**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure that each resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 2 (Residents #1 and #2) of 12 residents reviewed for resident to resident altercations. The facility failed to prevent Resident #2 from being abused when Resident #1 punched him and knocked him on the floor, resulting in pain. Staff failed to notify the ADM, who was the abuse coordinator of the incident. This failure resulted in an IJ being identified on 07/22/25. The IJ template was provided to the facility on [DATE] at 6:05 p.m. While the IJ was removed on 07/23/25, 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 that is not immediate jeopardy because of the facility's need to evaluate the effectiveness of the corrective systems. These deficient practices could place residents at risk of abuse, neglect, change in condition, and receiving untimely care and services. Review of Resident #1's admission Record, dated 07/22/25, reflected he was a [AGE] year-old male who was admitted to the facility on [DATE] and had an RP. Resident #1 had medical diagnoses including late onset Alzheimer's disease (a progressive neurodegenerative disorder that primarily affects memory, thinking, and behavior), dementia (a general term for a decline in mental ability, severe enough to interfere with daily life), and unsteadiness on feet. Review of Resident #1's Quarterly MDS, dated [DATE], reflected he had a BIMS score of 4/15, which indicated he had severe cognitive impairment. Resident #1 also had a fluctuated presence of inattention and disorganized thinking behaviors. Resident #1 had no other noted behavior symptoms. Resident #1 also had no wandering behaviors noted. Review of Resident #1's Care Plan, dated 05/05/25, reflected no notes related to aggression and other behaviors. Resident #1 had impaired cognitive function/dementia or impaired thought process related to Alzheimer's dementia. All staff was required to keep his routine and caregivers consistent to decrease confusion, administer medications as ordered, ask yes/no questions to determine his needs, and break tasks one step at a time. There was no other interventions noted. Resident #1 was also at risk for elopement and/or wandering with unsafe boundaries related to his dementia. Nursing staff and the SW was required to assess his continued need for residing in the memory care/secure unit and identify exit seeking patterns and intervene as appropriate to minimize behavior. There was no other interventions noted. Resident #1 also had a communication problem related to his Alzheimer's dementia. Nursing staff was required to anticipate and meet his needs, notify the MD PRN for changes in communication, and encourage him to continue stating thoughts even if he was having difficulty. There was no other interventions noted. Review of Resident #1's Progress Notes reflected:-A nursing progress note by LVN A on 05/27/25 at 11:38 a.m., While taking BS before lunch, I heard screaming. Found [Resident #1] in the door way standing up with his Foley dragging on the ground. [Resident #2] was lying on the floor. [Resident #1] punch [Resident #2] who tried to enter is room in the face. [Resident #2] was punched to the ground, [Resident #1] needed to be held back by staff to keep him from hitting [Resident #2] again. [Resident #1] was screaming, ‘I ain't done with him.' Was able to talk [Resident #1] down and keep him in his room to avoid further altercation. MD made aware. Will continue with plan of care. Review of Resident #2's admission Record, dated 07/22/25, reflected he was an [AGE] year-old male who was admitted to the facility on [DATE] and had an RP. Resident #2 had medical diagnoses including dementia, late onset Alzheimer's disease, repeated falls, mood disorder, unsteadiness on feet, and cognitive communication deficit. Review of Resident #2's admission MDS, dated [DATE], reflected he had a BIMS score of 8/15, which indicated he had moderate cognitive impairment. Resident #2 did not have any acute onset mental status change in behaviors noted. Resident #2 had physical and verbal behaviors directed towards others and other behavioral symptoms not directed toward others that occurred every 1-3 days noted. Resident #2 also had wandering behaviors that occurred every 1-3 days. Review of Resident #2's Care Plan, dated 04/08/25, reflected no notes related to aggressive behaviors. Resident #2 was also at risk for wandering with unsafe boundaries related to his cognitive impairment/judgement and safety awareness. Nursing staff and the SW were required to assess Resident #2's need for residing in the memory care unit and wander guard use as interventions for his wandering risk. There were no other interventions noted. Resident #2 also chose not to follow recommendations made by his physician and clinical team related to his care and services. Nursing staff were required to ensure his safety and health by attempting several times to provide care even if he initially refuses and to redirect and approach again when he was no longer agitated. There were no other interventions noted. Resident #2 also had a communication problem related to his Alzheimer's dementia. Nursing staff were required to anticipate and meet his needs and notify the MD PRN and nurse for changes in his communication. There were no other interventions noted. Resident #2 also had impaired cognitive function/dementia or impaired thought process related Alzheimer's dementia. All staff were required to keep his routine and caregivers consistent, administer medications as ordered, ask yes/no questions in order to determine his needs, and break tasks one step at a time. There were no other interventions noted. Review of Resident #2's Progress Notes reflected:-A nursing progress note by LVN C on 05/27/25 at 5:31 a.m., This morning, staff attempted to change [Resident #2] brief per routine care. However, [Resident #2] refused stating, ‘leave me alone.' Reattempt made later, but [Resident #2] became verbally aggressive, yelling ‘Get out.' No physical aggression observed. Will reattempt at a later time.-A nursing progress note by LVN A on 05/27/25 at 11:30 a.m., While taking BS heard [Resident #2] scream. [Resident #2] was found on the floor in the hall way, he had been punched in the face d/t entering another [Resident #1] room without permission. No injuries noted. VSS. 160/78, 64HR, 97%02 RA, 97.7, 18RR. Neuro checks in progress.-A nursing progress note by LVN A on 05/27/25 at 6:07 p.m., [Resident #2] continue to wander w/o walker and into peers room despite several reminders. Review of Resident #2's Pain Level Summary reflected his pain level was assessed using a PAINAD scale (a tool used to assess pain in individuals with advanced dementia who may not be able to verbally communicate their pain) on 05/27/25 at 9:12 p.m. and he exhibited 2/10 pain. During an interview on 06/07/25 at 10:00 a.m., Resident #1 stated he was fine and could not remember the incident with Resident #2 on 05/27/25. An attempt to interview Resident #2 was made on 06/07/25 at 10:30 a.m., but Resident #2 was unable to answer any questions about the incident with Resident #1 on 05/27/25 and deemed not interviewable. During an interview on 06/07/25 at 11:45 a.m., MA D stated she was working on 05/27/25. MA D stated on 05/27/25, she heard someone scream, turned around, and observed Resident #2 on the floor and Resident #1 was furious. MA D stated more staff came in and deescalated the incident. During an interview on 06/07/25 at 11:55 a.m., RN E stated Resident #1 was territorial and will not let other people enter his space. RN E stated Resident #2 was a wanderer with dementia. RN E stated she did not witness Resident #1 and #2's incident on 05/27/25. RN E stated she was informed that on 05/27/25, Resident #2 entered Resident #1's room, Resident #1 was standing at the doorway of his room, and Resident #1 punched Resident #2 down. RN E stated staff then intervened and deescalated the incident. During an interview on 06/07/25 at 12:30 p.m., the ADM stated he was not aware, and no one reported to him about Resident #1 and #2's incident on 05/27/25. During an interview on 06/07/25 at 1:10 p.m., the MCD stated Resident #1 preferred to be in his room, was protective of his personal space, and did not like if anyone intruded into his space without his permission. The MCD stated Resident #2 was a wanderer. The MCD stated staff reported to her that on 05/27/25 at about 11:30 a.m., Resident #2 wandered and invaded into Resident #1's room, Resident #1 knocked Resident #2 down to the floor, and Resident #2's hand went on Resident #1's face. During an interview on 06/07/25 at 2:30 p.m., LVN A stated she was working on 05/27/25. LVN A stated during her rounds on 05/27/25 at about 11:00 a.m., she observed Resident #1 sleeping in his bed. LVN A stated on 05/27/25 at about 11:30 a.m., she was attending to another resident, heard a scream coming from Resident #1's room, rushed to Resident #1's room, and observed Resident #2 on the ground and Resident #1 standing against him with [NAME]. LVN A stated staff intervened and separated Resident #1 and #2 without further incident. LVN A stated staff reported to her that Resident #2 wandered into Resident #1's room and Resident #1 knocked Resident #2 down. LVN A stated staff also reported that Resident #2's hand met Resident #1's face. LVN A stated she reported Resident #1's and #2's incident to the MCD. During an interview on 06/07/25 at 3:40 p.m., CNA B stated she was working on 05/27/25 and witnessed Resident #1 and #2's incident. CNA B stated on 05/27/25 at about 11:30 a.m., she was making Resident #2's bed when she heard a loud argument between Resident #1 and #2. CNA B stated she observed Resident #2 standing in front of Resident #1 in the doorway of Resident #1's room, Resident #2's right arm was up and towards Resident #1's face, and Resident #1 punched Resident #2's both shoulders and knocked him down. CNA B stated Resident #2's right hand might have brushed the left side of Resident #1's face. CNA B stated staff immediately intervened and deescalated the incident. CNA B stated her and LVN A separated Resident #1 and #2. CNA B stated she explained the incident to LVN A. During an interview on 06/20/25 at 11:20 a.m., the MCD stated she immediately notified the DON about Resident #1 and #2's incident on 05/27/25. The MCD stated she thought the DON reported the incident to the ADM, who was the abuse and neglect coordinator. During an interview on 06/20/25 at 11:30 a.m., the DON stated he was not present when Resident #1 and #2's incident occurred. The DON stated the MCD called and reported the incident to him. The DON stated the MCD was supposed to report the incident to the ADM. During an interview on 06/20/25 at 12:20 p.m., the DON stated the MCD notified him about Resident #1 and #2's incident on 05/27/25. The DON stated he thought the MCD also notified the ADM about the incident. During an interview on 07/22/25 at 1:55 p.m., MA D stated Resident #1 had a history of wanting his door shut and not wanting other residents and staff coming into his room. MA D stated Resident #1 would yell, Get out! if anyone came into his room and his door was left open. MA D stated nursing staff were taught to redirect other residents away from Resident #1's room whenever they wandered towards his room. MA D stated Resident #1 never been physically aggressive with other residents before the 05/27/25 incident. MA D stated Resident #2 had a history of getting up on his own and wandering into other residents' rooms. MA D stated Resident #2 also had a history of verbal aggression towards staff and other residents and telling other residents to, Shut up. MA D stated Resident #2 also had a history of pushing staff away in self-defense. MA D stated Resident #2 never been physically aggressive with other residents before the 05/27/25 incident. MA D stated sometime in the afternoon on 05/27/25, she was administering medications to residents in the memory care unit when she heard yelling. MA D stated she could not identify who was yelling. MA D stated she came to the area where she heard the yelling and observed Resident #2 on the ground screaming and yelling. MA D stated she also observed CNA B trying to help Resident #2 off the ground and asking him if he was okay. MA D stated she also observed Resident #1 standing in the doorway of his room. MA D stated Resident #1 told her that he did not want Resident #2 in his room. MA D stated CNA B told her that she was trying to get Resident #2 out of Resident #1's room. MA D stated she notified LVN A. MA D stated she was trained and in-serviced on abuse and resident to resident altercations by the MCD and DON before the incident on 05/27/25. MA D stated she learned to immediately notify a nurse, the DON, and ADM whenever there was a resident to resident altercation. MA D stated she did not know a resident to resident altercation could be resident abuse. MA D stated she defined resident abuse as hitting, verbal, sexual, and neglecting residents. During an interview on 07/22/25 at 3:31 p.m., LVN A stated Resident #1 had a history of not wanting other residents and staff in his room and would yell, Get out! of anyone came into his room and left his door open. LVN A stated nursing staff were taught to redirect other residents aware from Resident #1's room whenever they wandered towards his room. LVN A stated Resident #1 never been physically aggressive with other residents before the 05/27/25 incident. LVN A stated Resident #2 had a history of getting up on his own and wandering into other residents' rooms, falling, and unsteadiness on his feet. LVN A Stated Resident #2 also had a history of verbal and physical aggression towards staff and others. LVN A did not clarify who she meant by others. LVN A stated Resident #2 also told other residents to, Shut up, whenever he was yelled at by another resident. LVN A stated Resident #2 never been physically aggressive with other residents before the05/27/25 incident. LVN A stated on 05/27/25, she walked into the memory care unit, heard a loud noise, and heard someone yell, Ow! LVN A stated she believed Resident #2 yelled, Ow! LVN A stated she came to the area she where she heard the yelling and observed Resident #1 standing in the doorway of his room, both his fists were balled up, he was in a fighting stance, and he yelled, Get him the fuck out my room! LVN A stated she tried to hold back Resident #1, but he kept trying to push her out the way and said, I ain't done with him. LVN A stated she eventually was able to redirect Resident #1 back into his room and had to stand in front of the doorway of his room. LVN A stated she also observed Resident #2 on the floor and CNA B trying