**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for 1 of 4 residents (Resident #1) reviewed for accidents and hazards. The facility failed to ensure Resident #1 was transferred safely, with a gait belt, correct positioning and with at least two staff, by CNA B when Resident #1 fell and sustained a femur (thigh bone) fracture which required surgery on 06/10/2025. An Immediate Jeopardy (IJ) was identified on 06/13/2025. While the IJ was removed on 06/15/2025, the facility remained out of compliance at a scope of isolated with a potential for more than minimal harm, due to the facility's need to evaluate the of the corrective systems . This failure could place residents at risk of unsafe transfers, falls, injuries, hospitalizations and/or death. Findings include: Record review of Resident #1's face sheet, dated 06/16/2025, reflected an [AGE] year-old man who was admitted to the facility on [DATE]. Resident #1 discharged on 06/10/2025. Resident #1 had with diagnoses which included vascular parkinsonism (disease that is caused by damage to blood vessels in the brain that leads to movement and balance problems that particularly affect the lower body), unspecified atrial fibrillation (irregular or rapid heartbeat), dysphagia (difficulty swallowing), need for assistance with personal care (need for help with activities of daily living), unsteadiness on feet (being unbalanced or unstable while standing or walking), other abnormalities of gait and mobility (abnormal walking pattern), weakness, unspecified intellectual disabilities, developmental disorder of scholastic skills, muscle weakness and dementia (loss of memory, language, problem-solving and other thinking abilities that interfere with daily life). Record review of Resident #1's fall risk evaluation, dated 02/04/2025, reflected Resident #1 was a high fall risk with no falls in the past three months. Resident #1 had balance problems while standing / walking. Record review of Resident #1's BIMS assessment, dated 02/22/2025, reflected a score of 6 which indicated severe cognitive impairment. Record review of Resident #1's MDS, dated [DATE], reflected Resident #1 required substantial/ maximal assistance (helper does more than half the effort, 2-staff requred) for chair/bed-to-chair transfers. Resident #1 had no falls since the prior assessment or admission. Resident #1 was 228 lbs and 74 inches tall. Record review of Resident #1's care plan, dated 05/31/2015, reflected Resident #1 had impaired cognitive function with interventions to remember one/two step instructions. Review of Resident #1's care plan, dated 12/21/2021, reflected he had a self-care deficit and required substantial/maximal assist staff participation with transfers. Resident #1 was at risk for falls related to gait/balance problems. Review of care plan reflected no information regarding use of gait belt when transferring Resident #1. Review of Resident #1's chart reflected Kardex was unable to be reviewed due to Resident #1 being discharged from the facility. Record review of incident report, dated 06/10/2025 at 5:00 AM, reflected CNA B stated she helped Resident #1 get ready for the day and she tried to use the stand and pivot method to transfer but while doing so Resident #1's leg slid, and she helped the resident slowly to the ground and Resident #1 tried to support himself with his knees. Resident #1 was transferred to the ER for evaluation and treatment. Record review of progress note, dated 06/10/2025, by LVN A, reflected Resident #1 was assisted by CNA B when LVN A saw Resident #1 on the floor. LVN A completed an assessment and completed vitals. Resident #1 was transferred to bed. Resident #1 was repositioned and had right hip tenderness noted with limited range of motion and pain level of 10/10. Resident #1 screamed when his right foot was moved but was calm when the right leg was at rest. Resident #1's right thigh appeared to be swollen. Reached out to the on-call provider and advised Resident #1 be sent to the hospital via EMS. Record review of hospital records, dated 06/13/2025, reflected Resident #1 sustained a right femoral shaft fracture. Procedure performed was an open reduction and internal fixation of right femur shaft fracture with a cephalomedullary nail (surgically exposing fracture and realigning bone fragments and stabilizing the fracture with a nail inserted in the femur). During an interview on 06/13/2025 at 2:11 PM and 3:05 PM, CNA B stated she assisted Resident #1 with getting ready for the day on 06/10/2025. CNA B stated she attempted to transfer Resident #1 and she did not use a gait belt because the nurse did not tell her she needed to use one with Resident #1. CNA B stated she positioned Resident #1's wheelchair close to his bed and she was to the side and behind him. CNA B stated Resident #1 stood and then fell forward to his knees during the transfer. CNA B stated Resident #1 went straight down to the floor. CNA B stated Resident #1 usually stepped and then pivoted to the chair and he usually did most of the work. CNA B stated she usually stood behind Resident #1 for transfers and Resident #1 was the only resident she transferred from behind. CNA B stated she could find information on the Kardex (nursing tool for patient information) for what the resident needed for assistance during transfers. CNA B stated her hands were on Resident #1's pants or back. CNA B stated she did not remember if she was on his left or right side but stated she was behind him. CNA B stated Resident #1 sat on the edge of the bed and she usually told him to stand but that day (06/10/2025) he did not stand as usual and when she tried to help him, he felt like he was going down. CNA B stated Resident #1 fell forward after he lifted off the bed and he was standing and then went down with CNA B behind him. CNA B did not state if she checked the Kardex prior to the transfer . CNA B stated she usually got Resident #1 up for the day on her shift and he was usually able to stand and take a step and pivot . During an interview on 06/13/2025 at 2:23 PM, CNA D stated staff could find transfer requirements on the Kardex. CNA D stated the Kardex told staff if a resident needed a 1 or 2 person transfer or minimum or maximum assistance. CNA D stated there was not a transfer that would occur where the CNA stood behind a resident. CNA D stated she stood in front of residents when she assisted them from bed to chair and chair to bed. CNA D stated gait belts should be used during transfers. During an interview on 06/13/2025 at 2:28 PM, the OT stated Resident #1's transfers fluctuated and sometimes Resident #1 needed more help, but it depended on the day . The OT stated Resident #1 was on therapy services because of the fluctuation in his transfers. The OT stated there were not one-person transfers in which the staff would stand behind a resident . The OT stated the staff would only stand behind the resident if there was another staff member present. The OT stated a gait belt should be used for all transfers for safety reasons. During an interview on 06/13/2025 at 2:48 PM, CNA E stated staff were supposed to always use a gait belt when they transferred a resident . CNA E stated staff was supposed to stand in front of residents during a transfer. CNA E stated unless there was another staff member then she would not be behind the residents. CNA E stated staff viewed the Kardex to show whether a resident needed a 1 or two person transfer or a mechanical lift. CNA E stated substantial / maximal assistance usually meant to bring another staff member with you. During an interview on 06/13/2025 at 2:51 PM, CNA C stated with a little muscle from the CNA Resident #1's wheelchair was positioned on the side of his bed at an angle with his bed rail in reach because Resident #1 utilized them to push up. CNA C stated Resident #1 needed guidance during the transfer and this included verbal cueing. CNA C stated a gait belt was required for every transfer with Resident #1. During an interview on 06/13/2025 at 3:31 PM, LVN F stated during a one-person transfer the staff would be facing the resident and be knee-to-knee or feet-to-feet. LVN F stated there were no transfers that occurred when a staff was behind the resident. LVN F stated a gait belt should be used at all time during a transfer. LVN F stated the purpose of a gait belt was to ensure you had a good grip on the resident and you did not have to grab the resident's clothing or skin. LVN F stated the risk of transferring a resident without a gait belt was losing balance or grip and a potential fall. LVN F stated it was important to have the correct positioning (being in front of the resident) during a transfer to prevent the resident from losing balance or the staff hurting themselves. During an interview on 06/13/2025 at 3:27 PM, the DON stated during a transfer the first thing was for staff to use a gait belt. The DON stated staff were positioned in front of the resident with the staff's foot in between the resident's legs. The DON stated it was best practice to have a gait belt because staff never knew what could happen. The DON stated a resident who required maximum assistance definitely needed a gait belt to be used. The DON stated the purpose of a gait belt was for extra support or caution during transfers. The DON stated if staff transferred without a gait belt a lot of injuries could happen. The DON stated there were no transfers where a staff would be behind a resident and every single transfer had the staff in front of the resident. The DON stated if staff were behind a resident they could not see what they were doing. The DON stated staff were observed often and assessed for their transfer skills. The DON stated staff were assessed after hire and from time-to-time and if a concern was raised someone completed a transfer incorrectly. The DON stated after the aide transferred Resident #1 and fell, they started re-education of staff. The DON stated when incidents like that happened management wanted to educate so incidents were not repeated. The DON stated she expected staff to use a gait belt when indicated. The DON stated a gait belt would not be used for a resident who required only supervision and could transfer themselves or walk without assistance from staff, otherwise a gait belt was expected to be used. The DON stated most CNAs had a gait belt provided to them and after Resident #1 fell staff were informed a gait belt was a part of their uniform. The DON stated she expected staff to have proper positioning during transfers and if they were not sure they needed to ask questions. The DON stated the Kardex told the staff what a resident's transfer status was and how many staff were required. The DON stated staff were reminded to use the Kardex almost daily during the stand-down meeting. The DON stated she was out on 06/10/2025 and reviewed the progress note on 06/11/2025 about Resident #1's fall and stated initially she read the aide helped Resident #1 slide down to the floor and she thought that's good she helped him. The DON stated CNA B stated she (CNA B) transferred Resident #1 and he slid down to the floor. The DON stated after the initial assessment