 11/15 on the BIMS, indicative of moderate cognitive impairment. Record review of a Psychosocial Evaluation dated 02/25/25 revealed Resident #59 scored 14/15 on the BIMS, indicative of intact cognition. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #59 reflected she scored 10 of 15 on the Brief Interview for Mental Status (BIMS), indicative of moderately impaired cognition. The MDS also reflected Resident #59 exhibited delusions and wandering. Record review of Resident #59's Care Plan, updated on 03/07/25, revealed she was found in her bed, naked with a male peer on 03/25/25. Resident #59 believed the male resident was her husband. Interventions included monitoring and charting behaviors as they occurred and reporting progress/declines to MD. Review of the care plan did not reveal goals or interventions to address the behavior of physical contact with peers. Record review of a Behavior Note for Resident #59, dated 03/29/25 at 9:40 p.m., reflected Resident #59 attempted to go to the men's side of the secured unit. She became combative with staff. She was redirected but attempted to return after ten minutes. She again said Resident #60 was her husband. Record review of an Orders-Administration Note for Resident #59, dated 04/05/25 at 6:34 p.m., reflected Resident #59 had her hand down a male resident's shirt. The nurse asked Resident #59 several times to stop. The male resident told the nurse 'You can't tell us what to do' and stuck his middle finger at the nurse. Resident #59 then stuck his middle finger up at the nurse. Both residents became aggressive with staff. Resident #60 Record review of the admission Record for Resident #60 revealed he was [AGE] years old and was admitted to the facility on [DATE]. Diagnoses included Alzheimer's disease (progressive disease characterized by memory loss), dementia (a group of symptoms that affect thinking, memory, and social abilities), and unspecified psychosis (a mental state marked by loss of contact with reality). The admission Record reflected he was his own RP. Record review of Resident #60's Quarterly MDS assessment dated [DATE] revealed he scored 10/15 on the BIMS, indicative of moderate cognitive impairment. He was able to walk independently. The resident did not exhibit physical or verbal adverse behaviors during the seven-day lookback period. Record review of Resident #60's Care Plan, initiated 07/18/24, reflected he was found naked in bed in a female peer's room on 03/25/25. Review of the care plan did not reveal goals or interventions to address the behavior of physical contact with peers. In an interview on 05/28/25 at 3:15 p.m., the DON said Resident #59 and Resident #60 may sit together in activities but were not allowed to go to each other's rooms. She said Resident #59 had delusions that she and Resident #60 were married, she was not able to make consensual decisions. In an interview on 05/28/25 at 4:09 p.m., the MDS Coordinator said on 03/25/25 Resident #59 was found in bed with Resident #60. She confirmed there was no Care Plan to address sexual activity. She said the Care Plans should have been updated. She said the interventions needed to be changed. The facility policy Care plan Revisions (revised May 2022) read, in part, .1. The comprehensive care plan will be reviewed and revised every quarter, when a resident experiences a status change and as deemed necessary .c. The care plan will be updated with the new or modified interventions. An IJ was identified on 6/16/2025 at 3:45 p.m. The IJ template was provided to the Administrator via email at 3:45 p.m and a Plan of Removal was requested. The following Plan of Removal was submitted by the facility and was accepted on 6/16/2025 at 10:08 p.m. and indicated the following: Plan of Removal Name of facility: _______ Date: 06/16/2025 According to the IJ Template, the facility failed to update care plans for Resident #59 and Resident #60 with measurable objectives and timeframes following a possible sexual encounter involving both residents. -Resident #31's care plan did not include interventions and services to appropriately address the resident's behavior of putting inedible items in her mouth. -Resident #59's Care Plan was not updated to include interventions and services to appropriately address inappropriate sexual behavior. -Resident #60's Care Plan was not updated to include interventions and services to appropriately address inappropriate sexual behavior. Immediate Action June 16, 2025 - 30-Day Incident Review Action: Regional Clinical Reimbursement Specialist will conduct full review of behavioral incidents from the past 30 days to ensure all related care plans were properly updated with measurable goals and appropriate interventions. There were not any negative findings. Responsible: Regional Clinical Reimbursement Specialist Completion Date: June 16, 2025 June 16, 2025 - MDS Nurse Education Action: Regional MDS Nurse will provide an in-service education to the facility's MDS Nurse on timely, individualized care plan updates in response to behavioral incidents. Responsible: Regional MDS Nurse/designee Completion Date: June 16, 2025 June 16, 2025 - Facility Medical Director Notified Action: The facility's Medical Director was formally notified of the F-0656 deficiency. Responsible: Administrator Completion Date: June 16, 2025 June 16, 2025 - Ad Hoc QAPI Meeting Held Action: Meeting conducted with Medical Director, DON, MDS Nurse, Regional MDS Nurse, Regional Director of Operations, and Regional Nurse Consultant to review recent incidents and care planning deficiencies. Performance Improvement Plan created. Responsible: Administrator Completion Date: June 16, 2025 June 16, 2025 - Daily Behavior Review and Care Plan Update Monitoring Action: The IDT team will review progress notes daily during the clinical morning meeting to identify behaviors, ensuring the care plans are updated with appropriate interventions. Responsible: DON June 16, 2025 - Care Plan Revision Policy Action: The Administrator reviewed the care plan revision policy. Upon review, no changes were noted. Responsible: Administrator Completion Date: June 16, 2025 Monitoring of the plan of removal included the following: In an interview on 06/15/2025 at 11:15 a.m. the Administrator said Resident #59 had been transferred from the facility. Observation on 06/15/2025 at 11:55 a.m. revealed Resident #60 had been relocated off of the secured unit. He was asleep when observed at that time. In an interview on 06/15/2025 at 12:06 p.m. the DON said she was reviewing the behaviors of the 24 residents on the secure unit. She said she would complete the audit that day. Record review on 06/16/2025 at 09:30 a.m. revealed all of the secured unit resident audits have been completed. The following interviews occurred on the Secured Unit: Observation on 06/17/2025 at 11:50 a.m. revealed Resident #70 relocated back to the Secured Unit. In an interview on 06/17/2025 at 1:55 p.m., The MDS Coordinator said the facility implemented the following changes: All incident/accident reports were reviewed in the morning meeting. Internal messaging for daily events were done via telephone or e-mail. There was a Standards of Care meeting conducted every Tuesday. She was reading Progress Notes every morning. She said she had received counselling from the Regional MDS Coordinator on 06/16/2025. In an interview on 06/17/2025 at 2:10 p.m. RN M (ADON) said information regarding care plans was discussed in the stand-up meeting in the mornings. She said the nurses could communicate concerns via email or telephone to the MDS Coordinator. In an interview on 06/17/2025 at 2:25 p.m. RN C said if there were incidents, accidents or changes in condition requiring Care Plan updates, she would notify the MDS Coordinator and DON via email or phone. The Administrator was informed the Immediate Jeopardy was removed on 06/17/2025 at 2:30 p.m. The facility remained out of compliance at a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put in place.