to help Resident #2 off the floor. LVN A stated CNA B told her that she witnessed Resident #1 reach out and punch Resident #2, Resident #2 fell to the ground, and that Resident #2 did not even have a chance to defend himself. LVN A stated she notified the MCD, MD, and both residents' families after the incident. LVN A stated she believed the MCD notified the DON after the incident. LVN A stated she believed Resident #1 deliberately hit Resident #2 and the incident was resident abuse. LVN A stated she was trained on abuse and resident to resident altercations before the incident on 05/27/25. LVN A stated she learned to immediately notify the ADM, who was the abuse and neglect coordinator, and the DON whenever there was a resident to resident altercation and resident abuse. During an interview on 07/22/25 at 5:01 p.m., CNA B stated Resident #1 had a history of not wanting other residents and staff in his room. CNA B stated Resident #1 would yell, Get out! if anyone came into his room and his door was left open. CNA B stated nursing staff were taught to redirect other residents away from Resident #1's room whenever they wandered towards his room. CNA B stated Resident #1 never been physically aggressive with other residents before the 05/27/25 incident. CNA B stated Resident #2 had a history of getting up on his own and wandering into other residents' rooms, falling, and unsteadiness on his feet. CNA B stated Resident #2 also had a history of verbal and physical aggression towards staff and yelling back, Shut up! whenever he got yelled at by another resident. CNA B stated Resident #2 never been physically aggressive with other residents before the 05/27/25 incident. CNA B stated on 05/27/25, she was in Resident #2's room changing his bed sheets and Resident #2 was standing next to his bed with his walker. CNA B stated Resident #2 walked out of his room while she was changing his bed sheets. CNA B stated she heard an argument ensue back and forth and remarks, such as, You don't belong here. This ain't your room. CNA B stated she could not identify who was making these comments. CNA B stated she came to the area where she heard the comments and observed Resident #1 standing in the doorway of his room, Resident #2 standing in front of Resident #1, Resident #1 leaned forward and towards Resident #2, Resident #1 punched Resident #2, Resident #2's right arm was up and made contact with one of Resident #1's cheeks, Resident #2 fell backwards onto the floor, and Resident #1's fists were balled up and he was in a fighting stance. CNA B stated she came next to Resident #2 and yelled for help. CNA B stated MA D and LVN A came to the area. CNA B stated MA D helped her get Resident #2 off the floor. CNA B stated Resident #1 was angry and said, This isn't his room. CNA B stated she told LVN A that she was changing Resident #2's bed sheets and she observed Resident #2 in the doorway of Resident #1's room, and she did not know if Resident #1 hit or pushed Resident #2 back. CNA B stated she believed LVN A notified the MCD and DON after the incident. CNA B stated she believed Resident #1 deliberately punched or pushed Resident #2 to the floor and the incident was resident abuse. CNA B stated she was trained on abuse and resident to resident altercations by the MCD and DON before the incident on 05/27/25. CNA B stated she learned to immediately notify the ADM, who was the abuse and neglect coordinator, and the DON whenever there was a resident to resident altercation and resident abuse. During an observation of the memory care unit on 07/23/25 at 11:50 a.m., there was a video camera mounted at the entrance of Resident #1's hall. During an interview on 07/23/25 at 12:02 p.m., the MS stated the video cameras do not work. Review of the facility's abuse and neglect in-services, dated 05/12/25, reflected, You should report ANE incidents immediately or no later than two hours after the incident occurs or suspected. ADM/Abuse Coordinator.It is the responsibility of everyone to stop any instances of ANE and then report it to the proper authorities. Immediately report abuse/neglect to the abuse and neglect coordinator [ADM]. Review of the facility's Abuse Guidance: Preventing, Identifying, and Reporting policy, revised January 2024, reflected, Compliance Guidelines: Every resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Residents should not be subjected to abuse by anyone, including, but not limited to, community team members, other residents, consultants, or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. It is the responsibility of our team members, Community consultants, attending physicians, family members, visitors, etc. to promptly report any incident of suspected neglect or resident abuse, including injuries of an unknown source, and theft or misappropriation of resident property to Community management. Types of abuse: Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. This includes the deprivation of goods or services that are necessary to attain or maintain physical, mental, and psychosocial wellbeing.Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment. This failure resulted in the identified of an IJ on 07/22/25. The ADM was notified and provided with the IJ template on 07/22/25 at 6:05 p.m. The following Plan of Removal was submitted by the facility and accepted on 07/23/25 at 4:20 p.m.: Community's Name: [Facility] Immediate Plan of Removal for: On 7/22/2025, an abbreviated survey was initiated at the community. On 7/22/25, the surveyor provided an IJ Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate threat to resident health and safety. The notification of the Immediate Jeopardy states as follows: The facility must ensure each resident's right to be free from abuse, neglect, misappropriation of resident property, and exploitations. Immediate Response: All residents on MCU were immediately assessed by the nurse and social workers to ensure physical and emotional well-being documented on safe survey. Date Completed: 7/22/2025. Outcome: No s/s of physical or emotional distress Risk Response[PH1] : Risk: All residents and those who reside on the memory care unit may potentially be affected. [NAME] President of Operations conducted re-education on 7/22/2023, to the Director of Nursing and Administrator regarding Abuse and Neglect, Identifying and Preventing, to ensure appropriate monitoring and supportive interventions are in place, and an investigation is conducted. Education on Residents' Rights was provided to the Administrator and Director of Nursing Services. [NAME] President of Operations conducted a re-education of Abuse and Neglect reporting guidelines to the Director of Nursing Services and Administrator.Date completed: 7/22/2025 The Director of Nursing Services conducted education to the Assisted Director of Nursing Services, Memory Care Director, and Health Information Coordinator on Abuse and Neglect reporting guidelines and regarding the Abuse and Neglect, Identifying and Preventing; thus, having the identified risk identified on the plan of care and to ensure appropriate monitoring and supportive interventions are in place and an investigation is conducted.Date Completed: 7/22/2025 System Response: Director of Nursing / Assistant Director of Nursing, Health Information Coordinator, and designee conducted re-education to the team members regarding Abuse and Neglect and Resident Rights.Date Completed: 7/22/2025 Monitoring Response: Director of Nursing / Administrator / Social Worker I Designee will conduct random daily rounds 3-7 days a week, on various shifts to validate the safety and well-being of our residents by conducting safe surveys. If signs of agitation or indicators of aggression are displayed. The medical director and resident responsible party will be notified of the incident. There were no changes in the plan of care, but resident was referred to Psych. Services. Team members will report incidents to the Administrator, Director of Nursing Services, or Immediate Supervisor, and the community will follow best practices by redirecting and separating the residents. Policy will be followed to keep residents safe. Director of Nursing/Designee will utilize an audit monitoring tool to review progress notes, changes in conditions, risk management reports, and the nursing 24-hour report daily, 1-7 days per week during the morning clinical meeting to validate appropriate follow-up and necessary interventions are in place accordingly. The Administrator will provide oversight by monitoring and validating these tasks to confirm completions. Interventions will be updated in the careplan/Kardex. The regional nurse assigned to the community will review this system during her visits to validate completed. This plan will remain in place for the next 30 days, and findings will be reported to the QAPI committee during monthly meetings for the next 2 months. The QAPI committee will then determine compliance or identify a need for additional training. The Survey Team monitored the POR on 07/23/25 as followed: During interviews from 07/23/25 at 4:54 p.m. through 07/23/25 at 8:14 p.m., MA D, CNA F, CNA G, CNA H, LVN I, LA J, the HKM, LVN K, MSA, LVN L, DA M, DA N, CNA O, RN E, MA P, CNA Q, LVN R, LVN S, RN T,CNA U, LVN V, CNA W, CNA X, LVN Y, CNA Z, and CNA AA stated they were in-serviced before they began their shifts. They were in-serviced on resident to resident abuse and neglect, abuse, neglect, and resident rights. They were able to give examples, factors, and interventions of resident to resident abuse and neglect and resident rights. They were also in-serviced on immediately reporting ANE to the ADM, was the abuse and neglect coordinator, and immediate supervisor as soon as an incident occurred. During an interview on 07/23/25 at 6:28 p.m., the ADON stated she was in-serviced before she began her shift. She was in-serviced on resident to resident abuse and neglect, abuse, neglect, and resident rights. She was able to give examples, factors, and interventions of resident to resident abuse and neglect and resident rights. She was also in-serviced on immediately reporting ANE to the ADM, was the abuse and neglect coordinator, and immediate supervisor as soon as an incident occurred by the DON. During an interview on 07/23/25 at 6:36 p.m., the DON stated the VPO in-serviced him on 07/22/25 regarding resident rights, abuse, neglect, reporting, identifying and preventing ANE, ensuring appropriate monitoring and supportive interventions are in place, ensuring investigation was conducted, and immediately reporting ANE to the ADM, who was the abuse and neglect coordinator. The DON stated he in-serviced the staff on ANE, resident rights, and resident to resident ANE. During an interview on 07/23/25 at 6:44 p.m., the MCD stated the DON in-serviced her on abuse and neglect reporting guidelines, abuse and neglect, identifying and prevention, updating the plan of care after a resident to resident altercation to ensure appropriate monitoring and supportive interventions are in place, conducting proper ANE investigation, and immediately reporting ANE to the ADM, who was the abuse and neglect coordinator. During an interview on 07/23/25 at 6:48 p.m., the ADM stated the VPO in-serviced him on 07/22/25 regarding abuse, neglect, identifying and preventing ANE, ensuring appropriate monitoring and supportive interventions are in place to alleviate ANE, if resident to resident altercations have occurred they are care planned, confirm an investigation was conducted, and residents' rights and abuse and neglect reporting guidelines. The ADM stated he then in-serviced the nurses, CNAs, CMA, and ancillary staff on the above information. During an interview on 07/23/25 at 6:58 p.m., the VPO stated she in-serviced the ADM on 07/22/25 regarding abuse and neglect, identifying and preventing ANE, ensuring appropriate monitoring and supportive interventions were in place, and confirming a proper and thorough investigation was conducted. The VPO stated she also in-serviced the DON and ADM on residents' rights and abuse and neglect reporting guidelines. Review of the facility's resident safety surveys, dated 07/22/25, reflected all residents on MCU were immediately assessed to ensure physical and emotional well-being was documented. There were no signs or symptoms of physical or emotional distress. Residents from outside the MCU were also assessed and believed they were well taken care of, felt safe in the facility, staff followed procedures when caring for them, needs were being met, no one took anything from them without their permission, staff was not rough with them when providing care, no other residents threatened them, and no current concerns needed to be addressed. Review of the VPO's in-services, initiated and completed 07/22/25, reflected the VPO conducted a re-education to the DON and ADM regarding Abuse, Guidance: Preventing, Identifying, and Reporting, Abuse, Neglect, Exploitation, Misappropriation of Resident Property and other incidents that a nursing facility must report to the health and human services commission provider letter, resident rights, and statement of resident rights. Review of the DON's in-services, initiated and completed on unknown date, reflected the DON conducted a re-education to all staff on abuse/neglect/exploitation, resident to resident altercations, factors contributing to resident to resident altercations, consequences of resident to resident altercations, prevention and intervention techniques. Review of the DON's audit monitoring tool, July 2025, reflected progress notes, changes in conditions, risk management reports, and the daily nursing 24-hour report were reviewed on 07/23/25 and validated appropriate follow-up and necessary interventions are in place accordingly. Review of QAPI meeting attendees sheet, dated 07/22/25, reflected all QAPI members attended the meeting to determine compliance or identify a need for additional training The ADM was notified on 07/23/25 at 8:36 p.m. that the IJ was removed. While the IJ was removed on 07/23/25, 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 that is not immediate jeopardy because of the facility's need to evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse and establish policies and procedures to investigate any such allegations for two out of eight residents (Resident #1 and Resident #2). 1.The facility staff did not report Resident #1 and Resident #2's resident-to-resident altercation to the administrator immediately after the incident on 05/27/25. 