Resident #1 was transferred to his bed and he started to scream and LVN A saw his leg was swollen and she reached out to the supervisor and on-call. The DON stated after she learned Resident #1 had a fracture she began re-education with staff. The DON stated she reviewed what each transfer was and proper transfer and body mechanics. The DON stated she did not ask CNA B if she had a gait belt and did not ask where CNA B was positioned during the transfer. The DON stated she was only able to speak with LVN B. The DON stated Resident #1 had not had any falls prior to this incident. During an interview on 06/13/2025 at 3:40 PM, the ADM stated he expected staff to transfer residents correctly and there was zero tolerance for incorrect transfers. The ADM stated he was not aware of the specific details of Resident #1's transfer. The ADM stated he expected staff to use a gait belt 100 percent of the time when indicated. The ADM stated the IDT reviewed Resident #1's fall and discussed what could have been done better. The ADM stated he was not aware of the details regarding whether CNA B had a gait belt or where she was positioned when she transferred Resident #1. The ADM stated he and the DON stressed to staff they should never be without supplies (including gait belts) and staff could call or text anytime they needed something. During an interview on 06/13/2025 at 4:12 PM, the NP stated she expected staff to utilize safe transfer techniques. She stated Resident #1 did have intermittent confusion and other diagnoses that made him a fall risk. The NP stated not utilizing a gait belt or proper positioning during transfers could obviously result in a fall leading to a fracture. During an interview on 06/23/2025 at 1:47 PM, the DON stated substantial/maximal assistance meant that two staff were required during the transfer. The DON stated when staff reported a resident had a change in level of assistance needed then care plans or Kardex was updated right away. The DON stated skills checks were observed upon hire. The DON stated she came to the building during off hours to check in with staff and observe care. The DON stated staff also had skills check three months after hire. The DON stated if staff expressed concerns or area where they needed more training during their new hire training their training would be extended. The DON stated if a resident required two people for their care then she expected two staff to provide that care. The DON stated the risk of not having another staff if a resident required two people for care was a fall that resulted in an injury. The DON stated staff were trained by a train the trainer method and new staff were paired with another staff and trained by the other staff through on the job training. The DON stated she checked in with staff at the end of their training to ask if they felt comfortable and if they needed any additional training in any area. The DON stated she or the ADON would complete the final skills check before staff were released to work independently . During an interview on 06/23/2025 at 3:45 PM, LVN A stated she was the charge nurse when Resident #1 fell. She stated it was considered a witnessed fall and from what she was told by CNA B, CNA B tried to transfer Resident #1, he missed a step and fell. LVN A stated she was not sure why CNA B transferred Resident #1 by herself. LVN A stated based on what the Kardex had and other the CNA said Resident #1 was a two-person transfer. LVN A stated substantial / maximal assistance was required a two people in the transfer. Record review of in-service, dated 06/11/2025, reflected substantial/maximal assistance required two people for transfers. Record review of in-service, dated 06/11/2025, with subject GGS (functional abilities and goals) reflected it reviewed types of assistance needed for transfer and staff required and reflected CNA B did not complete the in-service as of 06/13/2025. Record review of in-service, dated 06/11/2025, with subject Kardex reflected CNA B did not participate in the in-service as of 06/13/2025. The in-service included the purpose of Kardex and how it was used . Record review of in-service, dated 06/11/2025, with subject of body mechanics reflected CNA B did not participate in the in-service as of 06/13/2025. The in-service included body positioning during transfers . Record review of in-service, dated 06/11/2025, with topic safe resident transfers and handling reflected proper techniques, correct use of patient handing equipment and devices with the goal to ensure resident safety and reduce injury for both residents and staff. Review reflected CNA B completed this in-service as verified by signature and date of 06/11/2025. Record review of the facility's schedule / sign-in sheets for 06/11/2025 and 06/12/2025 reflected CNA B was not scheduled to work at the facility. Review of facility scheduled, dated 06/13/2025, reflected CNA B was scheduled to return to the facility from 10:00 pm - 6:00 am on 06/13/2025. Record review of the facility's policy titled Quality of Care Transfer of a Resident, Safe with revision, date of 05/2025, reflected use good body mechanics at all times .use a gait belt for all transfer if gait belts is indicated for the resident. The policy reflected for one-person transfers, apply gait belt around resident's waist, provide necessary assistance to help the resident stand up. The policy reflected two-person transfers using a gait belt required to apply the gait belt around the resident's wait, use good body mechanics at all times and provide the necessary help for the resident to stand up with caregivers on both sides of the resident and staff holding the gait belt. This was determined to be an Immediate Jeopardy (IJ) on 06/13/25 at 4:57 PM. The ADM and DON were notified . The ADM was provided with the IJ template on on 06/13/2025 at 4:57 PM. The following Plan of Removal submitted by the facility was accepted on 06/14/2025 at 4:01 PM : Immediate Plan of Removal The facility submits this Plan of Removal to address the Immediate Jeopardy identified, on 6/13/2025. Identification of Others Affected by Alleged Deficient Practice: All admissions and re-admissions have the potential to be affected by this alleged deficient practice. Summary: On 6/13/2025 an abbreviated survey was initiated at the facility. On 6/13/2025 the surveyor provided an Immediate Jeopardy (IJ) that the Regulatory Services has determined that the condition at the facility constitutes an immediate threat to resident health and safety. The notification of Immediate Jeopardy (IJ) states as follows: F689 - The facility must ensure each resident receives adequate supervision and assistance devices to prevent accidents. The facility failed to ensure Resident #1 was transferred safely (with gait belt and correct positioning) by CNA B on 06/10/2025. Resident #1 is an [AGE] year-old man admitted on [DATE] with diagnoses of vascular parkinsonism, dysphagia, need for personal assistance with care, unsteadiness on feet, weakness, other abnormalities of gait and mobility, dementia, and muscle weakness. Resident has a BIMS of 6. Resident #1 sustained a fall on 06/10/2025 resulting in injury to right hip. CNA B reported that resident slid down to knees while helping resident get out of bed after personal care. Resident #1 was admitted to the hospital and underwent subsequent open reduction internal fixation of right hip fracture on 06/10/2025. CNA B reported to surveyor on 06/13/2025 that she did not utilize gait belt and was standing behind the resident during the transfer. Resident #1 returned to the facility on [DATE]. Action: Resident #1 was re-admitted on [DATE] at 6:53 PM, at the time of readmission-these assessments were completed: Initial admission assessment, pain assessment, fall risk assessment, skin assessment, elopement, Braden scale (assessment to evaluate a resident's risk for developing pressure ulcers), functional observation GG assessment (resident's functional goals and abilities), and initial care plan. Start Date: 06/13/2025 Completion Date: 06/13/2025 Responsible: DON/Designee Action: Individual in-service with CNA B on transfer policy and understanding the Kardex. CNA B provided return demonstration competency on use of gait belt and a safe resident transfer. CNA B suspended effective 6.14.2025. Start Date: 06/13/2025 Completion Date: 06/14/2025 Responsible: Director of Nurses/Designee Action: Review of CNA B personnel file for skill competency for safe transfer. Competency check off for safe transfer completed upon hire on 04/09/2025. Start Date: 06/13/2025 Completion Date: 06/13/2025 Responsible: Director of Nursing (DON) Action: Thorough investigation of Resident #1 fall on 06/10/2025 conducted with root cause analysis identification of CNA B isolated error in performance of resident transfer. CNA B suspended effective 6.14.2025. Start Date: 6/13/25 Completion Date: 6/14/25 Responsible: Executive Director, IDT, DON, Clinical Resource, MSN/Ed, RN Action: Medical Director and Nurse Practitioner notification of immediate jeopardy. Details of incident, root cause analysis, resident status, and plan of removal discussed. Start Date: 6/13/25 Completion Date: 6/13/25 Responsible: Executive Director Action: Inservice Leadership Team, including but not limited to: Executive Director, Administrators in Training, Therapy Program Manager, Director of Nurses, Assistant Director of Nurses, and Staffing Coordinator on immediate jeopardy, details of incident, root cause analysis, resident status, plan of removal. Inservice Leadership Team on the following: Fall assessment performed by nursing staff will include: completion of SBAR, not moving resident if injury suspected, activation of 911, provider notification, DON notification, representative notification, change of condition completion, progress note documentation Transfer policy, use of gait belt, safety with transfers, identification of resident transfer requirements through use of Kardex Understanding the Kardex: how to access Knowledge retention demonstrated with post-test Start Date: 06/13/2025 Completion Date: 06/13/2025 Responsible: Clinical Resource, MSN/Ed, RN Action: Audit 100% care plans of all active residents to confirm resident transfer status includes number of staff members required for safe transfer on the care plan and Kardex. No changes to care plans were indicated. All Kardex were up to date and current for resident transfer needs. Start Date: 6/13/25 Completion Date: 6/13/25 Responsible: DON/Designee/Clinical Resource, MSN/Ed, RN Action: Inservice DON on the following: Fall assessment: completion of SBAR, not moving resident if injury suspected, activation of 911, provider notification, DON notification, representative notification, change of condition completion, progress note documentation. Transfer policy, use of gait belt, safety with transfers, identification of resident transfer requirements through use of Kardex. Understanding the Kardex: how to access Knowledge retention demonstrated with post-test Start Date: 6/13/25 Completion Date: 6/13/25 Responsible: Clinical Resource, MSN/Ed, RN Action: Inservice 100% nursing and nursing