2. The facility failed to report to Health and Human Services alleged abuse that occurred in the facility's secured unit on 05/27/25 involving Resident #1 and Resident #2. This failure resulted in the identification of Immediate Jeopardy (IJ) on 07/02/25 at 5:00pm. While the immediacy was removed on 07/03/25 at 12:58pm the facility remained out of compliance at scope of isolated and severity no actual harm due to the facility's need to monitor the implementation of the plan of removal. This failure could place residents at risk of ongoing abuse, neglect, pain, and diminished quality of life.Findings included: Review of Resident #1's face sheet, dated 06/07/25, reflected a [AGE] year-old male admitted on [DATE] with diagnoses of basal cell carcinoma of skin (skin cancer), iron deficiency anemia, vitamin D deficiency, chronic kidney disease, Alzheimer's disease, psychotic disturbance, mood disturbance and anxiety. Review of Resident #1's MDS assessment, dated 04/25/25, reflected a BIMS score of 04 reflecting severe cognitive impairment. The MDS did not indicate any behavior concerns. Review of Resident #1's care plan, dated 05/28/25, reflected Resident #1 can become aggressive when he perceived that others are invading his space. The relevant intervention was to monitor/document/report to MD PRN of any unexpected side effects to anti-anxiety therapy like mania, hostility, rage, aggressive or impulsive behavior and hallucinations. Review of Resident #1's progress notes on electronic medical record (EMR), dated 05/27/25 at 11:46 am authored by LVN A, reflected: While taking BS [a resident] before lunch, I heard screaming. Found resident [Resident #1] in the doorway standing up with his Foley dragging on the ground. His peer was lying on the floor. Resident punch his peer [Resident #2] who tried to enter his room in the face. His peer was punched to the ground, resident needed to be held back by staff to keep him from hitting his peer again. Resident was screaming I ain't done with him. Was able to talk resident down and keep him in his room to avoid further altercation. MD made aware. Will continue with plan of care. Progress notes of Resident #1 by LVN A on 05/27/25 at 14:40pm reflected: CNA notified this nurse that resident had bruising to the corner of left eye. When assessing resident eye noted pupil is enlarged and covering part of iris. Reached out to on-call MD, for sending out for CT of head. Also notified MD, who states to reach out to RP and if they prefer to be sent out or monitored in-house. RP- states to monitor in-house and if eye worsens to be sent out. MD made aware. Will continue with plan of care. Review of Resident #2's face sheet, dated 06/07/25, reflected an [AGE] year-old male admitted on [DATE] with diagnoses of Alzheimer's disease, mood disorder due to known physiological condition, type 2 diabetes, chronic kidney disease and unsteadiness on feet. Review of Resident #2's MDS, dated [DATE], reflected a BIMS score 8 reflecting moderate cognitive impairment. The MDS indicated physical and verbal behavioral symptoms directed towards others. Review of Resident #2's care plan, dated 05/28/25, reflected Resident #1 was at risk for elopement and/or wandering, r/t: cognitive impairment/judgement and enter other residents' rooms uninvited and do not want to leave as it happened on 05/27/25 . The relevant interventions were, assessing his continued need for residing on the memory care/secure unit and putting pictures on the wall beside the door of Resident #1's room to identify which room was his. Review of progress notes, dated 05/27/25 at 11:30 am, of Resident # 2 authored by LVN A reflected : While taking BS [a resident at the facility] heard resident scream. He (Resident #2) was found on the floor in the hallway, he had been punched in the face d/t entering another resident (Resident #1) room without permission. No injuries noted. Record review of Resident #1 and Resident #2's Q15 minute Behavior related time observation 72-hour hot box revealed 15 minutes check on Resident #1 and Resident #2 were commenced on 05/27/25 at 11:30 am and ended on 05/29/25 at 6:00 pm. Record review of safe surveys among the residents residing in memory care dated 05/27/25 revealed there were no negative remarks from any of the residents in the safe survey. During a telephone interview on 06/07/25 at 2:30pm, LVN A stated during her rounds on 05/27/25 at about 11:00 am, she saw Resident #1 in his bed sleeping. At about 11:30 am, while she was attending another resident, she heard a screaming from Resident #1's room. She stated she rushed to Resident #1's room to see Resident #2 was on the ground and Resident #1 was standing against him with [NAME]. LVN A said the staff intervened and separated them without further incidents. She said she had conducted a head-to-toe assessment on both and found no injuries, pain, or deformation. She stated both the residents spent the rest of the days with their normal activities. LVN A stated ,at about 2:30 pm, CNA B reported a hematoma at the left orbit of the left eye of Resident #1 . She stated during observation she noticed dilated pupils of the left eye as well. LVN A stated she immediately contacted the RP and NP for further instructions for care. LVN A said she was not sure if the injury occurred from the incident between Resident #1 and Resident #2 or an injury of unknown origin as there was no injuries observed during the initial assessment immediately after the incident . LVN A stated she reported the incident to UM. During a phone interview on 06/07/25 at 3:40 pm, CNA B stated she had witnessed the incident as she was in the 800 Hallway when the incident was occurred. She stated both Resident #1 and Resident #2 resided in Hall-800. CNA B stated at about 11:30 am, while she was doing the bed of Resident #2, she heard a loud argument between Resident #1 and Resident #2 . She stated Resident #2, who was shorter than Resident #1, was standing at the door of Resident #1 facing towards Resident #1. His right arm was up towards Resident #1's face, and in a fraction of a second, Resident #1 punched both of Resident #2's shoulders, and knocked him down. She stated she believed during the fall, Resident #2's right hand might have brushed Resident #1's left side of the face. She stated staff immediately intervened and deescalated the situation. She said she explained the incident to the charge nurse, LVN A, who was present to separate the residents. During an interview on 06/07/25 at 1:25 pm, the NP stated she visited and assessed Resident #1 on 05/28/25 . She stated she observed a hematoma at the left periphery of his left eye. The NP said there was no swelling or discomfort noticed at that time. She stated, during her assessment, Resident #1 asked her why everybody was inquiring if his eyes were hurting though he did not have any issue with his eyes. During an interview on 06/07/25 at 1:10 pm, the UM stated she was the manager for the memory care unit where Resident #1 and Resident #2 resided. She said the staff reported to her, that on 05/27/25 at about 11:30 am, Resident #1 knocked Resident #2 down to the floor when Resident #2 wandered into Resident #1's room. She stated Resident #2 was a wanderer whereas Resident #1 preferred to be in his room, and was protective of his personal space. The UM stated Resident #1 shared his room with another resident and he never had any issue with him, however, Resident #1 did not like if anyone else intruded into his space without his permission. The UM said Resident #1 and Resident #2 had no injuries from the incident, however, a few hours after the incident, Resident #1 developed a hematoma to the left side of his left eye. She added, it was unclear if the injury was from the incident between him and Resident #2. During another interview on 06/20/25 at 11:20 am, the UM stated she reported the incident on 05/27/25, immediately after the incident, to the DON. She stated she did not report the incident directly to the ADM, who was the abuse coordinator, since she had reported it to the DON so that he would report the incident to the ADM. During a phone interview on 06/07/25 at 1:10 pm, the DON stated he had not witnessed the incident, however, he saw the resident when the staff reported of the hematoma at the left eye area, and conducted a neuro assessment . He stated the facility informed the RP about the plan to send Resident #1 to the hospital, however the RP stated it would be okay to put him under observation at the facility if the injury was not serious. The DON stated, per his assessment, the resident had a discoloration at the periphery of the left eye with a dilated pupil. He stated no swelling , pain, or other issues were noticed . He stated the NP at the facility did an assessment on him later, and recommended to keep him under close observation at the facility. During an interview on 06/20/25 at 12:20 pm, the DON stated the UM phoned him and let him know about the incident, and he thought she had informed the ADM as well. He said per facility policy, any abuse or neglect were reported to the ADM, the abuse coordinator, directly instead of following the chain of command. He stated in-services conducted on abuse and neglect that covered reporting . He stated he was under the impression that all staff were aware of it. The DON stated he did not conduct any knowledge check on staff in this regard. The DON stated in-services were conducted by the clinical management team that included peoples like the DON, the Physical therapy manager and the wound care nurse. The DON stated, after the incident, the nurse conducted a head-to-toe assessment on Resident #1 and Resident #2, mental status assessments were completed on all residents to ensure emotional safety, safe surveys were conducted by the social worker, and the family and physician were contacted. The DON stated both the residents involved were under close monitoring every 15 minutes for 72 hours, and there were no incidents after the incident occurred on 05/27/25, between Resident #1 and Resident #2. During an interview on 06/20/25 at 10:30 am, CNA C stated she worked at the facility for about 3 years. She said she received in-services often on abuse and neglect. CNA C stated she would follow the chain of command and would report abuse and neglect to the nurse in charge. She stated she believed the abuse coordinator was the ADM though she was not very sure. During an interview on 06/20/25 at 10:20 am, the HK D stated he worked at the facility for two months. He stated he received abuse and neglect training during orientation. HK D stated if he witnessed any abuse or neglect, he would report it to the nurse in charge. He stated he did not know who the facility abuse coordinator was. During an interview on 06/20/25 at 11:55 am, MA E stated she would follow the chain of command and report any abuse or neglect to the nurse in charge so that she would be able to report it to the ADM who was the abuse coordinator. During an interview on 06/20/25 at 12:00 pm, CNA F stated she has been working at the facility since October 2024 . She said if she was in suspicion of any abuse or neglect at the facility, she would report that to the ADM and nurse in charge. CNA F stated she did not know who the abuse coordinator was. During an interview on 06/20/25 at 12:05 pm, CNA G stated she would report abuse or neglect to the nurse in charge of the unit on that day. She stated she did not know who the abuse coordinator was. An observation on 06/20/25 in Hall A, B, C and D revealed the abuse coordinator's name (ADM) and phone number was displayed in the nursing stations, instructing to contact him to report abuse and neglect. During an interview on 06/07/25 at 12:30 pm, the ADM stated he had no idea about any reportable incidents that occurred at the facility recently. He stated he was not aware of the altercation between Resident #1 and Resident #2 that occurred on 05/27/25. He stated he was not aware of it as no one reported to him. The ADM stated there was no specific system of reporting in writing, however, staff members generally met him at the office to report incidents or phoned him if he was away from facility. During an interview on 06/20/25 at 1:30 pm, the ADM stated he was the abuse coordinator, and it was his responsibility to report any reportable incidents reported to state agency. He stated, in his absence, it was delegated to other responsible team members and ensured that the incidents were reported by them in a timely manner in his absence. He stated the staff required further training in reporting abuse and neglect directly to him instead of following the chain of command. He stated he monitored if reportable incidents were reported to him, by reviewing the progress notes and reports in EMR, daily rounding in the facility by administrative staff, talking to residents about any concerns or incidents, discussing in the daily morning staff meeting, and reviewing 24 hours reporting forms. Record review on 06/20/25 of the in-services since 03/01/25 reflected revealed in-services on abuse and neglect and reporting were conducted on 6/18/25, 6/12/25,5/28/25, 5/12/25, 4/17/25, and 3/23/25. These in-services indicated: You should report ANE incidents immediately or no later than two hours after the incident occurs or suspected to Administrator /Abuse coordinator. It is the responsibility of everyone to stop any instances of ANE and then report it to the proper authorities. Immediately report abuse/neglect to the abuse and neglect coordinator [ADM] ph. xxxx. Record review on 06/07/255 of Texas Unified Licensure Information Portal (TULIP- the online portal used by healthcare providers in Texas to report various incidents, including those related to abuse and neglect) reflected no initial self-report by the facility for an incident occurred on 05/27/25 involving Resident #1 and Resident #2. Record review of the facility's policy Abuse Guidance: Preventing, Identifying and Reporting implemented in February 2017 reflected: . Seven Elements of ANE:Screening - All team members are to report any signs and symptoms or suspicions of abuse/neglect to the Administrator/Abuse Coordinator, their supervisor or to the Director of Nursing immediately.Training- All new and existing team members receive periodic in-service training relative to resident rights and abuse neglect and exploitation ANE prevention, identification, protecting and reporting.Prevention- The Administrator/Abuse Coordinator has the overall responsibility for the coordination and implementation of the ANE prevention and reporting program.Identification- It is the responsibility of our team members, consultants, attending physicians, family members, visitors, etc. to promptly report any incident of suspected neglect or resident abuse, including injuries of an unknown source, and theft or misappropriation of resident property to the Abuse Coordinator/Administrator and/or community's management.Protection- Our community will protect residents from harm during investigations of abuse allegations.Reporting/Response- All alleged/suspected violations and all substantiated incidents of abuse will be promptly reported to appropriate state agencies and other entities are individuals as may be required by law and per the current state/federal reporting requirements.Investigation- All phases of the investigation will be kept confidential in accordance with the Community's policies concerning the confidentiality of medical records.Reporting Allegations or Suspicions of Abuse :Allegations of, incidents of or suspicions of abuse or neglect are reportable to state authorities in accordance with HHSC's PL 19-17. A community owner, operator or team member who has knowledge of an allegation of or cause to believe that abuse, neglect, or exploitation has been allegedly occurred should report the suspicion or allegation of abuse, neglect, or exploitation to state authorities and may also be reported to local authorities as indicated.Report alleged or suspicions of abuse to HHSC by email reporting or via TULIP reporting within the designated time frames in accordance with HHSC's PL 19-17 (Replaces PL 17-18).Resident-to-resident altercation should be reviewed as a potential situation of abuse, as per HHSC's PL 19-17 (Replaces PL 17-18). On 07/02/25 at 5:00pm an Immediate Jeopardy (IJ) was identified. The ADM was notified. The ADM was provided with the IJ template, and a Plan of Removal (POR) was requested at that time. The following Plan of Removal, submitted by the facility and accepted on 07/03/2025 at 12:58 pm, indicated the following: Plan of Removal Community's Name: [facility]Immediate Plan of Removal for: Abuse and Neglect/Resident to resident Failure to report. Immediate Response:All residents were immediately assessed by the nurse to ensure physical and emotional well-being. Date Completed: 7/2/2025.Outcome: No s/s of physical or emotional distressRisk Response:Risk: All residents and those who reside on the memory care unit may potentially be affected. Administrator/Social Worker/Director of Nursing/Designee will conduct team members and resident interviews to identify any concerns. If any are identified nursing and social service will assess, notify the physician, local authorities and the IDT and will review the plan of care as indicated. Date completed: 7/2/2025.Outcome: No negative outcomes were identified.Interviews with staff and residents and record review of inservice files on 07/03/25 revealed this was accomplished on 07/02/25. [NAME] President of Operations conducted re-education to the Director of Nursing and Administrator regarding the Abuse and Neglect, Identifying and Preventing; thus, having the identified risk identified on the plan of care and to ensure appropriate monitoring and supportive interventions are in place and an investigation is conducted. Date completed: 7/2/2025.Record review of the in-service folder on 07/03/25 revealed vice president of operations conducted an in service on 07/02/25. Review of the sign in sheet revealed Director on Nursing Services and Administrator had attended. During an interview on 07/03/25 the DON and ADM stated they attended the reeducation program. [NAME] President of Operations conducted a re-education of Abuse and Neglect reporting guideline to the Director on Nursing Services and Administrator. Date completed: 7/2/2025.Record review of the in-service folder on 07/03/25 revealed vice president of operations conducted an in service on 07/02/25. Review of the sign in sheet revealed Director on Nursing Services and Administrator had attended. During an interview on 07/03/25 the DON and ADM stated they attended the reeducation program. The Director of Nursing Services conducted education to the Assisted Director of Nursing Services, Memory Care Director, and Health Information Coordinator on Abuse and Neglect reporting guidelines and regarding the Abuse and Neglect, Identifying and Preventing; thus, having the identified risk identified on the plan of care and to ensure appropriate monitoring and supportive interventions are in place and an investigation is conducted. Date Completed: 7/2/2025. Record review of the in-service folder and interviews with various staff members on 07/03/25 revealed this was accomplished on 07/02/25. System Response: Director of Nursing / Assistant Director of Nursing, Health Information Coordinator and Memory Care Director conducted re-educated to the team members regarding the Abuse and Neglect, Identifying and Preventing; thus, having the identified risk identified on the plan of care and to ensure appropriate monitoring and supportive interventions are in place. Date completed: 7/2/2025.Record review of the in-service folder and interviews with various staff members on 07/03/25 revealed this was accomplished on 07/02/25. Director of Nursing / Administrator / Designee provided education to all team members regarding the process for monitoring, observing, and reporting all concerns, involving resident to resident altercations or s/s ANE, by anyone, including family, visitors or staff immediately to their immediate supervisor and administrator/abuse coordinator in order to protect the safety and well-being of all residents and to ensure appropriate interventions are in place and the care plan/ Kardex are adhered to as per facility's expected practices. Date completed: 7/2/2025.Record review of the in-service folder and interviews with various staff members on 07/03/25 revealed this was accomplished on 07/02/25. Director of Nursing / Designee to conduct re-education for all team members on Abuse and Neglect and reporting of Abuse and Neglect to all new team members and if when using agency staff. Date completed: 7/2/2025. Record review of the in-service folder and interviews with various staff members on 07/03/25 revealed this was accomplished on 07/02/25. Ad Hoc QAPI held with Administrator, Director of Nursing and Medical Director to review abuse and neglect policy, reporting abuse and neglect and review the plan of removal.Date Completed: 7/2/2025.Record review on 07/03/25 of the facility document Ad Hoc quality and performance improvement meeting revealed the meeting was conducted on 07/02/2025 to discuss Observations and monitoring regarding a resident-to-resident Altercation that occurred on the memory care unit. The review of the sign in sheet revealed 10 attendees including Administrator, Director of Nursing and Medical Director were participated. Monitoring Response: Director of Nursing / Administrator / Social Worker / Designee will conduct random daily rounds 3-7 days a week, on various shifts to validate the safety and well-being of our residents by conducting safe surveys. Director of Nursing/Designee will utilize an audit monitoring tool to review progress notes, changes in conditions, risk management reports and the nursing 24 hr report daily 5-7 days per week during the morning clinical meeting in order to validate appropriate follow up and necessary interventions are in place accordingly. The Administrator will provide oversight by monitoring and validating this task to confirm completions. The regional nurse assigned to the community will review this system during her visits to validate completed. This plan will remain in place for the next 2 months and findings will be reported to the QAPI committee during monthly meeting for the next 2 months. The QAPI committee will then determine compliance or identify a need for additional training. The Administrator was informed the Immediate Jeopardy was removed on 07/03/25 at 1:40 pm. 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.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse and establish policies and procedures to investigate any such allegations for two out of eight residents (Resident #1 and Resident #2) 1.The facility staff did not report Resident #1 and Resident #2's resident-to-resident altercation to the administrator immediately after the incident on 05/27/25. 2. The facility failed to report to Health and Human Services alleged abuse that occurred in the facility's secured unit on 05/27/25 involving Resident #1 and Resident #2. This failure resulted in the identification of Immediate Jeopardy (IJ) on 07/02/25 at 5:00pm. While the immediacy was removed on 07/03/25 at 12:58pm the facility remained out of compliance at scope of isolated and severity no actual harm due to the facility's need to monitor the implementation of the plan of removal. This failure could place residents at risk of ongoing abuse, neglect, pain, and diminished quality of life. Findings included: Review of Resident #1's face sheet dated 06/07/25, reflected a [AGE] year-old male admitted on [DATE] with diagnoses of basal cell carcinoma of skin (skin cancer), iron deficiency anemia, vitamin D deficiency, chronic kidney disease, Alzheimer's disease, psychotic disturbance, mood disturbance and anxiety. Review of Resident #1's MDS assessment, dated 04/25/25, reflected a BIMS score of 04 reflecting severe cognitive impairment. The MDS did not indicate any behavior concerns. Review of Resident #1's care plan dated 05/28/25 reflected Resident #1 can become aggressive when he perceived that others are invading his space. The relevant intervention was to monitor/document/report to MD PRN of any unexpected side effects to anti-anxiety therapy like mania, hostility, rage, aggressive or impulsive behavior and hallucinations. Review of Resident #1’s progress notes on electronic medical record (EMR) dated 05/27/25 at 11:46 am authored by LVN A reflected : “While taking BS [a resident] before lunch, I heard screaming. Found resident [Resident #1] in the doorway standing up with his Foley dragging on the ground. His peer was lying on the floor. Resident punch his peer [Resident #2] who tried to enter his room in the face. His peer was punched to the ground, resident needed to be held back by staff to keep him from hitting his peer again. Resident was screaming I ain’t done with him. Was able to talk resident down and keep him in his room to avoid further altercation. MD made aware. Will continue with plan of care.” Progress notes of Resident #1 by LVN A on 05/27/25 at 14:40pm reflected: “ CNA notified this nurse that resident had bruising to the corner of left eye. When assessing resident eye noted pupil is enlarged and covering part of iris. Reached out to on-call MD, for sending out for CT of head. Also notified MD, who states to reach out to RP and if they prefer to be sent out or monitored in-house. RP- states to monitor in-house and if eye worsens to be sent out. MD made aware. Will continue with plan of care.” Review of Resident #2's face sheet dated 06/07/25, reflected an [AGE] year-old male admitted on [DATE] with diagnoses of Alzheimer’s disease, mood disorder due to known physiological condition, type 2 diabetes, chronic kidney disease and unsteadiness on feet. Review of Resident #2's MDS, dated [DATE], reflected a BIMS score 8 reflecting moderate cognitive impairment. The MDS indicated physical and verbal behavioral symptoms directed towards others. Review of Resident #2's care plan dated 05/28/25 reflected Resident #1 was at risk for elopement and/or wandering, r/t: cognitive impairment/judgement and enter other residents' rooms uninvited and do not want to leave as it happened on 05/27/25 . The relevant interventions were, assessing his continued need for residing on the memory care/secure unit and putting pictures on the wall beside the door of Resident #1’s room to identify which room was his. Review of progress notes dated 05/27/25 at 11:30 am of Resident # 2 authored by LVN A reflected : “While taking BS [a resident at the facility] heard resident scream. He (Resident #2) was found on the floor in the hallway, he had been punched in the face d/t entering another resident (Resident #1) room without permission. No injuries noted….” Record review of Resident #1 and Resident #2’s “Q15 minute Behavior related time observation 72-hour hot box” revealed 15 minutes check on Resident #1 and Resident #2 were commenced on 05/27/25 at 11:30 am and ended on 05/29/25 at 6:00 pm. Record review of safe surveys among the residents residing in memory care dated 05/27/25 revealed there were no negative remarks from any of the residents in the safe survey. During a telephone interview on 06/07/25 at 2:30pm, LVN A stated during her rounds on 05/27/25 at about 11:00 am, she saw Resident #1 in his bed sleeping. At about 11:30 am, while she was attending another resident, she heard a screaming from Resident #1’s room. She stated she rushed to Resident #1’s room to see Resident #2 was on the ground and Resident #1 was standing against him with [NAME]. LVN A said the staff intervened and separated them without further incidents. She said she had conducted a head-to-toe assessment on both and found no injuries, pain, or deformation. She stated both the residents spent the rest of the days with their normal activities. LVN A stated ,at about 2:30 pm, CNA B reported a hematoma at the left orbit of the left eye of Resident #1 . She stated during observation she noticed dilated pupils of the left eye as well. LVN A stated she immediately contacted the RP and NP for further instructions for care. LVN A said she was not sure if the injury occurred from the incident between Resident #1 and Resident #2 or an injury of unknown origin as there was no injuries observed during the initial assessment immediately after the incident . LVN A stated she reported the incident to UM. During a phone interview on 06/07/25 at 3:40 pm, CNA B stated she had witnessed the incident as she was in the 800 Hallway when the incident was occurred. She stated both Resident #1 and Resident #2 resided in Hall-800. CNA B stated at about 11:30 am, while she was doing the bed of Resident #2, she heard a loud argument between Resident #1 and Resident #2 . She stated Resident #2, who was shorter than Resident #1, was standing at the door of Resident #1 facing towards Resident #1. His right arm was up towards Resident #1’s face, and in a fraction of a second, Resident #1 punched both of Resident #2’s shoulders, and knocked him down. She stated she believed during the fall, Resident #2’s right hand might have brushed Resident #1’s left side of the face. She stated staff immediately intervened and deescalated the situation. She said she explained the incident to the charge nurse, LVN A, who was present to separate the residents. During an interview on 06/07/25 at 1:25 pm, the NP stated she visited and assessed Resident #1 on 05/28/25 . She stated she observed a hematoma at the left periphery of his left eye. The NP said there was no swelling or discomfort noticed at that time. She