leadership staff on the following: Fall assessment: completion of SBAR, not moving resident if injury suspected, activation of 911, provider notification, DON notification, representative notification, change of condition completion, progress note documentation Transfer policy, use of gait belt, safety with transfers, identification of resident transfer requirements through use of Kardex Understanding the Kardex: how to access Knowledge retention demonstrated with post-test Start Date: 6/13/25 Completion Date: 6/16/25 Responsible: DON/Designee Action: Inservice 100% CNA and therapy staff (including all PRN staff, new hires, and agency staff) on the following: Transfer policy, use of gait belt, safety with transfers, identification of resident transfer requirements through use of Kardex Understanding the Kardex: how to access Knowledge retention demonstrated with post-test Start Date: 6/13/25 Completion Date: 6/16/25 Responsible: DON/Designee Action: Ad hoc QA meeting. Attendees will include ED , DON, Clinical Resource, Cluster Partners, Medical Director. Meeting will include the Plan of Removal and inventions. Start Date: 6/13/25 Completion Date: 6/13/25 Responsible: Executive Director Systemic Change to Prevent Re-Occurrence: DON/Designee and IDT will ensure safe transfer requirements are assessed upon admission and added to the care plan and Kardex for all residents. DON/Designee and IDT will ensure safe transfer requirements are updated on the care plan and Kardex for any resident that has had a change in transfer status. Start Date: 6/13/25 Completion Date: Ongoing Monitoring of the POR from 06/14/2025 to 06/15/2025 included the following: During an interview with the ADM and the DON on 06/14/2025 at 10:29 AM, they stated Resident #1 returned to the facility on [DATE] at 6:49 PM. A telephone call was attempted to CNA B on 06/14/2025 at 3:08 PM with message requesting for call back. No message was returned by CNA B . During an interview with the ADM and the DON on 06/14/2025 at 10:29 AM, it was stated CNA received in-service and skills check off prior to her shift on 06/13/2025. CNA B was suspended at 2:00 PM on 06/14/2025 after the ADM and DON decided to suspend CNA B until a formal corrective action plan could be developed and implemented . Observation and interview with Resident #1 on 06/14/2025 at 1:15 PM revealed Resident #1 laid in bed with the call light in reach. Resident #1 responded to simple questions with garbled speech. Resident #1 denied any pain and that it was controlled . During interviews conducted from 06/14/2025 to 06/15/2025 with 6 CNAs, 2 LVNs, ADM, DON and 2 AITs reflected staff received in-service either on 06/14/2025 or 06/15/2025 prior to their shifts. Interviewed staff stated they were trained on how to safely transfer a resident from bed-to-chair/chair-to-bed, how to access the Kardex to review transfer status of a resident , use of gait belts (required to have as part of uniform) and to use when indicated when transferring a resident. Interviewed staff stated they took a posttest and demonstrated skills check off on transfers. During an interview on 06/15/2025 at 11:53 AM, the ADM stated the Medical Director and Nurse Practitioner were notified of the IJ. Review of phone logs reflected MD was contacted at 6:05 PM on 6/13/2025 and NP was contacted on 06/13/2025 at 5:45 PM. During an interview on 06/15/2025 at 11:57 AM, the ADM and the DON, stated they were at 90% completion of staff in-servicing. The ADM stated they had reached out to all staff who had not received the in-service and staff were not allowed to work until the training was completed. Review of the spread sheet of in-serviced staff reflected almost all staff were in-serviced as of 06/15/2025. During an interview on 06/15/2025 at 11:56 AM, the DON stated the audit was completed and no changes were identified during the audit. Record review of in-service sign-in sheets, dated 06/13/2025, reflected CNA B participated in the in-service on transfer policy and understanding the Kardex. CNA B provided return demonstration competency on use of gait belt and safe resident transfer and knowledge demonstrated via post-test, dated 06/13/2025. Review of CNA B's employee file reflected a skills competency was completed on 04/09/2025. Record review of counseling/disciplinary notice, dated 06/14/2025, reflected CNA B was suspended pending investigation and CNA B was informed via phone call. Record review of the QAPI meeting sign in sheet and agenda, dated 06/13/2025, reflected MD and NP were notified and meeting was held. Record review of root cause analysis, dated 06/13/2025, reflected the incident with CNA B was an isolated incident after she transferred Resident #1 alone and without a gait belt. CNA B was suspended on 06/14/2025. Record review of care plan resident roster audit documentation, dated 06/13/2025, reflected all resident's charts were audited and Kardex and care plan were updated as needed. Record review of in-service sign-in, dated 06/13/2025, reflected transfer policy and procedure was reviewed, understanding the Kardex, fall management was completed with DON by clinical resource. Record review of in-service sign-in sheets, dated 06/13/2025, reflected transfer policy and procedure was reviewed and understanding the Kardex reflected 19 staff participated. Record review of in-service sign-in sheet, dated 06/13/2025, reflected fall management in-service was completed with 6 nurses and 1 ADON. Record review of in-service sign-in sheet, dated 06/13/2025, reflected IJ, details of incident, root cause analysis, resident status and plan of removal was completed with ADM, 2 AITs , ADON and DON by clinical resource. Record review of 11 post-tests and 11 skills check-offs sheets, dated 06/13/2025, reflected staff demonstrated proper transfer skills and returned demonstration of knowledge from in-services. Record review of Resident #1's fall assessment, dated 06/13/2025, reflected Resident #1 was a high risk for falls and regularly incontinent. Record review of Resident #1's pain assessment, dated 06/13/2025, reflected Resident #1 had a dull pain and rated 4/10 at incision site. Record review of Resident #1's re-admission asking assessment reflected Resident #1 had outer right knee had 2 intact sutures, lateral right thigh had 2 intact sutures and right trochanter had 3 intact sutures. Review of Resident #1 elopement assessment, dated 06/13/2025, reflected Resident #1 was a low risk for elopement. Record review of Resident #1's Braden scale assessment, dated 06/13/2025, reflected the resident was a moderate risk for developing pressure sores. Record review of Resident #1's Kardex, dated 06/14/2025, reflected Resident #1 required substantial / maximal assistance staff participation with transfers . The ADM was informed the Immediate Jeopardy was removed on 06/15/2025 at 4:00 PM. The facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that was not immediate jeopardy and a scope of isolated 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 interview and record review the facility failed to ensure that nurse aides were able to demonstrate competency in skill and techniques necessary to care for resident's needs, as identified through resident assessments, and described in the plan of care for 1 of 4 (Resident #1) related to safe transfers. The facility failed to ensure CNA B used the accurate technique to transfer Resident #1 safely (with gait belt, correct positioning and/or two-people) on 06/10/2025. An Immediate Jeopardy (IJ) situation was identified on 06/23/2025. While the IJ was removed on 06/24/2025, the facility remained out of compliance at a scope of isolated with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems . This failure could place residents at risk of avoidable falls, injuries, hospitalization and/or death. Findings include: Review of Resident #1's face sheet dated 06/16/2025 reflected an [AGE] year-old man admitted on [DATE] with discharge day of 06/10/2025 with diagnoses of vascular parkinsonism (disease that is caused by damage to blood vessels in the brain that leads to movement and balance problems that particularly affect the lower body), unspecified atrial fibrillation (irregular or rapid heartbeat), dysphagia (difficulty swallowing), need for assistance with personal care (need for help with activities of daily living), unsteadiness on feet (being unbalanced or unstable while standing or walking), other abnormalities of gait and mobility (abnormal walking pattern), weakness, unspecified intellectual disabilities, developmental disorder of scholastic skills, muscle weakness, and dementia (loss of memory, language, problem-solving and other thinking abilities that interfere with daily life). Review of Resident #1's fall risk evaluation dated 02/04/2025 reflected Resident #1 was a high fall risk with no falls in the past three months. Resident #1 had balance problems while standing / walking. Review of Resident #1's BIMS assessment dated [DATE] reflected a score of 6 which indicated severe cognitive impairment. Review of Resident #1's MDS dated [DATE] reflected Resident #1 required substantial/ maximal assistance (helper does more than half the effort) for chair/bed-to-chair transfers. Further review reflected Resident #1 had no falls since the prior assessment or admission. Review reflected Resident #1 was 228 lbs and 74 inches tall. Review of Resident #1's care plan dated 05/31/2015 reflected Resident had impaired cognitive function with interventions to remember one/two step instructions. Review of Resident #1's care plan dated 12/21/2021 reflected he had a self-care deficit and required substantial/maximal assist staff participation with transfers. Further review reflected Resident #1 was at risk for falls related to gait/balance problems. Review of care plan reflected no information regarding use of gait belt when transferring Resident #1. Review of incident report dated 06/10/2025 at 5:00 AM reflected CNA B stated she helped Resident #1 get ready for the day and she tired to use stand and pivot method to transfer but while doing so Resident #1's leg slid, and she helped the resident slowly to the ground and Resident #1 tried to support himself with his knees. Resident #1 was transferred to the ER for evaluation and treatment. Review of progress note dated 06/10/2025 by LVN A reflected Resident #1 was assisted by CNA B when LVN A saw Resident #1 on the floor. LVN A completed an assessment and completed vitals. Review reflected Resident #1 was transferred to bed. Resident #1 was repositioned and had right hip tenderness noted with limited range of motion and pain level of 10/10. Resident #1 screamed when his right foot was moved but was calm when right leg was at rest. Resident #1's right thigh appeared to be swollen. Reached out to the on call provider and advised Resident #1 be sent to the hospital via EMS. Review of hospital records dated 06/13/2025 reflected Resident #1 sustained a right femoral shaft fracture. Procedure performed was an open reduction and internal fixation of right femur shaft fracture with a cephalomedullary nail (surgically exposing fracture and realigning bone fragments and stabilizing the fracture with a nail inserted in the femur). During an interview on 06/13/2025 at 2:11 PM and 3:05 PM, CNA B stated that she assisted Resident #1 with getting ready for the day on 06/10/2025. CNA B stated that she attempted to transfer Resident #1 and that she did not use a gait belt because the nurse did not tell her she needed to use one with Resident #1. CNA B stated she positioned Resident #1's wheelchair close to his bed and she was to the side and behind him. CNA B stated Resident #1 stood and then fell forward to his knees during the transfer. CNA B stated that Resident #1 went straight down to the floor. CNA B stated that Resident #1 usually stepped and then pivoted to the chair and he usually did most of the work. CNA B stated she usually stood behind Resident #1 for transfers and Resident #1 was the only resident she transferred from behind. CNA B stated that she could find information on the Kardex (nursing tool for patient information) for what the resident needed for assistance during transfers. CNA B stated that her hands were on Resident #1's pants or back. CNA B stated she did not remember if she was on his left or right side but stated she was behind him. CNA B stated Resident #1 sat on the edge of the bed and she usually told him to stand but that day (06/10/2025) he did not stand as usual and when she tried to help him he felt like he was going down. CNA B stated that Resident #1 fell forward after he lifted off the bed and he was standing and then went down with CNA B behind him. CNA B did not state if she checked the Kardex prior to the transfer. CNA B stated she usually got Resident #1 up for the day on her shift and he was usually able to stand and take a step and pivot. During an interview on 06/13/2025 at 2:23 PM, CNA D stated that staff could find transfer requirements on Kardex. CNA D stated that the Kardex told staff if a resident needed a 1 or 2 person transfer or minimum or maximum assistance. CNA D stated that there was not a transfer that would occur where the CNA stood behind a resident. CNA D stated that she stood in front of residents when she assisted them from bed to chair and chair to bed. CNA D stated gait belts should be used during transfers. During an interview on 06/13/2025 at 2:28 PM, the OT stated that Resident #1's transfers fluctuated and sometimes Resident #1 needed more help, but it depended on the day. The OT stated that Resident #1 was on therapy service because of the fluctuation in his transfers. The OT stated that there were not one-person transfers in which the staff would stand behind a resident. The OT stated that the staff would only stand behind the resident if there was another staff member present. The OT stated that a gait belt should be used for all transfers for safety reasons. During an interview on 06/13/2025 at 2:48 PM, CNA E stated that staff were supposed to always use a gait belt when they transferred a resident. CNA E stated staff was supposed to stand in front of residents during a transfer. CNA E stated unless there was another staff member then she would not be behind the residents. CNA E stated that staff viewed the Kardex to show whether a resident needed a 1 or two person transfer or a mechanical lift. CNA E stated substantial / maximal assistance usually meant to bring another staff member with you. During an interview on 06/13/2025 at 2:51 PM, CNA C stated with a little muscle from the CNA Resident #1's wheelchair was positioned on the side of his bed at an angle with his bed rail in reach because Resident #1 utilized them to push up. CNA C stated that Resident #1 needed guidance during the transfer and this included verbal cueing. CNA C stated that a gait belt was required for every transfer with Resident #1. During an interview on 06/13/2025 at 3:31 PM, LVN F stated that during a one-person transfer the staff would be facing the resident and be knee-to-knee or feet-to-feet. LVN F stated that there were no transfers that occurred when a staff was behind the resident. LVN F stated a gait belt should be used at all times during a transfer. LVN F stated the purpose of a gait belt was to ensure you had a good grip on the resident and you did not have to grab the resident's clothing or skin. LVN F stated the risk of transferring a resident without a gait belt was losing balance or grip and a potential fall. LVN F stated it was important to have the correct positioning (being in front of the resident) during a transfer to prevent the resident from losing balance or the staff hurting themselves. During an interview on 06/13/2025 at 3:27 PM, the DON stated that during a transfer that first thing was for staff to use a gait belt. The DON stated that staff were positioned in front of the resident with the staff's foot in between the resident's legs. The DON stated that it was best practice to have a gait belt because staff never knew what could happen. The DON stated that a resident that required maximum assistance definitely needed a gait belt to be used. The DON stated the purpose of a gait belt was for extra support or caution during transfers. The DON stated if staff transferred without a gait belt a lot of injuries could happen. The DON stated there were no transfers that a staff would be behind a resident and every single transfer had the staff in front of the resident. The DON stated if staff were behind a resident they could not see what they were doing. The DON stated staff were observed often and assessed for their transfer skills. The DON stated staff were assessed after hire and from time-to-time and if a concern was raised that someone completed a transfer incorrectly. The DON stated after the aide transferred Resident #1 and fell, they started re-education of staff. The DON stated that when incidents like that happened management wanted to educate so incidents were not repeated. The DON stated that she expected staff to use a gait belt when indicated. The DON stated a gait belt would not be used for a resident who required only supervision and could transfer themselves or walk without assistance from staff, otherwise a gait belt was expected to be used. The DON stated that most CNAs had a gait belt provided to them and after Resident #1 fell staff were informed a gait belt was a part of their uniform. The DON stated that she expected staff to have proper positioning during transfers and that if they were not sure they needed to ask questions. The DON stated the Kardex told the staff what a resident's transfer status was and how many staff were required. The DON stated that staff were reminded to use the Kardex almost daily during the stand-down meeting. The DON stated that she was out on 06/10/2025 and reviewed the progress note on 06/11/2025 about Resident #1's fall and stated that initially she read the aide helped Resident #1 slide down to the floor and she thought that's good she helped him. The DON stated that CNA B stated she (CNA B) transferred Resident #1 and he slid down to the floor. The DON stated that after the initial assessment Resident #1 was transferred to his bed and he started to scream and LVN A saw that his leg was swollen and she reached out to the supervisor and on-call. The DON stated that after she learned Resident #1 had a fracture she began re-education with staff. The DON stated she reviewed what each transfer was and proper transfer and body mechanics. The DON stated she did not ask CNA B if she had a gait belt and did not ask where CNA B was positioned during the transfer. The DON stated she was only able to speak with LVN B. The DON stated that Resident #1 had not had any falls prior to this incident. During an interview on 06/13/2025 at 3:40 PM the ADM stated that he expected staff to transfer residents correctly and there was zero tolerance for incorrect transfers. The ADM stated he was not aware of the specific details of Resident #1's transfer. The ADM stated he expected staff to use a gait belt 100 percent of the time when indicated. The ADM stated the IDT reviewed Resident #1's fall and discussed what could have been done better. The ADM stated he was not aware of the details regarding whether CNA B had a gait belt or where she was positioned when she transferred Resident #1. The ADM stated that he and the DON stressed to staff that they should never be without supplies (including gait belts) and staff could call or text anytime they needed something. During an interview on 06/13/2025 at 4:12 PM, the NP stated that she expected staff to utilize safe transfer techniques. She stated Resident #1 did have intermittent confusion and other diagnoses that made him a fall risk. NP stated not utilizing a gait belt or proper positioning during transfers could obviously result in a fall leading to a fracture. During an interview on 06/23/2025 at 1:47 PM, the DON stated substantial/maximal assistance meant that two staff were required during the transfer. The DON stated when staff reported a resident had a change in level of assistance needed then care plans or Kardex was updated right away. The DON stated skills checks were observed upon hire. The DON stated she came to the building during off hours to check in with staff and observe care. The DON stated staff also had skills check three months after hire. The DON stated if staff expressed concerns or area where they needed more training during their new hire training their training would be extended. The DON stated if a resident required two people for their care then she expected two staff to provide that care. The DON stated the risk of not having another staff if a resident required two people for care was a fall that resulted in an injury. The DON stated staff were trained by a train the trainer method and new staff were paired with another staff and trained by the other staff through on the job training. The DON stated she checked in with staff at the end of their training to ask if they felt comfortable and if they needed any additional training in any area. The DON stated she or the ADON would complete the final skills check before staff were released to work independently . During an interview on 06/23/2025 at 3:45 PM, LVN A stated she was the charge nurse when Resident #1 fell. She stated it was considered a witnessed fall and from what she was told by CNA B, CNA B tried to transfer Resident #1, he missed a step and fell. LVN A stated she was not sure why CNA B transferred Resident #1 by herself. LVN A stated based on what the Kardex had and other the CNA said Resident #1 was a two-person transfer. LVN A stated substantial / maximal assistance was required a two people in the transfer. Record review of CNA B's employee file reflected skills check off was completed for CNA B on 01/10/2025 and 04/09/2025 and included one-person, two-person and hoyer transfers. Record review of in-service, dated 06/11/2025, with subject GGS (functional abilities and goals) reflected it reviewed types of assistance needed for transfer, staff required and reflected CNA B did not complete the in-service as of 06/13/2025. Record review of in-service, dated 06/11/2025, with subject Kardex reflected CNA B did not participate in the in-service as