stated, during her assessment, Resident #1 asked her why everybody was inquiring if his eyes were hurting though he did not have any issue with his eyes. During an interview on 06/07/25 at 1:10 pm, the UM stated she was the manager for the memory care unit where Resident #1 and Resident #2 resided. She said the staff reported to her, that on 05/27/25 at about 11:30 am, Resident #1 knocked Resident #2 down to the floor when Resident #2 wandered into Resident #1’s room. She stated Resident #2 was a wanderer whereas Resident #1 preferred to be in his room, and was protective of his personal space. The UM stated Resident #1 shared his room with another resident and he never had any issue with him, however, Resident #1 did not like if anyone else intruded into his space without his permission. The UM said Resident #1 and Resident #2 had no injuries from the incident, however, a few hours after the incident, Resident #1 developed a hematoma to the left side of his left eye. She added, it was unclear if the injury was from the incident between him and Resident #2. During another interview on 06/20/25 at 11:20 am, the UM stated she reported the incident on 05/27/25, immediately after the incident, to the DON. She stated she did not report the incident directly to the ADM, who was the abuse coordinator, since she had reported it to the DON so that he would report the incident to the ADM. During a phone interview on 06/07/25 at 1:10 pm, the DON stated he had not witnessed the incident, however, he saw the resident when the staff reported of the hematoma at the left eye area, and conducted a neuro assessment . He stated the facility informed the RP about the plan to send Resident #1 to the hospital, however theRP stated it would be okay to put him under observation at the facility if the injury was not serious. The DON stated, per his assessment, the resident had a discoloration at the periphery of the left eye with a dilated pupil. He stated no swelling , pain, or other issues were noticed . He stated the NP at the facility did an assessment on him later, and recommended to keep him under close observation at the facility. During an interview on 06/20/25 at 12:20 pm, the DON stated the UM phoned him and let him know about the incident, and he thought she had informed the ADM as well. He said per facility policy, any abuse or neglect were reported to the ADM, the abuse coordinator, directly instead of following the chain of command. He stated in-services conducted on abuse and neglect that covered reporting. He stated he was under the impression that all staff were aware of it. The DON stated he did not conduct any knowledge check on staff in this regard. The DON stated in-services were conducted by the clinical management team that included peoples like the DON, the Physical therapy manager and the wound care nurse. The DON stated, after the incident, the nurse conducted a head-to-toe assessment on Resident #1 and Resident #2, mental status assessments were completed on all residents to ensure emotional safety, safe surveys were conducted by the social worker, and the family and physician were contacted. The DON stated both the residents involved were under close monitoring every 15 minutes for 72 hours, and there were no incidents after the incident occurred on 05/27/25, between Resident #1 and Resident #2. During an interview on 06/20/25 at 10:30 am, CNA C stated she worked at the facility for about 3 years. She said she received in-services often on abuse and neglect. CNA C stated she would follow the chain of command and would report abuse and neglect to the nurse in charge. She stated she believed the abuse coordinator was the ADM though she was not very sure. During an interview on 06/20/25 at 10:20 am, the HK D stated he worked at the facility for two months. He stated he received abuse and neglect training during orientation. HK D stated if he witnessed any abuse or neglect, he would report it to the nurse in charge. He stated he did not know who the facility abuse coordinator was. During an interview on 06/20/25 at 11:55 am, MA E stated she would follow the chain of command and report any abuse or neglect to the nurse in charge so that she would be able to report it to the ADM who was the abuse coordinator. During an interview on 06/20/25 at 12:00 pm, CNA F stated she has been working at the facility since October 2024 . She said if she was in suspicion of any abuse or neglect at the facility, she would report that to the ADM and nurse in charge. CNA F stated she did not know who the abuse coordinator was. During an interview on 06/20/25 at 12:05 pm, CNA G stated she would report abuse or neglect to the nurse in charge of the unit on that day. She stated she did not know who the abuse coordinator was. An observation on 06/20/25 in Hall A, B, C and D revealed the abuse coordinator’s name (ADM) and phone number was displayed in the nursing stations, instructing to contact him to report abuse and neglect. During an interview on 06/07/25 at 12:30 pm, the ADM stated he had no idea about any reportable incidents that occurred at the facility recently. He stated he was not aware of the altercation between Resident #1 and Resident #2 that occurred on 05/27/25. He stated he was not aware of it as no one reported to him. The ADM stated there was no specific system of reporting in writing, however, staff members generally met him at the office to report incidents or phoned him if he was away from facility. During an interview on 06/20/25 at 1:30 pm, the ADM stated he was the abuse coordinator, and it was his responsibility to report any reportable incidents reported to state agency. He stated, in his absence, it was delegated to other responsible team members and ensured that the incidents were reported by them in a timely manner in his absence. He stated the staff required further training in reporting abuse and neglect directly to him instead of following the chain of command. He stated he monitored if reportable incidents were reported to him, by reviewing the progress notes and reports in EMR, daily rounding in the facility by administrative staff, talking to residents about any concerns or incidents, discussing in the daily morning staff meeting, and reviewing 24 hours reporting forms. Record review on 06/20/25 of the in-services since 03/01/25 reflected revealed in-services on abuse and neglect and reporting were conducted on 6/18/25, 6/12/25,5/28/25, 5/12/25, 4/17/25, and 3/23/25. These in-services indicated: “You should report ANE incidents immediately or no later than two hours after the incident occurs or suspected to Administrator /Abuse coordinator.” “It is the responsibility of everyone to stop any instances of ANE and then report it to the proper authorities. Immediately report abuse/neglect to the abuse and neglect coordinator [ADM] ph. xxxx.” Record review on 06/07/255 of Texas Unified Licensure Information Portal (TULIP- the online portal used by healthcare providers in Texas to report various incidents, including those related to abuse and neglect) reflected no initial self-report by the facility for an incident occurred on 05/27/25 involving Resident #1 and Resident #2. Record review of the facility’s policy “Abuse Guidance: Preventing, Identifying and Reporting” implemented in February 2017 reflected: “…… Seven Elements of ANE: Screening - All team members are to report any signs and symptoms or suspicions of abuse/neglect to the Administrator/Abuse Coordinator, their supervisor or to the Director of Nursing immediately. Training- All new and existing team members receive periodic in-service training relative to resident rights and abuse neglect and exploitation ANE prevention, identification, protecting and reporting. Prevention- The Administrator/Abuse Coordinator has the overall responsibility for the coordination and implementation of the ANE prevention and reporting program. Identification- It is the responsibility of our team members, consultants, attending physicians, family members, visitors, etc. to promptly report any incident of suspected neglect or resident abuse, including injuries of an unknown source, and theft or misappropriation of resident property to the Abuse Coordinator/Administrator and/or community’s management. Protection- Our community will protect residents from harm during investigations of abuse allegations. Reporting/Response- All alleged/suspected violations and all substantiated incidents of abuse will be promptly reported to appropriate state agencies and other entities are individuals as may be required by law and per the current state/federal reporting requirements. Investigation- All phases of the investigation will be kept confidential in accordance with the Community’s policies concerning the confidentiality of medical records. …Reporting Allegations or Suspicions of Abuse : Allegations of, incidents of or suspicions of abuse or neglect are reportable to state authorities in accordance with HHSC’s PL 19-17. A community owner, operator or team member who has knowledge of an allegation of or cause to believe that abuse, neglect, or exploitation has been allegedly occurred should report the suspicion or allegation of abuse, neglect, or exploitation to state authorities and may also be reported to local authorities as indicated… ….Report alleged or suspicions of abuse to HHSC by email reporting or via TULIP reporting within the designated time frames in accordance with HHSC’s PL 19-17 (Replaces PL 17-18)…. ….Resident-to-resident altercation should be reviewed as a potential situation of abuse, as per HHSC’s PL 19-17 (Replaces PL 17-18)…” On 07/02/25 at 5:00pm an Immediate Jeopardy (IJ) was identified. The ADM was notified. The ADM was provided with the IJ template, and a Plan of Removal (POR) was requested at that time. The following Plan of Removal, submitted by the facility and accepted on 07/03/2025 at 12:58 pm, indicated the following: Plan of Removal Community’s Name: [facility] Immediate Plan of Removal for: Abuse and Neglect/Resident to resident Failure to report. Immediate Response: All residents were immediately assessed by the nurse to ensure physical and emotional well-being. Date Completed: 7/2/2025. Outcome: No s/s of physical or emotional distress Risk Response: Risk: All residents and those who reside on the memory care unit may potentially be affected. · “Administrator/Social Worker/Director of Nursing/Designee will conduct team members and resident interviews to identify any concerns. If any are identified nursing and social service will assess, notify the physician, local authorities and the IDT and will review the plan of care as indicated. Date completed: 7/2/2025.Outcome: No negative outcomes were identified.” Interviews with staff and residents and record review of inservice files on 07/03/25 revealed this was accomplished on 07/02/25. · “Vice President of Operations conducted re-education to the Director of Nursing and Administrator regarding the Abuse and Neglect, Identifying and Preventing; thus, having the identified risk identified on the plan of care and to ensure appropriate monitoring and supportive interventions are in place and an investigation is conducted.” Date completed: 7/2/2025. Record review of the in-service folder on 07/03/25 revealed vice president of operations conducted an in service on 07/02/25. Review of the sign in sheet revealed Director on Nursing Services and Administrator had attended. During an interview on 07/03/25 the DON and ADM stated they attended the reeducation program. · “Vice President of Operations conducted a re-education of Abuse and Neglect reporting guideline to the Director on Nursing Services and Administrator. Date completed: 7/2/2025.” Record review of the in-service folder on 07/03/25 revealed vice president of operations conducted an in service on 07/02/25. Review of the sign in sheet revealed Director on Nursing Services and Administrator had attended. During an interview on 07/03/25 the DON and ADM stated they attended the reeducation program. · “The Director of Nursing Services conducted education to the Assisted Director of Nursing Services, Memory Care Director, and Health Information Coordinator on Abuse and Neglect reporting guidelines and regarding the Abuse and Neglect, Identifying and Preventing; thus, having the identified risk identified on the plan of care and to ensure appropriate monitoring and supportive interventions are in place and an investigation is conducted. Date Completed: 7/2/2025.” Record review of the in-service folder and interviews with various staff members on 07/03/25 revealed this was accomplished on 07/02/25. System Response: · “Director of Nursing / Assistant Director of Nursing, Health Information Coordinator and Memory Care Director conducted re-educated to the team members regarding the Abuse and Neglect, Identifying and Preventing; thus, having the identified risk identified on the plan of care and to ensure appropriate monitoring and supportive interventions are in place. Date completed: 7/2/2025.” Record review of the in-service folder and interviews with various staff members on 07/03/25 revealed this was accomplished on 07/02/25. “Director of Nursing / Administrator / Designee provided education to all team members regarding the process for monitoring, observing, and reporting all concerns, involving resident to resident altercations or s/s ANE, by anyone, including family, visitors or staff immediately to their immediate supervisor and administrator/abuse coordinator in order to protect the safety and well-being of all residents and to ensure appropriate interventions are in place and the care plan/ Kardex are adhered to as per facility’s expected practices. Date completed: 7/2/2025.” Record review of the in-service folder and interviews with various staff members on 07/03/25 revealed this was accomplished on 07/02/25. · “Director of Nursing / Designee to conduct re-education for all team members on Abuse and Neglect and reporting of Abuse and Neglect to all new team members and if when using agency staff. Date completed: 7/2/2025.” Record review of the in-service folder and interviews with various staff members on 07/03/25 revealed this was accomplished on 07/02/25. · “Ad Hoc QAPI held with Administrator, Director of Nursing and Medical Director to review abuse and neglect policy, reporting abuse and neglect and review the plan of removal. Date Completed: 7/2/2025.” Record review on 07/03/25 of the facility document “Ad Hoc quality and performance improvement meeting” revealed the meeting was conducted on 07/02/2025 to discuss “Observations and monitoring regarding a resident-to-resident Altercation that occurred on the memory care unit”. The review of the sign in sheet revealed 10 attendees including Administrator, Director of Nursing and Medical Director were participated. Monitoring Response: · Director of Nursing / Administrator / Social Worker / Designee will conduct random daily rounds 3-7 days a week, on various shifts to validate the safety and well-being of our residents by conducting safe surveys. · Director of Nursing/Designee will utilize an audit monitoring tool to review progress notes, changes in conditions, risk management reports and the nursing 24 hr report daily 5-7 days per week during the morning clinical meeting in order to validate appropriate follow up and necessary interventions are in place accordingly. The Administrator will provide oversight by monitoring and validating this task to confirm completions. The regional nurse assigned to the community will review this system during her visits to validate completed. · This plan will remain in place for the next 2 months and findings will be reported to the QAPI committee during monthly meeting for the next 2 months. The QAPI committee will then determine compliance or identify a need for additional training. The Administrator was informed the Immediate Jeopardy was removed on 07/03/25 at 1:40 pm. 