of 06/13/2025. The in-service included the purpose of Kardex and how it was used. Record review of in-service, dated 06/11/2025, with subject of body mechanics reflected CNA B did not participate in the in-service as of 06/13/2025. The in-service included body positioning during transfers. Record review of in-service, dated 06/11/2025, reflected substantial/maximal assistance required two people for transfers. Record review of in-service, dated 06/11/2025, with topic safe resident transfers and handling reflected proper techniques, correct use of patient handing equipment and devices with the goal to ensure resident safety and reduce injury for both residents and staff. Review reflected CNA B completed this in-service as verified by signature and date of 06/11/2025. Record review of the facility's schedule / sign-in sheets for 06/11/2025, 06/12/2025 reflected CNA B was not scheduled to work at the facility. Review of the facility schedule dated 06/13/2025 reflected CNA B was scheduled to return to the facility from 10:00 pm - 6:00 am on 06/13/2025. Record review of the facility's policy titled Quality of Care Transfer of a Resident, Safe with revision date of 05/2025 reflected use good body mechanics at all times and use a gait belt for all transfer if gait belts is indicated for the resident. The policy reflected for one-person transfers, apply gait belt around resident's waist, provide necessary assistance to help the resident stand up. The policy reflected two-person transfers using a gait belt required to apply the gait belt around the resident's wait, use good body mechanics at all times and provide the necessary help f or the resident to stand up with caregivers on both sides of the resident and staff holding the gait belt. This was determined to be an Immediate Jeopardy (IJ) on 06/23/2025. The ADM and DON were notified on 06/23/2025 at 3:45 PM and a template was given. The following Plan of Removal submitted by the facility was accepted on 06/24/2025 at 7:48 AM: Immediate Plan of Removal The facility submits this Plan of Removal to address the Immediate Jeopardy identified, on 6/23/2025. Identification of Others Affected by Alleged Deficient Practice: All admissions and re-admissions have the potential to be affected by this alleged deficient practice. Summary: On 6/13/2025 an abbreviated survey was initiated at the facility. On 6/13/2025 the surveyor provided an Immediate Jeopardy (IJ) that the Regulatory Services has determined that the condition at the facility constitutes an immediate threat to resident health and safety. On 6/23/2025 after review by enforcement, an additional Immediate Jeopardy (IJ) has been cited. The notification of Immediate Jeopardy (IJ) states as follows: F726 - The facility must ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. The facility failed to ensure CNA B used the accurate technique to transfer Resident #1 safely (with gait belt, correct positioning and/or two-people) on 06/10/2025. Resident #1 is an [AGE] year-old man admitted on [DATE] with diagnoses of vascular parkinsonism, dysphagia, need for personal assistance with care, unsteadiness on feet, weakness, other abnormalities of gait and mobility, dementia, and muscle weakness. Resident has a BIMS of 6. Resident #1 sustained a fall on 06/10/2025 resulting in injury to right hip. CNA B reported that resident slid down to knees while helping resident get out of bed after personal care. Resident #1 was admitted to the hospital and underwent subsequent open reduction internal fixation of right hip fracture on 06/10/2025. CNA B reported to surveyor on 06/13/2025 that she did not utilize gait belt and was standing behind the resident during the transfer. Resident #1 returned to the facility on [DATE]. Action: Resident #1 was re-admitted on [DATE] at 18:53 PM , at the time of readmission-these assessments were completed: Initial admission assessment, pain assessment, fall risk assessment, skin assessment, elopement, Braden scale, functional observation GG assessment, and initial care plan Start Date: 06/13/2025 Completion Date: 06/13/2025 Responsible: DON/Designee Action: Individual in-service with CNA B on transfer policy and understanding the Kardex. CNA B provided return demonstration competency on use of gait belt and a safe resident transfer. CNA B suspended effective 6.14.2025 and subsequently terminated on 6.18.2025. Start Date: 06/13/2025 Completion Date: 06/18/2025 Responsible: Director of Nurses/Designee Start Date: 6/13/25 Completion Date: 6/14/25 Responsible: Executive Director, IDT, DON, Clinical Resource, MSN/Ed, RN Action: Medical Director and Nurse Practitioner notification of immediate jeopardy. Details of incident, root cause analysis, resident status, and plan of removal discussed. Start Date: 6/13/25 and 6/23/25 Completion Date: 6/13/25 and 6/23/25 Responsible: Executive Director Action: Inservice Leadership Team, including but not limited to: Executive Director, Administrators in Training, Therapy Program Manager, Director of Nurses, Assistant Director of Nurses, and Staffing Coordinator on immediate jeopardy, details of incident, root cause analysis, resident status, plan of removal. Inservice Leadership Team on the following: Fall assessment performed by nursing staff will include: completion of SBAR, not moving resident if injury suspected, activation of 911, provider notification, DON notification, representative notification, change of condition completion, progress note documentation Transfer policy, use of gait belt, safety with transfers, identification of resident transfer requirements through use of Kardex Understanding the Kardex: how to access Knowledge retention demonstrated with post-test Start Date: 06/13/2025 Completion Date: 06/13/2025 Responsible: Clinical Resource, MSN/Ed, RN Action: Audit 100% care plans of all active residents to confirm resident transfer status includes number of staff members required for safe transfer on the care plan and Kardex. No changes to care plans were indicated. All Kardex were up to date and current for resident transfer needs. Start Date: 6/13/25 Completion Date: 6/13/25 Responsible: DON/Designee/Clinical Resource, MSN/Ed, RN Action: Inservice DON on the following: Fall assessment: completion of SBAR, not moving resident if injury suspected, activation of 911, provider notification, DON notification, representative notification, change of condition completion, progress note documentation Transfer policy, use of gait belt, safety with transfers, identification of resident transfer requirements through use of Kardex Understanding the Kardex: how to access Knowledge retention demonstrated with post-test Start Date: 6/13/25 Completion Date: 6/13/25 Responsible: Clinical Resource, MSN/Ed, RN Action: Inservice 100% nursing and nursing leadership staff on the following: Fall assessment: completion of SBAR, not moving resident if injury suspected, activation of 911, provider notification, DON notification, representative notification, change of condition completion, progress note documentation Transfer policy, use of gait belt, safety with transfers, identification of resident transfer requirements through use of Kardex Understanding the Kardex: how to access Knowledge retention demonstrated with post-test and return demonstration Start Date: 6/13/25 Completion Date: 6/16/25 Responsible: DON/Designee Action: Inservice 100% CNA and therapy staff (including all PRN staff, new hires, and agency staff) on the following: Transfer policy, use of gait belt, safety with transfers, identification of resident transfer requirements through use of Kardex Understanding the Kardex: how to access Knowledge retention demonstrated with post-test and return demonstration Start Date: 6/13/25 Completion Date: 6/16/25 Responsible: DON/Designee Action: Ad hoc QA meeting. Attendees will include ED , DON, Clinical Resource, Cluster Partners, Medical Director. Meeting will include the Plan of Removal and inventions. Start Date: 6/13/25 Completion Date: 6/13/25 Responsible: Executive Director Action: Ad hoc QA meeting. Attendees will include ED, DON, Clinical Resource, Cluster Partners, Medical Director. Meeting will include the Plan of Removal and interventions. Start Date: 6/23/25 Completion Date: 6/23/25 Responsible: Executive Director Systemic Change to Prevent Re-Occurrence: DON/Designee and IDT will ensure safe transfer requirements are assessed upon admission and added to the care plan and Kardex for all residents. DON/Designee and IDT will ensure safe transfer requirements are updated on the care plan and Kardex for any resident that has had a change in transfer status. Start Date: 6/13/25 Completion Date: Ongoing Monitoring of the POR on 06/24/2025 included the following: A telephone call was attempted to CNA B on 06/14/2025 at 3:08 PM with message requesting for call back. No message was returned by CNA B . During an interview with the ADM and the DON on 06/14/2025 at 10:29 AM, it was stated CNA received in-service and skills check off prior to her shift on 06/13/2025. CNA B was suspended at 2:00 PM on 06/14/2025 after ADM and DON decided to suspend CNA B until a formal corrective action plan could be developed and implemented. During an interview on 06/15/2025 at 11:56 AM, the DON stated the audit was completed and no changes were identified during the audit. Observation and interview with Resident #1 on 06/14/2025 at 1:15 PM revealed Resident #1 laid in bed with call light in reach. Resident #1 responded to simple questions with garbled speech. Resident #1 denied any pain and that it was controlled. During an interview on 06/24/2025 at 12:59 PM, the ADM stated he was not able to get ahold of the 3 suspended staff to in-service them . The ADM stated they were not on the floor until they got the in-service. The ADM stated he had not been able to contact the staff to terminate them. During interviews conducted from 06/14/2025 - 06/15/2025 and on 06/23/2025 with 8 CNAs, 3 LVNs, ADM, DON and 2 AITs reflected staff received in-services either 06/14/2025 or 06/15/2025 prior to their shifts. Interviewed staff stated they were trained on how to safely transfer a resident from bed-to-chair/chair-to-bed, how to access the Kardex to review transfer status of a resident, use of gait belts (required to have as part of uniform) and to use when indicated when transferring a resident . Interviewed staff stated they took a posttest and demonstrated skills check off on transfers. During interviews with staff in-training on 06/24/2025, 3 CNAs stated they were currently in-training. CNAs stated they started at the facility between 06/19/2025 and 06/21/2025. CNAs stated they received in-services on using the Kardex, levels of transfer status and how many staff are involved in each transfer and to use a gait belt for each transfer . Interviewed staff were able to stated a gait belt should be used for each transfer, that staff should stand in front of the resident for transfers (except for mechanical lift transfers) and the Kardex was where to find how many staff were needed for a transfer, how much assistance was needed for a transfer and if a resident required a mechanical lift for a