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.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for 1 (Resident #1) of 12 residents reviewed for elopement. 1. The facility failed to ensure Resident #1's wander guard bracelet was secured on his wrist so he could not remove it before he eloped from the facility on 03/15/25. 2. The facility failed to ensure staff noticed Resident #1 was missing until approximately 11 hours after he left the faciity on [DATE]. An IJ was identified on 03/21/25. The IJ template was provided to the facility on [DATE] at 4:57 p.m. While the IJ was removed on 03/22/25, the facility remained out of compliance at a scope of isolated and a severity of potential for more than minimal harm because of the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of not receiving adequate supervision, injury, and death. Findings included: Review of Resident #1's admission Record, dated 03/21/25, reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, unspecified dementia, depression, and unsteadiness on feet. Resident #1 had an MPOA and FPOA, which were his responsible parties. Review of Resident #1's admission and Modified MDS Assessments, dated 12/25/24, reflected he had a BIMS score of 12, which indicated he had moderate cognitive impairment. Resident #1 used a wander/elopement alarm daily. Resident #1 required supervision with toileting, bathing, dressing, and transferring, set-up assistance with personal and oral hygiene, and was independent with eating and repositioning. Review of Resident #1's admission Assessment, dated 03/21/25, reflected he was a high risk for elopement and had on one or more occasions attempted to exit or had exited the facility. Review of Resident #1's Care Plan, dated 01/01/25, reflected he was exit-seeking and at risk for elopement and/or wandering with unsafe boundaries related to his dementia. Resident #1 was also at risk for falls related to his unsteady gait, poor balance, history of falls, osteoarthritis, and dementia. Review of Resident #1's Order Summary Report, dated 03/21/25, reflected he had the following active orders: -Check Functionality of the Wander Guard/Alert Device: may use system check wand or use door alarm to confirm functionality every shift for Wandering/Exit Seeking related to Alzheimer's disease ordered and started on 12/19/24 -Check placement of wander guard/roam alert on (left wrist). Document N = Not present/Not in place - replace and document in progress notes. Y - Yes, Present/in place (Add N/Y to supplementary documentation) every shift for Wandering/Exit Seeking related to Alzheimer's disease ordered and started on 12/19/24 Review of Resident #1's Psychological Services Progress Note, dated 02/28/25, reflected, Patient reported some increase in depression. He stated that he has been rethinking his feelings about nursing home placement because he is realizing that he is not going to be able to do some of the things he wants to do .Patient continues to appear impulsive and somewhat grandiose and unrealistic in his thinking. Another Psychological Services Progress Note also reflected he could travel outside the home only when accompanied and supervised. Review of Resident #1's Hotel Registration, printed on 03/15/25 at 2:14 p.m., reflected Resident #1's arrived at the hotel on 03/15/25 and signed his check in registration in-person. Review of Resident #1's Progress Notes reflected there were no notes from 02/21/25 through 03/15/25. The progress notes also reflected: -A note by LVN A on 03/16/25 at 6:01 a.m., This nurse was notified by CNA's at approx. 2130 (9:30 p.m.) that resident had not been seen since the beginning of the shift. We began searching his regular spots, like the library and dining room. When we couldn't locate him, RN supervisor was informed and she notified DON and administrator. Family was notified and Police and PD were also informed and responded to the incident. Every hall was instructed to check every room, bathroom, closet and office. The perimeter of the building was searched and Police searched the entire property by their patrol vehicles. DON and administrator were informed and administrator arrived to the facility to aid in the investigation. PD was informed and also arrived on scene to obtain more information about resident's appearance and other pertinent information. Family was informed and kept updated throughout the shift. -A note by the DON on 03/16/25 at 8:26 a.m., Notified by CNAs on duty that resident was not located in room upon rounds. Staff immediately initiated room search which then extended to entire community and campus without identifying resident's location. Said nurse immediately called Administrator, Police and PD to inform of possible missing person. PD onsite and additional details were provided. Family reported that resident has previously done this before and to notify them if resident's whereabouts are identified. Resident confirmed that he left the community yesterday evening with the intention of not returning. Resident is A&O x 4 and verbalized his plans of moving from the area to Oklahoma where he has friends. Resident was asked why he failed to alert the staff of his intentions and resident replied that he chose not to alert staff because he thought that the staff would not allow him to leave the facility. Resident reports that he is not happy with his family and does not want his family making his decisions. Resident has communicated that he is capable of making his own decisions and intends on doing so. Resident is in a local hotel room and reports that his plan continues to be to go to a friend's home and ultimately plans to move to Oklahoma. He stated that may consider a community in Oklahoma or wants his own apartment. He also reported that he is going to store tomorrow to get a phone, but for now he will remain at his hotel. Resident was informed that his PCP has provided orders that he is discharged from community AMA and that his medications will be released to him and that a nurse will review the medications with him as recommended and that Home Health will be referred if he is agreeable. Resident was informed that out of an abundance of caution community will refer to APS for wellness checks as well as possible assistance that he may need for relocating since resident is not agreeable to remain in the facility. Resident was informed that any additional belongings he may have in the community will also be brought to him at the hotel along with his medications and that in good faith the community is going to have a nurse review his medications with him to ensure he is able to properly administer and that we strongly recommend that he allow home health services. Despite education and resident has been discharged AMA at his request. Community will adhere to MD's recommendations for home health referral and out of an abundance of caution SW will notify APS for a wellness check and any additional support that resident may need. -A Late Entry note by the SW on 03/16/25 10:00 a.m., SW was notified that resident expressed a desire to no longer reside at facility. SW was asked to bring the AMA waiver to resident's location. The waiver was signed by resident, with a nurse serving as the witness. SW conducted a Brief Interview for Mental Status exam with resident, scoring 9. Additionally, SW provided information regarding a nursing home in Oklahoma, which resident expressed interest in. Upon returning to facility, SW immediately called APS to report resident leaving AMA. Review of Resident #1's BIMS Evaluation, dated 03/16/25 at 1:46 p.m. by SW, reflected he had a BIMS of 9, which indicated his cognitive status declined since his admission. Review of Resident #1's AMA Waiver, dated 03/16/25 12:25 p.m., reflected Resident #1 reviewed and signed the waiver with LVN B. Review of the facility's Provider Investigation Report reflected the RN Supervisor notified the facility on 03/16/25 that on 03/16/25 at 12:30 a.m., Resident #1 was not present in his room. There were no witnesses. Investigation Summary reflected, At approximately 9:45 p.m., CNAs reported to their charge nurse that they last recalled seeing Resident #1 on 03/15/25 around 6:30 p.m. The charge nurse promptly informed the RN Supervisor, who prompted the team to initiate an initial search. The facility conducted a search of the entire community and immediate area outside the community and could not locate Resident #1. On 03/16/25 at approximately 12:30 a.m., the RN Supervisor notified the ADM, DON, and police. During this process, the RN Supervisor discovered an itinerary in the copy room containing various pertinent details, including information regarding a train company, cab company, hotel, and bank. This information was communicated to the ADM and responding police officer upon their arrival on-site. The search efforts were then expanded within the community by reaching out to the contacts and businesses listed on the itinerary. The ADM first contacted the hotel at approximately 2:00 a.m., only to be informed that Resident #1 was not present there. However, later that morning, the memory care director contacted the hotel again and was informed that Resident #1 was indeed at the hotel. In response, the memory care director, accompanied by another team member and a social worker, proceeded to the hotel to retrieve Resident #1. An assessment was conducted, and attempts were made to persuade Resident #1 to return to the community; however, Resident #1 declined. Resident #1 who has a BIMS of 12 and when assessed by the charge nurse on site shared, he is alert and oriented x4, explained that he had intentionally departed from the community without signing out or notifying his nurse, as he believed the nurse would not support his desire to visit a friend. He expressed plans to continue to a friend's home in Oklahoma, where he preferred to be. Resident #1 was subsequently informed that should he choose not to return, he would need to sign out of the community AMA, which he proceeded to do. One of the team members then returned to the community to collect all of his medications and APS was notified. Additionally, his family was informed that he had been located and was safe. The following morning, the community dispatched a charge nurse back to Resident #1's hotel room to conduct a health and welfare check, ensuring that he remained safe, alert, and oriented. Upon this visit, it was confirmed that he was indeed safe, alert, and oriented, and his family had arrived at the hotel. The facility's investigation findings were unfounded. Staff were in-serviced on elopement response on unknown date by unknown person, abuse and neglect reporting on unknown date by the DON, and medication administration documentation on unknown date by the DON. There were no in-services related to checking residents' wander guard devices to ensure functionality and placement. During facility's immediate response, staff identified Resident #1's exit seeking device was removed and left within the community. There were no immediate, risk, system, and monitoring response interventions related to checking and ensuring all other residents' wander guard devices and wander guard alarm system were functional and in place. Staff statements reflected CNA C observed Resident #1 on 03/15/25 in the early afternoon, CNA D observed Resident #1 around 3:00 p.m., CNA F observed Resident #1 lying in his bed around 5:45 p.m., CNA E observed Resident #1 lying in his bed around 6:00 p.m., LVN A observed Resident #1 lying in his bed at approximately 6:20 p.m., the RN Supervisor was notified by LVN A that Resident #1 was missing at approximately 10:00 p.m., and the Memory Care Director called and found Resident #1 at a hotel on unknown date. During an interview on 03/21/25 at 11:40 a.m., the ADM stated Resident #1 was discharged from the facility. The ADM stated he could not recall the exact discharge date . During an interview on 03/21/25 at 11:49 a.m., Resident #1's FAM stated Resident #1 wore a wander guard device at the facility. FAM stated LVN G called and told them on 03/15/25 at 10:30 p.m. the facility staff were unable to locate and were searching for Resident #1. The FAM stated LVN G called and told them on 03/16/25 at 12:00 a.m. that Resident #1 was last seen lying in his bed in his room on 03/15/25 at 6:30 p.m. The FAM stated on 03/16/25 at 12:46 p.m., the ADM called and told them Resident #1 was found at a hotel, did not want to return to the facility, staff conducted a BIMS evaluation, and allowed Resident #1 to sign himself out AMA. The FAM stated Resident #1 told them he was able to take off the wander guard device on his own, had taken off his wander guard device, and placed it in his dresser one month ago (February 2025). The FAM stated Resident #1 told them he left the facility through the front door, and they did not know if anyone observed Resident #1 leave the facility. The FAM stated Resident #1 told them he got a ride to the hotel by giving his walker to some strangers. The FAM stated Resident #1 told them he fell in the hotel shower and scraped his knee. The FAM stated Resident #1 was in denial about his dementia, limitations, and was a high fall risk. The FAM stated they took Resident #1 to the hospital on [DATE] to be evaluated because they believed the facility did not evaluate him. During an interview on 03/21/25 at 2:16 p.m., Resident #1 stated he took off his wander guard device one month ago and staff did not notice him not wearing it since he took it off. Resident #1 stated staff last checked on him on 03/15/25 around 7:00 a.m., he ate breakfast in his room around 8:00 a.m., walked out the facility's front door around 11:00 a.m., and did not return. Resident #1 stated no one observed him walk out the facility's front door because the receptionist and staff were all on a break and not present. Resident #1 stated he did not tell anyone that he left the facility because it was nobody's business, and he did not want to return to the facility. Resident #1 stated he left the facility because the facility ran out of tissue paper. Resident #1 stated he walked for two hours to a store (approximately 2.8 miles from the facility), got a ride at some point to the store, got another ride to the hotel, and arrived at the hotel (approximately 10 miles from the store) around 3:00 p.m.-4:00 p.m. Resident #1 stated he lost his balance, fell, and hit his shin while taking a shower at the hotel on the morning of 03/16/25. Resident #1 stated he often fell before his admission to the facility. Resident #1 stated the facility staff found him at the hotel on 03/16/25 around 11:00 a.m. Resident #1 stated the SW had him sign an AMA after he told the facility staff he did not want to return to the facility. Resident #1 stated his FAM were his POAs and the facility typically notified his FAM for decisions about his care. Resident #1 stated he went to the hospital from [DATE] through 03/21/25 and did not know why he was kept at the hospital. An attempt to call and interview the MD was made on 03/21/25 at 3:08 p.m. The phone number provided was a general phone number. During an interview on 03/21/25 at 3:09 p.m., the NP stated she expected CNAs and nurses to make hourly rounds on the residents. The NP defined elopement as someone attempting to leave and was deemed as not being safe to be on their own. The NP stated she did not know Resident #1 was an elopement risk. The NP stated Resident #1 had dementia, history of elopement, and wore a wander guard device. The NP stated she did not know if it was safe for Resident #1 to be out alone without supervision because he had mild dementia and took medications to slow down his dementia progression. The NP stated the wander guard alarm rang if a resident tried to leave the facility. The NP stated she did not know how often the wander guard was required to be checked. The NP stated she expected the nurses to check residents' wander guard devices daily, notify her if a resident took off the wander guard device and said, Because it's for safety. The NP stated she knew the importance of checking residents' wander guard devices and said, It was a device used to determine if a resident left the facility unsupervised. It's a safety issue. It's not supposed to be easy to take off a wander guard. The wander guards were supposed to be placed securely around residents' ankles or wrists. During an interview on 03/22/25 at 9:34 a.m., RN F stated CNAs and nurses were responsible for checking on residents every two hours. RN F stated she defined elopement as when a resident left the facility or locked unit. RN F stated residents' wander guards were to be checked daily and placed on a resident's right arm. RN F stated she never observed a resident take of their wander guard and believed residents could find a way of taking off their wander guard. RN F stated she knew the importance of checking residents' wander guard devices and said, To ensure safety and make sure the resident was able to use it and make sure the alarm worked. I'm sure there were some that would try and take it off. Residents could go any number of places, walk out in the street, and be injured or taken any numbers of ways and unimaginable things. During an interview on 03/22/25 at 10:04 a.m., CNA G stated she checked on residents every hour. CNA G stated she knew the importance of checking on residents and said, To know where resident was and to prevent falls. CNA G stated she defined elopement as a resident getting out of the facility. CNA G stated she would search for the resident if a resident was missing and notify the nurse if she could not find the resident. CNA G stated CNAs and nurses checked residents' wander guards and ensured the wander guards were functioning and in place daily. During an interview on 03/22/25 at 10:14 a.m., LVN H stated CNAs and nurses were required to check on residents every two hours. LVN H stated she defined elopement as a resident leaving the facility and was unable to be found without anyone knowing. LVN H stated nurses were responsible for checking residents' wander guard devices and ensuring they were functioning and in place. LVN H stated she knew the importance of checking residents' wander guard devices and said, Residents could go missing, and staff could just not know that residents were outside. During an interview on 03/22/25 at 10:31 a.m., CNA I stated CNAs and nurses were responsible for checking on residents every 15 or 20 minutes. CNA I stated she could not define elopement because she did not know what it meant. CNA I stated she would immediately notify a nurse and search for the resident if a resident was missing and she was unable to locate the resident. CNA I stated she was unsure who was responsible for checking residents' wander guard devices to ensure they were functioning and in place. CNA I stated she knew the importance of checking residents' wander guard devices and said, Just in case a resident took off, to make sure the wander guard alarm goes off, residents don't walk out the building and get lost, and so we wouldn't know they were gone because it could be devastating. During an interview on 03/22/25 at 10:51 a.m., the Memory Care Director stated CNAs and nurses checked on residents every two hours. The Memory Care Director stated she defined elopement as someone leaving the facility. The Memory Care Director stated she would look for the resident if a resident was not in their room and notify the DON and the ADM if the resident was still missing. The Memory Care Director stated nurses checked residents' wander guard devices to make sure they were functioning and in place. The Memory Care Director stated she knew the importance of checking the wander guard devices and said, So you know if a resident left and could locate the resident. The resident could disappear, and no one could know where they were at. During an interview on 03/22/25 at 11:02 a.m., CNA J stated CNAs and nurses checked on residents every 30 minutes. CNA J stated she knew the importance of checking on residents and said, Because a resident could go missing or fall. CNA J stated she would locate a resident and notify the nurse if she could not find a resident. CNA J stated CNAs and nurses were responsible for checking residents' wander guard devices. CNA J stated she knew the importance of checking residents' wander guard devices and said, If we don't, residents will wander out the doors. Very important. During an interview on 03/22/25 at 11:14 a.m., the MS stated the RN Supervisor called and notified him on 03/16/25 around 12:45 a.m.-12:50 a.m. that Resident #1 eloped from the facility and there was damage to an exit door on Resident #1's hall. The MS stated the ADM called and notified him on 03/16/25 at 12:52 a.m. that Resident #1 broke off the facility's back door wander guard alarm plate and removed the battery. The MS stated he visited the facility on 03/16/25 and observed a paperclip, screw, and wander guard alarm system cover stored in a fire extinguisher box near the exit door on Resident #1's hall. The MS stated he checked the wander guard alarm system daily and did not document the daily inspections before Resident #1's incident. The MS stated he repaired the exit door, verified the wander guard alarm system on the door was operable, and provided a wander guard tester to staff after Resident #1's incident. The MS stated he and the nurses checked residents' wander guard devices to ensure they were functioning. The MS stated the nurses checked residents' wander guard devices to ensure they were in place. The MS stated he checked the facility's exit doors and computers to ensure residents' wander guard devices were functioning and notified the DON whenever they were inoperable. The MS stated residents required assistance with taking off their wander guard devices. The MS stated he never observed a resident take off their wander guard device by themself. The MS stated he knew the importance of checking residents' wander guard devices and said, Because it's for the safety of the resident. Residents could get out, get hurt, get struck, and could pass away. During an interview on 03/22/25 at 1:15 p.m., CNA K stated she frequently checked on residents and could not clarify on what she meant by frequent. CNA K stated CNAs and nurses checked on residents every two hours. CNA K stated she knew the importance of checking on residents and said, To make sure everyone was alive, and wellbeing was okay, and care was provided. CNA K stated she defined elopement as when a resident was not in the facility. CNA K stated she would notify a nurse if a resident was missing. CNA K stated CNAs monitored residents' wander guard devices and management installed the wander guard alarms. CNA K stated she knew the importance of checking residents' wander guard devices and said, You don't want anything to happen to them. Some people have dementia. They could get hurt out there. During an interview on 03/22/25 at 1:45 p.m., CNA D stated she last saw Resident #1 in his room on 03/15/25 around 3:00 p.m. CNA D stated she was the only CNA working on Resident #1's hall on 03/15/25. CNA D stated the RN Supervisor notified her on 03/16/25 that Resident #1 was missing. CNA D stated she checked on residents every two hours. CNA D stated she knew the importance of checking on residents and said, Because residents who were ADL dependent were bed bound and needed to be repositioned and some residents were incontinent and needed to be changed and some residents had wander guard so to make sure they were in the facility. CNA D stated she defined elopement as a resident who escaped from the facility and wandered into the facility, and no one was aware of it. CNA D stated she would search for the resident and notify the nurse or another supervisor if a resident was missing. CNA D stated she did not know who was responsible for checking residents' wander guard devices and ensuring they were functional and in place. CNA D stated she knew the importance of checking residents' wander guard devices and said, Residents could leave the facility and get harmed easily. If a resident had Alzheimer's disease, they could slip out of the wander guard and leave the facility and wander out into street and no one would know. During an interview on 03/22/25 at 2:05 p.m., the RN Supervisor stated LVN A notified her on 03/15/25 around 10:00 p.m. that Resident #1 was not in his room and missing. The RN Supervisor searched inside and outside the facility, did a head count, and could not find Resident #1. The RN Supervisor stated LVN A notified the police, and she notified the ADM, the DON, and the Pharmacy Coordinator, who told her that she noticed Resident #1's itinerary and suspected Resident #1 left sometime during the day. The RN Supervisor stated CNA L told her that he noticed Resident #1's lunch tray was untouched around 5:30 p.m.-6:00 p.m. and told CNA D, who told him to replace Resident #1's lunch tray with a dinner tray. The RN Supervisor stated she observed Resident #1's dinner tray in Resident #1's room and found his wander guard device in his drawer. The RN Supervisor stated the Memory Care Director and LVN B found Resident #1 at a hotel on 03/16/25. The RN Supervisor stated she defined elopement as when a person wandered off from the facility without a caregiver being aware of him or her leaving the facility. The RN Supervisor stated CNAs and nurses checked on residents every two hours or more frequently on residents who were an elopement risk and had a history of wandering. The RN Supervisor stated she knew the importance of checking on residents and said, To be there to prevent a fall. Residents could fall and be on the floor for a while. The RN Supervisor stated charge nurses were responsible for checking residents' wander guards to ensure they were functioning and in place. The RN Supervisor stated she knew the importance of checking residents' wander guard devices and said, Sometimes wander guards could be loose or not working and sometimes residents could take them off like what happened that night . Residents could elope from the facility and end up somewhere. During an interview on 03/22/25 at 2:35 p.m., LVN A stated she defined elopement as when a resident got out of the building, expressed desire or a need to leave the facility, and not wanting to come back to the facility or be at the facility. LVN A stated she would ask a CNA, look for the resident, and notify the RN Supervisor if a resident was missing. LVN A stated CNA E notified her on 03/15/25 between 9:00 p.m. and 9:30 p.m. that she did not observe Resident #1 in his room since the beginning of their shift, which was from 6:00 p.m. through 6:00 a.m. LVN A stated she observed Resident #1 walking from his room towards what she believed was the facility library around 6:15 p.m. and 6:20 p.m. and did not observe him after that observation because she was conducting medication pass for 48 other residents. LVN A stated she told CNA E to search for Resident #1 in the facility and around the facility's perimeter. LVN A stated she found Resident #1's wander guard device in his drawer. LVN A stated nurses checked residents' wander guard devices every shift to ensure functionality and they were in place. LVN A stated she checked Resident #1's wander guard device at the beginning of her shift on 03/15/25. LVN A stated she observed the exit door at the end of Resident #1's hall did not have an outside wander guard alarm system panel on it during her search for Resident #1. LVN A stated the MS was responsible for checking the wander guard alarm system panel and did not know how often the MS completed that task. LVN A stated she found Resident #1's itinerary, called the hotel, and the hotel staff told her that he was not there. LVN A stated the Memory Care Director called the hotel again and found out Resident #1 was at the hotel on 03/16/25. During an interview on 03/22/25 at 3:09 p.m., CNA E stated CNAs and nurses checked on residents every two hours. CNA E stated she knew the importance of checking on residents and said, Because residents could wander around and get lost and so residents are clean and well-positioned. CNA E stated she defined elopement as when a resident wanders without a trace. CNA E stated she did not observe Resident #1 