transfer. Staff stated they received the in-service after they started, but before they started their shift working on the floor at the facility over the phone and again in-person. During an interview with the DON on 06/24/2025 at 12:37 PM, the DON stated when a new admission arrived an initial assessment was conducted by the nurse or therapy to determine transfer status. The DON stated the nurse completed the assessment until therapy was able to come in and assess the resident. The DON stated periodically information was gathered by staff when they observed a change in a resident's care needs or abilities to participate in transfer during care. The DON stated if a staff reported a resident required more help, transfer status was changed to reflect assistance needed immediately in the Kardex. During an interview with the ADM on 06/24/2025 at 12:50 PM, the IDT was responsible to ensure transfer needs were updated in the Kardex for any changes and new admission . The ADM stated leadership staff were responsible to train any new hires on transfer required and the Kardex. Record review of in-service sign-in sheets, dated 06/13/2025, reflected CNA B participated in the in-service on transfer policy and understanding the Kardex. CNA B provided return demonstration competency on use of gait belt and safe resident transfer and knowledge demonstrated via post-test, dated 06/13/2025. Review of CNA B's employee file reflected a skills competency was completed on 04/09/2025. Record review of counseling/disciplinary notice, dated 06/14/2025, reflected CNA B was suspended pending investigation and CNA B was informed via phone call. Record review of the QAPI meeting sign in sheet and agenda, dated 06/23/2025, reflected MD and NP were notified and meeting was held. Record review of text message from ADM to MD and NP, dated 06/23/2025, reflected MD and NP were notified of IJ. Record review of root cause analysis, dated 06/13/2025, reflected the incident with CNA B was an isolated incident after she transferred Resident #1 alone and without a gait belt. CNA B was suspended on 06/14/2025. Record review of care plan resident roster audit documentation, dated 06/13/2025, reflected all resident's charts were audited and Kardex and care plan were updated as needed. Record review of in-service sign-in, dated 06/13/2025, reflected transfer policy and procedure was reviewed, understanding the Kardex, fall management was completed with DON by clinical resource. Record review of in-service sign-in sheets, dated 06/13/2025, reflected transfer policy and procedure was reviewed and understanding the Kardex reflected 19 staff participated. Record review of in-service sign-in sheet, dated 06/13/2025, reflected fall management in-service was completed with 6 nurses and 1 ADON. Record review of in-service sign-in sheet, dated 06/13/2025, reflected IJ, details of incident, root cause analysis, resident status and plan of removal was completed with ADM, 2 AITs , ADON, and DON by clinical resource. Record review of 11 post-tests and 11 skills check-offs sheets, dated 06/13/2025, reflected staff demonstrated proper transfer skills and returned demonstration of knowledge from in-services. Record review of Resident #1's fall assessment, dated 06/13/2025, reflected Resident #1 was a high risk for falls and regularly incontinent. Record review of Resident #1's pain assessment, dated 06/13/2025, reflected Resident #1 had a dull pain and rated 4/10 at incision site. Record review of Resident #1's re-admission asking assessment reflected Resident #1 had outer right knee had 2 intact sutures, lateral right thigh had 2 intact sutures and right trochanter had 3 intact sutures. Review of Resident #1 elopement assessment dated [DATE] reflected Resident #1 was a low risk for elopement. Record review of Resident #1's Braden scale assessment, dated 06/13/2025, reflected resident was a moderate risk for developing pressure sores. Record review of Resident #1's kardex, dated 06/24/2025, reflected Resident #1 required mechanical lift transfer with 2 person assistance . Record review of Resident #1's care plan and 5 other resident care plans reflected transfer status included

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on 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 1 of 10 residents (Resident #1) reviewed for accidents and supervision. The facility failed to prevent Resident #1 from eloping on 09/27/2024. The non-compliance was identified as PNC. The facility had corrected the non-compliance on 9/27/2024 before the investigation/complaint began. This deficient practice could place residents who were elopement risks at-risk of harm, serious injury, or death. The findings were: During an interview on 11/20/24 at 12:23 PM with Resident #1, he stated he didn't remember what he was going to HEB for. He stated he was going for a machine for his head. Resident #1 was advised there were no machines for his head there and he stated well he doesn't know what he was there for. Record review of Resident # 1's face sheet, dated 11/27/2024, revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnosis that includes Nontraumatic Intracerebral Hemorrhage In Hemisphere, Subcortical (a bleeding into the brain that can occur in the cerebral cortex or basal ganglia), Essential (Primary) Hypertension ( a type of high blood pressure that doesn't have an identifiable cause), Contusion and Laceration of Cerebrum, Unspecified, Without Loss of Consciousness, Sequela (a medical diagnosis indicating a brain injury where there was bruising and tearing of the cerebral tissue, but the person did not lose consciousness), Cerebral Infarction, Unspecified (a medical condition where a blood vessel supplying blood to the brain is blocked, resulting in brain tissue damage), Hyperlipidemia, Unspecified (a common condition where there are too many fats in the blood. It's usually asymptomatic but can lead to serious health problems if left untreated), Other Psychoactive Substance Abuse, Uncomplicated, Dysphasia, Unspecified, Personal History of Other Mental and Behavioral Disorders (Mental and behavioral disorders due to psychoactive substance use. Overview . - Mental and behavioral disorders due to multiple drug use and use of other), Cerebral aneurysm, Nonruptured (a bulge in a brain artery that hasn't burst yet), Hemiplegia and Hemiparesis following other Nontraumatic Intracranial Hemorrhage Affecting Right Dominant Side (a person has experienced weakness or paralysis on the left side of their body due to a brain bleed that occurred on the right side of the brain, specifically in the dominant hemisphere). Record review of Resident's # 1 admission MDS assessment, dated 10/15/2024 revealed a BIMS score of 05 means sever cognitive impairment. Review of Resident #1's care plan dated 11/21/2024 revealed no evidence of wandering or risk for elopement. Record review of witness statement from LVN A dated 9/27/2024 stated she saw Resident #1 all day and he seemed normal. Around noon she noticed that Resident #1 wasn't in the dining room for lunch like he normally is. LVN A stated she didn't see him in his room or in the back patio, so she let the DON and Administrator know that she did not know where Resident #1 is. LVN B told LVN A that she received a call from her family member that someone got kicked out of the store for trying to shoplift a bunch of steaks. CNA A advised LVN A she heard Resident #1 talking about getting some steak and asking his roommate for directions. LVN A advised the DON and the Administrator about the conversation she had with CNA regarding Resident #1. LVN A stated when Resident #1 returned to the building she completed an assessment on him and provided the report to EMS when they came and picked Resident #1 up around 2 PM. Record review of witness statement from LVN B dated 9/27/2024 stated she saw Resident #1 moving around the building as normal. She stated she did not see him trying to leave the building at all. She stated after they started the code pink to search the building for him, she received a call from her family member around 12:45pm that someone got kicked out of the store for trying to shoplift some steaks and she mentioned it to LVN A and CNA A. That is when CNA A stated she overheard Resident #1 asking his roommate how to get to the local grocery store so he can get some steaks. She notified the DON and the Administrator immediately about the information. During an interview on 11/21/24 at 9:35 am with CNA A stated Resident #1 took a shower, and she heard him say he was going to get him some steaks. She stated Resident #1's roommate can come and go, and she figured the roommate was going to get the steak. She went and got the iron, and she asked him where he was going looking all sharp. And he said he was going to get him some steaks. Once Resident #1 finished dressing for the day, she made his bed, and then she went looking for him to give him his tray. She stated he waited until someone came in and snuck out the front door. Resident #1 went to the local grocery store and stole $230 worth of steaks. She stated that LVN B's family member worked at the local grocery store, and she called her and stated someone was in there trying to steal steaks. When LVN B's family member described him, CNA A realized it was him. CNA A said when he got back, Resident #1 was evaluated, and they sent him to the hospital to make sure he was alright. CNA A stated they were in-serviced on Elopement and what to do in case of an elopement, what code pink means and who to notify as soon as they realize the resident is missing. During an interview on 11/20/24 at 12:15 PM with Reception stated Resident #1 got out in the front while she was helping someone else. She stated she did not realize he slipped out. She stated there was a lot going on that day. Receptionist stated a code pink was called. An unknown staff member brought him back from the local grocery story. After Resident #1 returned, EMS was called to bring him to the hospital to have him checked out. Resident #1 was checked out and he was fine. Receptionist denies he tried to get out since being back. She stated he only goes by the door when he is going to a doctor's appointment. The ADM and DON added him to the elopement binder, they went over the elopement process, and they have been doing training every week. During an interview on 11/20/24 at 2:55 PM with DON stated Resident #1 was sitting in the building and a nurse stated she could not find him. DON stated a code pink was called. DON stated she and the ADM went driving around to find him. DON stated someone called and stated they saw someone that looked like a resident. She stated she and the ADM drove by the local grocery store and picked him up. Resident #1 stated he fell while he was out there. Resident #1 denied wanting to go to the hospital, but he was sent anyway to ensure he was alright. Resident #1 returned to the facility from the emergency room with no injuries noted on the paperwork. The DON was advised Resident #1 walking out the door when hospice walked in. DON stated he knows when people come in and out. He was able to get out with the little crack in the door. DON stated he has not tried to escape since. DON stated his family was called and they came down and had a care plan. During an interview on 11/20/2024 at 2:38pm with ADM stated there were two hospice staff that were waiting at the front door. Resident #1 was able to get out the front door when they were coming in. Resident #1 walked to the local grocery store. Resident #1 said that he went to the store to get some steaks. Staff found Resident #1 about an hour later and returned Resident #1 to the facility. Staff were in-serviced on elopement of residents. Resident #1 has not tried to elope since then. Record review of policy Wandering/ Elopement revised December 2023 revealed: It is policy of the facility to provide a safe environment, as free of accidents as possible, for all residents through appropriate assessment, interventions, and adequate supervision to prevent accidents related to unsafe wandering or elopement while maintaining the least restrictive manner for those at risk for elopement. The facility course of action prior to surveyor entrance included: Search of facility and surrounding areas. Checked and accounted for all residents. Staff in the daytime will make rounds every two hours and at nighttime, the staff will make rounds every four hours to ensure the residents are counted for and safe. Observed all exit doorways and alarms in complete working order. Resident #1 was sent to the hospital for ER for evaluation after being located. Medical records review reveled Resident #1 returned to the facility with no issues or follow up appointments. Resident placed on 1:1 supervision after being located. CNA A was assigned to do 1:1 with Resident #1. The staff was in-serviced on Elopement policies and procedures process; ensure residents sign in/out; how to fill out an elopement assessment; informed elopement binders are located at each nurses station on 9/27/2024. Elopement drill was performed. The faculty and staff performed a drill showing they can perform the elopement protocol. The staff stated when a resident is missing, a code pink is called. Then they will start a search of all rooms and once that room is checked, they will place the garbage can outside the door to confirm that room was already checked. Faculty and staff search inside and outside the facility. The facility contacted the alarm company, which a test operation was perform on the doors, locks, and alarms on 09/27/2024. Observation was done by observing the doors which were pushed and left open for 15 seconds and the alarm sounded. The code for the doors were changed. Pink binders were placed at the nurses stations. Once they cannot find the resident, they will call the police and file a missing report. Doors were checked. The alarm company came. Prior to the survey the facility implemented: 1:1 monitoring of the resident until further assessment (target date 1/13/2025). Assess for fall risk. Provided structured activities walking inside and outside, toileting, reorientation, strategies including signs, pictures, and memory boxes. Psych evaluation. There was another resident listed in the elopement binder, but I did not collect information for that resident. Everything was completed on 09/27/2024. Upon admission Resident #1 was considered a low risk. (4) but after the elopement, his score is now at a high risk (11). Resident #1 score is currently an 11. He is in the pink binder along with another resident. The 2 residents are in the pink elopement binder and the care plan for Resident #1 is updated. Interviews were conducted with employees who consisted of LVN's (2), Staffing Coordinator/Med Aide (1), CNAs (9), Receptionist (1), and Resident #1 on 11/20-21/2024 from 10:00 am to 11:30 am and revealed they had received in-services on Elopement Response, all were able to state the key elements of the Emergency response plan and elopement policy which was included.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents were free from abuse for 1 (Resident #1) of 5 residents on 200 Hall. On 2/23/2023 at approximately 11:00pm Resident # 1 was physically assaulted (choked) by staff causing a skin tear to Resident # 1's neck that required medical treatment. This failure resulted in an identification of an (IJ) Immediate Jeopardy on 2/24/2023. The IJ Immediate Jeopardy template was provided to the ADM on 2/25/2023 at 5:45pm. While the (IJ) Immediate Jeopardy was removed on 2/25/2023 at 4:30pm, the facility remained out of compliance at a scope of actual harm with potential for more than minimal harm that is Immediate Jeopardy because all staff had not been trained on Abuse/Neglect This failure placed all residents at risk for abuse. Findings included: Review of Resident #1's face sheet dated 2/25/2023, reflected Resident # 1 was a 78- year- old man, admitted to the facility on [DATE]. Resident # 1 was diagnosed with acute respiratory failure (difficulty breathing on own), Atherosclerotic Heart disease (build- up of cholesterol plaque in the arteries causing obstruction of blood flow), Emphysema (lung condition that causes shortness of breath), Esophageal obstruction (the malformation in which the esophagus is interrupted and forms a blind-ending pouch rather than connecting normally to the stomach), Chronic pulmonary disease (lung disease that block the airflow making it difficult to breathe). Review of Resident #1's Quarterly MDS dated [DATE], reflected Resident # 1 had a BIMS score of 04, not cognitive to understand and answer questions, section G of MDS reflected Resident # 1 was total dependent for bathing and toileting one person assist. Review of Resident # 1's care plan dated 1/17/2023, reflected Resident # 1 had the following goal: Resident # 1 will remain free from skin breakdown due to incontinence and brief use through the review date. The facility had the following interventions in place: 1. Intervention: Check as required for incontinence, wash, rinse, and dry perineum and change clothing PRN (as needed) after each episode. 2. Toilet use: totally dependent on staff for toilet use Review of progress note dated 2/23/2023 by LVN A, reflected the following: This nurse was called by CNA stating that this resident was wanting to speak to the nurse. When I walked into the room, I could see that the resident was bleeding on the right side of his neck. Resident is stating that the CNA had choked him with both hands and that she had scratched the side of his neck when she let him go. Resident with a large skin tear on the right side of his neck which is approximately 2 inches by 1 which continued to bleed for about 5 minutes. S/T (skin tear) is cleaned with Wound cleaner and triple antibiotic ointment placed on S/T (skin tear) and covered with dressing. Resident is extremely upset. He states that she cursed him out d/t (due to) resident asking can A to change his brief. Resident asking for us to call the police, so that he may press charges. During an interview on 2/24/2023 at 3:25pm with Resident # 1. Resident # 1 stated, last night Resident # 1 unable to give specific time of incident, CNA A had just changed his brief and was providing care to his roommate. He stated before CNA A left the room he asked if she could change him again, because he had another bowel movement. Resident # 1 stated CNA A got upset and started hitting him with his call light, he stated he had to put his arm up to shield his face from getting hit. Resident # 1 stated CNA A then grabbed him by the throat, he stated he could not breathe, he stated she grabbed him with both hands. Resident # 1 stated CNA A scared the hell out of him he stated he had never had anything like this ever happen to him. Resident # 1 stated the facility called the police and he made a report about the incident. He stated he has had problems with CNA A before but stated he let it go, when he asked her to do something. Resident # 1 stated he did let staff know when this incident happened. He stated CNA A caused the injury to the right side of his neck. Resident # 1 stated he told the nurse that was on duty and asked her to call the police so he could file charges. Resident # 1 stated LVN A contacted the police, and he made a report. Resident # 1 stated LVN A cleaned his neck and put a bandage on his neck. Observation on 2/24/2023 at 3:30pm of Resident #1's injury. LVN C, completed wound care for Resident #1. Resident # 1 was observed to have an open skin tear to the right side of his neck, the wound was open, red and bloody, the skin around that side of the neck appeared to be purplish in color. LVN C, cleaned the wound and placed a bandage back over the wound. The left side of Resident # 1's neck was observed and front of neck, the neck was red however did not show any bruising or injuries. LVN C, stated he was not on duty when the incident occurred, he stated he heard about the incident when he arrived at work the following day. LVN C stated he had been trained on Abuse/Neglect and reported the ADM was the abuse/neglect coordinator. During a phone interview on 2/24/2023 at 2:30pm with CNA A, stated she worked the 6pm to 6am shift the night of 2/23/2023. CNA A stated was could not remember the time she provided care for Resident # 1and his roommate. CNA A stated Resident # 1 continued to ring his call light stating that he needed his brief changed. She stated she reminded Resident # 1 that he did not need his brief changed, she denied yelling, cursing, or hurting Resident # 1. She stated after she advised Resident # 1 that he did not need his brief changed, she stated he requested she get the nurse on duty. CNA A stated she could not remember the time she provided care for Resident # 1 and his roommate she stated she just remembers she was advised by the other charge nurse of duty LVN B that she needed to leave. During a phone interview on 2/24/2023 at 2:40pm with POA(Power of attorney), stated Resident # 1 contacted him very upset and was not able to speak because he was so upset. He stated Resident # 1 stated CNA A went off on him when he asked to be changed, he stated they had a verbal confrontation. POA (Power of attorney) stated Resident # 1 stated CNA A, started choking him and he could not breathe, yell out and thought he was going to die. POA (Power of attorney) stated the facility called the police and a report was filed. POA (Power of attorney) stated the ADM contacted him and apologized and advised him that CNA A had been terminated. During a phone interview on 2/24/2023 at 4:59pm with LVN A, stated she was on duty the night of the incident 2/23/2023. When asked LVN A stated she could not remember the exact time of the incident. LVN A stated there was a commotion in the hall and stated CNA A advised her that Resident # 1 wanted to speak with a nurse. She stated when she went into Resident # 1's room she noticed that Resident # 1 was bleeding on the right side of his neck. LVN A stated Resident # 1 stated to her that CNA A choked him, and he could not breathe she stated Resident # 1 was very shook-up. LVN A stated the resident wanted to call the police and file charges, so she called the police, ADM, and DON. LVN A stated she advised CNA A that she could not go back into Resident # 1's room. LVN A, stated while she provided care to Resident # 1 cand calmed him down, she stated LVN B spoke with ADM via phone, and she terminated CNA A. LVN A reported that she had been previously trained on Abuse/Neglect she stated the ADM was the abuse/neglect coordinator. LVN A stated she was advised that once she returned to work that she would be re in serviced on abuse/ neglect. In an interview on 2/24/2023 at 3:55pm with SW, stated she spoke with Resident # 1 regarding the incident. SW stated Resident # 1 advised her that CNA A put her hands around his neck and choked him, he stated he was scared. SW stated she had been checking on Resident #1 since the incident occurred. SW stated she had been trained on abuse/neglect previously and stated the ADM was the abuse/neglect coordinator. During an interview on 2/24/2023 at 6:20pm with Resident # 2, stated he was the roommate of Resident # 1 before he was moved the next morning. Resident # 2 stated Resident # 1 and CNA A got into it some kind of way, and she ended up with her hands on Resident # 1. Resident # 2 stated he could not see that well and it happened so fast. He stated Resident # 1 had marks on his neck. Resident # 2 stated CNA A had never hit or hurt him. During an interview on 2/24/2023 at 6:30pm with Resident #3, stated her room is across the hall from Resident # 1. Resident #3 stated Resident # 1 wanted to be changed and CNA A stated, I already changed you MF (mother fucker), she stated CNA A was yelling, she stated CNA A got fired. Resident # 3 stated CNA A never yelled, hurt, or hit her. During an interview on 2/24/2023 at 7:00pm with Resident # 4, stated she heard CNA A yelling and cursing at another resident, but never at her. Resident # 4 stated when she asked CNA A to close her window blinds, she stated CNA A told her to close them herself. She stated CNA A had never hit, hurt or yelled at her. During an interview on 2/24/2023 at 4:45PM with ADM, stated he got the call about the incident the nurse on duty immediately sent CNA A home and was advised that she was terminated. ADM stated, they had not started their investigation of the incident because it had just happened. ADM stated he did speak with Resident # 1 and his POA (Power of attorney) and apologized and advised them that CNA A had been terminated. ADM stated all staff are trained on abuse/neglect when they are hired. ADM stated he had been trained on abuse/neglect and reported that CNA A must have a bad day. ADM stated no Review of facility Abuse/Neglect policy dated 11/28/2017, reflected Each Resident has the right to be free from abuse, neglect. Abuse -willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, or mental anguish. Review of QAPI - (Quality Assurance and Performance Improvement) dated November 2022- February 2023 completed monthly. This failure resulted in an identification of an (IJ) Immediate Jeopardy on 2/24/2023. The IJ Immediate Jeopardy template was provided to the ADM on 2/25/2023 at 5:45pm. While the (IJ) Immediate Jeopardy was removed on 2/25/2023 at 4:30pm, the facility remained out of compliance at a scope of actual harm with potential for more than minimal harm that is Immediate Jeopardy because all staff had not been trained on Abuse/Neglect A Plan of Removal was first submitted by the ADM on 2/24/2023 at 8:34pm. The Plan of removal accepted on 2/25/2023 at 1:24pm. Plan of Removal Immediate Plan of Removal The facility submits this Plan of Removal to address the Immediate Jeopardy identified on 2/24/23. Identification of Others Affected by Alleged Deficient Practice: All residents have the potential to be affected by this alleged deficient practice. Summary: Per the IJ (Immediate Jeopardy) template, the facility failed to ensure the resident was free from abuse. Immediate Action Taken: 1. The Medical Director was notified on 2/24/23. 2. In-service on Abuse, Neglect, and Exploitation and Resident Rights and quiz started on 2/24/23 with staff in the facility by Administrator, DON, or designee. Quizzes are given after the in-service is conducted. Before taking assignment after clocking in, each employee will be in-serviced prior to resident care. Completion of training will be 2/25/23 and those on leave have been contacted and instructed to complete training prior to shift. HR/designee will be responsible for monitoring compliance. Monitoring to take place daily by reconciling the schedule with the employee roster. 3. Social Services will be responsible for evaluating resident for emotional trauma with completion date of 2/25/23. Social Services will complete trauma assessment and complete social services UDA (trauma assessment). If trauma is noted, psychology services will be offered within seven days and any interventions they deem appropriate will be implemented immediately. DON/designee will ensure this happens by conducting a chart review and reviewing orders to ensure interventions are in place. 4. Social worker/designee will conduct safe surveys (a tool used to determine if resident feels safe in a facility) on all residents with a BIMs score of 12 or greater with completion date of 2/25/23. DON/designee will review all safe surveys and compare against roster of residents to ensure completeness. 5. Social worker scheduled psychology services ervices provider] for Resident #1 that took place on 2/25/23 at 10 am. DON/designee will verify it is completed by reviewing chart notes from psychology. 6. Charge nurse to perform skin assessments for all residents on 200 hall with a BIM of 11 or less and these will be completed by 2/25/23. DON/designee will review all skin assessments and compare against roster of residents to ensure completeness. Systemic Change to Prevent Re-Occurrence 1. Administrator and DON in-serviced all staff on Abuse, Neglect and Exploitation and Resident Rights. Staff to be in-serviced on Abuse, Neglect and Exploitation and Resident Rights upon hire, periodically with any allegation of abuse and annually starting on 2/24/23 as a permanent part of the new hire training and will be ongoing. In-services began on 2/24/23 and will be completed on 2/25/23. All staff on leave have been contacted and instructed to complete training prior to working assigned shift. HR will ensure compliance with in-servicing. 2. The regional RN resource in-serviced and quizzed Administrator and DON on Abuse, Neglect and Exploitation and Resident Rights on 2/24/23. Monitoring to Ensure Ongoing Compliance 1. All staff will be in-serviced regarding Abuse, Neglect, Exploitation and Resident Rights upon hire, annually, and as needed by administrator/DON/designee starting on 2/24/23 and will be ongoing. 2. The Abuse Coordinator will provide a summary of any investigations related to Abuse, Neglect and Exploitation and Resident Rights monthly at the QAPI meeting for review for 90 days. Monitoring of Plan of removal on 2/25/2023 is as follows: 1. 2/25/2023 - Interview with ADM at 3:00pm reported he texted the MD (medical director) regarding the incident on 2/24/2023 and advised of the Immediate Jeopardy. 2. 2/25/2023- Reviewed in-service and quizzes regarding: Abuse/Neglect and Exploitation and Resident Rights 73 staff have completed this training and taken the skills test. List verified against staff roster. 3. 2/25/2023- Review of psychologist progress note dated 2/25/2023, reflected she completed assessments for the resident and other residents today. She stated her information has not been entered into the system at this time but should be entered tomorrow. The resident accepted the psychological services. 4. 2/25/2023 - Review of safe surveys completed and reviewed in binder to assess if the resident has been threatened, mistreated by staff, if they feel safe, do they feel comfortable reporting their concerns, and if they know who to report abuse/neglect to. Verified against resident roster surveys completed. 5. 2/25/2023- Interview with social worker at 3:10pm stated she continues to follow-up with the resident since the incident. She stated her assessment is in Point Click Care under the progress notes. 6. 2/25/2023- Reviewed all skin assessments completed for residents on 200 hall with a BIMS of 11 or less. Verified using roster and Point Click Care system completed. Systematic Change to Prevent Re-Occurrence monitoring completed 2/25/2023: 1. 2/25/2023- reviewed Administrator and DON in-serviced staff currently working. 2. 2/25/2023- reviewed - Administrator and DON were in-serviced on Abuse/Neglect, Exploitation and Resident Rights, skills test completed by RN, Clinical Resources Monitoring to Ensure Ongoing Compliance completed on 2/25/2023: 1. Reviewed in-services dated 2/24/2023 completed by staff Abuse, Neglect, Exploitation and Resident Rights 2. Reviewed of QAPI (Quality assurance performance improvement) dated 2/25/2023. In an interview on 2/25/2023 at 12:00pm with Resident # 5, reported the night of the incident, he asked CNA A if she could move his roommate over because he was blocking the door and he could not get his wheelchair through the door. Resident # 5 stated, CNA A got upset with him and cursed at him and called him some names, he stated she also threw a cup of water on him. Resident # 5 stated he did let the staff on duty know and the ADM contacted him that night and advised him that CNA A was terminated. Resident # 5 stated he does feel safe now that she is gone. In an interview on 2/25/2023 at 12:15pm with Resident #1, stated he felt safe, now that the staff is no longer at the facility. He stated he just never had anything like that happen to him before and it scared him. In an interview on 2/25/2023 at 12:20pm with Resident # 6, stated things have been going ok with him. Stated the staff had been nice and helpful to him, stated he did feel safe. Resident # 6 stated no one has ever hit or hurt him. In an interview on 2/25/2023 at 1:00pm with CNA B, stated she had been trained on Abuse/Neglect/ and Exploitation. CNA B stated who the abuse/neglect coordinator was and when to report. CNA B stated she understood the expectation of client care. In an interview on 2/25/2023 at 1:10pm with CNA C, stated she had been trained on Abuse/Neglect/ and Exploitation. CNA C stated who the abuse/neglect coordinator was and when to report. CNA C stated she understood the expectation of client care. In an interview on 2/25/2023 at 1:20pm with LVN B, stated she had been trained on Abuse/Neglect/ and Exploitation. LVN B stated who the abuse/neglect coordinator was and when to report. LVN B stated she understood the expectation of client care. In an interview on 2/25/2023 at 1:30pm with LVN C, stated she had been trained on Abuse/Neglect/ and Exploitation. LVN C stated who the abuse/neglect coordinator was and when to report. LVN C stated she understood the expectation of client care. In an interview on 2/25/2023 at 3:00pm with ADM, he expected that all staff would provide quality care to each resident at facility. He stated he expected all staff to adhere to the abuse/ neglect policy and procedures at all times. He stated as the ADM, when abuse/neglect is reported he would address it immediately and ensure the safety of all residents.