when she started her shift on 03/15/25 around 6:10 p.m. and 6:15 p.m. CNA E stated she thought she observed Resident #1 underneath his bed sheet in his bed. CNA E stated she noticed Resident #1's dinner tray was untouched and realized Resident #1 was not in his bed. CNA E stated she notified LVN A around 8:00 p.m. CNA E stated her and LVN A searched in the facility and around the facility's premises to look for Resident #1 and notified the RN Supervisor and the police. CNA E stated she observed Resident #1's wander guard device was in his drawer. Resident #1 had a phone on his bed in which he made calls to a cab company on 03/15/25 around 12:13 p.m. Resident #1 had an itinerary listing hotel information and notified LVN A. CNA E stated everyone who cared for the resident was responsible for checking wander guard devices to ensure functionality and they were in place. CNA E stated she knew the importance of checking residents' wander guard devices and said, For resident safety. Residents could leave the building, and no one would know because the alarm would not turn on. During an interview on 03/22/25 at 3:32 p.m., CNA C stated she defined elopement as a resident not being on the premises or in the facility. CNA C stated she would notify the nurse if she could not locate a resident. CNA C stated she last observed Resident #1 walking up the hall towards the nursing station on 03/15/25 around 4:00 p.m. CNA C stated nurses were responsible for checking residents' wander guard devices. CNA C stated she knew the importance of checking residents' wander guard devices and said, Residents could go out the door and get away if a resident's wander guard was not checked. During an interview on 03/22/25 at 3:46 p.m., CNA L stated he defined elopement as when a resident left the facility. CNA L stated he would notify a nurse if a resident was missing. CNA L stated he did not observe Resident #1 in his room during his shift on 03/15/25 from 2:00 p.m. through 10:00 p.m. CNA L stated on 03/15/25 around 5:15 p.m., he was passing out dinner trays and observed Resident #1 was not in his room and his lunch tray was still in his room. CNA L stated he notified an unknown name CNA (CNA D) that he did not observe Resident #1 in his room, observed Resident #1's lunch tray was in his room on his bedside table, and that Resident #1 did not eat his lunch. CNA L stated the CNA (CNA D) told him to take Resident #1's lunch tray and replace it with Resident #1's dinner tray. CNA L stated he did not notify a nurse because he did not know the facility's system because it was his third day of training on 03/15/25. During an interview on 03/22/25 at 4:20 p.m., CNA M stated she defined elopement as a resident who ran away from the facility. CNA M stated she would notify the nurse and the ADM if a resident was missing. CNA M stated CNAs and nurses checked on residents every two hours. CNA O stated she knew the importance of checking on residents and said, To make sure they received care and not trying to leave or on the side of their bed. CNA O stated anyone can check the residents' wander guard devices. CNA O stated she knew the importance of checking residents' wander guard devices and said, Resident could walk out the door and no one would know or be alerted. During an interview on 03/22/25 at 4:33 p.m., LVN G stated CNAs and nurses checked on residents every two hours. LVN G stated she knew the importance of checking on residents and said,[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe environment and to help prevent the development and transmission of communicable diseases and infections for 9 (Resident #11, Resident #51, Resident #54, Resident #62, Resident #77, Residents #105, Resident #116, Resident #135, and Resident #137) out of 148 residents reviewed for infection control. The facility failed to: 1. Isolate a resident with confirmed scabies (Resident #105) and five other residents (Residents #11, #51, #54, #62, #116, and #137) presented with rashes. On 01/10/24 at7:20 PM an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 01/12/24 at 9:27 PM, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that at a scope of pattern due to staff needing more time to monitor the plan of removal for effectiveness. 2. Ensure CMA M administered Resident #135's eye drops in a sanitary condition. 3. Ensure Resident # 77's oxygen tubing was stored in a sanitary manner. These failures placed residents at risk of transmission and/or spread of infection or contagious disease which could lead to infections and hospitalization. Findings included: 1.) Review of Resident #105's face sheet printed 01/11/24, reflected a [AGE] year-old male admitted on [DATE]. His diagnoses included dementia, chronic obstructive pulmonary disease (a lung disease limiting air flow from the lungs), hypertension (high blood pressure), and major depressive disorder. Review of Resident #105's quarterly MDS assessment dated [DATE], Section C (Cognitive Patterns) reflected a BIMS score of 8 indicating moderately impaired cognition. Section GG (Functional Abilities) reflected he was able to ambulate with supervision. Section M (Skin Conditions) reflected no ulcers, wounds, or other skin problems. Review of Resident #105's Patient Handout (The summary and physician orders) from the dermatology clinic, dated 01/09/24, reflected in part, Scabies Located on the right proximal dorsal middle finger and right proximal dorsal index finger. Review of Resident #105's physician's order dated 01/09/24 at 2:30 PM reflected, Permethrin External Cream 5% apply to neck down to feet topically at bedtime every 7 day(s) for scabies Leave on for 8 hours/wash off in AM. Repeat in one week. Review of Resident #105's physician's order dated 01/09/24 at 3:41 PM reflected, Ivermectin oral tablet 3 MG, give 6 tablet [sic] by mouth one time only for Scabies for 1 day Start when in house. The medication was ordered by the Med Dir. Review of Resident #105's Medication and Treatment Administration Records for December 2024, reflected permethrin cream was applied on 01/09/21 at 11:18 PM, Ivermectin tablets were given 01/10/24 at 3:28 AM by the MSU Mgr, and the resident was placed on contact isolation on 01/10/24 during the 6:00 PM to 6:00 AM shift. Review of Resident #105's nursing progress note dated 01/10/24 at 9:07 PM reflected in part, Resident continues follow up Permethrin External Cream 5% due to skin rash for prophylaxis. Medication applied from neck down, scabbed over red rash present to bilateral arms, legs, abdomen, buttocks . Review of Resident #105's nursing progress note dated 01/10/24 at 3:36 PM, written by the Director of Nurses, reflected, Reconfirmed with physician the need for isolation for veteran . Physician states that that veteran was treated with PERMETHRIN 5% CREAM(GM)on 01/09/24 @ 2218, linen was removed, unit was deep cleaned, and veteran is in a private room. No need for isolation at this time. Skin to be assessed daily for 5 days, notify physician of any changes in condition. Review of Resident #11's face sheet printed 01/11/24, reflected an [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included dementia, type 2 diabetes, essential hypertension, and chronic kidney disease stage 4. Review of Resident #11's quarterly MDS assessment dated [DATE], Section C (Cognitive Patterns) reflected a BIMS score of 5 indicating severely impaired cognition. Section M (Skin Conditions) reflected no ulcers, wounds, or other skin problems. Review of Resident #11's physician's order, dated 01/10/24, reflected Permethrin External Cream 5% (Permethrin) Apply to neck down to feet topically at bedtime every 7 days for prophylactically apply overnight for 8 hours and wash off in the AM. Review of Resident #11's Total Body Skin assessment dated [DATE] reflected turgor - good elasticity, skin color - normal for ethnic group, temperature - warm (normal), moisture - normal, and condition - normal. The assessment reflected no new wounds. Review of Resident #51's face sheet printed 01/11/24, reflected a [AGE] year-old male admitted to the facility 03/15/17 and readmitted [DATE]. His diagnoses included neurocognitive disorder with Lewy Bodies (a dementia where protein deposits develop in nerve cells in the brain), Alzheimer's disease, cerebral infarction (stroke), and osteoarthritis. Review of Resident #51's quarterly MDS assessment dated [DATE], Section B (Hearing, Speech, and Vision) reflected the resident had clear speech, was usually understood, and he usually understands. Section C (Cognitive Patterns) reflected no BIMS score. Section GG (Functional Abilities) reflected he used a wheelchair for mobility with supervision or touching assistance. Section M (Skin Conditions) reflected no ulcers, wounds, or other skin problems. Review of Resident #51's care plan, printed 1/11/24, reflected an Upper chest rash - NEW 1/5/24 with no new interventions documented. Review of Resident #62's face sheet printed 01/11/24, reflected an [AGE] year-old male admitted on [DATE]. His diagnoses included Alzheimer's disease, post-traumatic stress disorder, atherosclerotic heart disease, hypertension, and chronic kidney disease stage 3. Review of Resident #62's quarterly MDS assessment dated [DATE], Section C (Cognitive Patterns) reflected a BIMS score of 9 indicating moderately impaired cognition. Section GG (Functional Abilities) reflected he was able to ambulate with only supervision. Section M (Skin Conditions) reflected no ulcers, wounds, or other skin problems. Review of Resident #62's physician's order, dated 01/10/24, reflected Permethrin External Cream 5% (Permethrin) Apply to neck down to feet topically at bedtime every 7 days for prophylactically apply overnight for 8 hours and wash off in the AM. Review of Resident #62's nursing progress note dated 01/10/24 at 11:26 PM reflected, Resident continues follow up Permithrin External Cream 5 % for prophylaxis day 1/7, red patches noted from neck down to feet, resident has not complained of pain or discomfort so far during this shift. Resident currently resting in bed, with call light within reach. Plan of care continued. Review of Resident #116's face sheet printed 01/11/24, reflected an [AGE] year-old male admitted on [DATE]. His diagnoses included chronic obstructive pulmonary disease (a lung disease limiting air flow from the lungs) , major depressive disorder, essential hypertension, dementia, and benign prostatic hyperplasia (the flow of urine is blocked due to an enlarged prostate gland). Review of Resident #116's quarterly MDS assessment dated [DATE], Section C (Cognitive Patterns) reflected a BIMS score of 3 indicating severely impaired cognition. Section M (Skin Conditions) reflected the resident did not have any ulcers, wounds, or any skin problems . Review of Resident #137's face sheet printed 01/10/24, reflected an [AGE] year-old male admitted to the facility 03/17/23. His diagnoses included unspecified dementia, post-traumatic stress disorder, and adult failure to thrive. Review of Resident #137's quarterly MDS assessment dated [DATE], Section C (Cognitive Patterns) reflected a BIMS score of 8 indicating moderately impaired cognition. Section GG (Functional Abilities) reflected he was able to ambulate with only supervision. Section M (Skin Conditions) reflected no ulcers, wounds or other skin problems were present. Review of Resident #137's physician's order, dated 01/10/24, reflected, Permethrin external Cream 5% (Permethrin) Apply to neck down to feet topically at bedtime every 7 days for prophylactically apply overnight for 8 hours and wash off in the AM. Review of Resident #137's progress note written 01/10/24 at 4:43 PM by MSU Mgr reflected, This writer, DON, DCO assessed skin. Resident has itchy, dry skin. Resident schedule hydrocortisone cream. Will continue plan of care. All parties notified about skin condition. Observation on 01/09/24 at 11:40 PM revealed Resident #105 standing by the nurse's station with two other residents standing nearby. Observation on 01/09/24 at 12:28 PM revealed Resident #137, Resident #62, and Resident #11 eating lunch in the dining room/dayroom. Observation on 01/10/24 at 2:15 PM revealed Resident #105 lying in bed in his room. There was no sign on or near the door to indicate if transmission-based precautions were used. There was no PPE outside of the room. During an observation and interview on 01/10/24 at 2:17 PM with LVN A, she stated, Resident #105 had his rash for a while, maybe it had started last week. She stated the resident had gone to the doctor on 01/09/24 and was tested for scabies but she did not have the results. She stated if the results were back, she would have received that information in the morning report. She stated staff wear gloves in the room but no other PPE. She stated they were treating all the residents on the unit prophylactically. She stated she had just received more medication from the pharmacy. Observation revealed seven tubes of Permethrin cream (a medication used to treat scabies) for seven residents on the unit. Observation on 01/10/24 at 2:47 PM revealed Resident #105 lying in bed. There was no sign on the door indicating transmission-based precautions. There was no PPE near the room. Observation on 01/10/24 from 2:45 PM to 3:05 PM revealed nursing staff and housekeeping personnel enter Resident #105's room without gloves or other PPE. Observation on 01/11/24 at 8:32 AM revealed a Contact Isolation sign on the door of Resident #105's room. A cart containing PPE was observed next to the room. Resident #105 was lying in his bed. Observation on 01/11/24 at 9:56 AM revealed Resident #51 as he sat in a wheelchair and wheeled himself up and down the hall. His arms and chest had multiple red dots. He was not able to say how long he had the rash or if it was itching. During an observation and interview on 01/11/24 at 10:10 AM with Resident #105, he stated he had a rash all over his body. LVN A assisted resident to turn and adjusted his clothes to reveal red dots on the resident's neck, torso, both arms, back, and both legs. The resident stated they put some cream on him and he recently showered to wash off the medication. He stated he did not remember taking the six pills that the dermatologist had ordered. LVN A stated she gave him the pills during morning med pass. Observation on 01/11/24 at 3:04 PM revealed Resident #137 in the day room with other residents. MSU Mgr asked resident to go to his room for a skin check. The check revealed a rash, red dots, on the left side of his trunk from the hip up to the ribs. Observation on 01/11/24 at 3:09 PM revealed Resident #62 had red spots on both legs, both arms, and his trunk. MSU Mgr stated the rash is throughout his whole body except for his face. Observation on 01/11/24 at 3:15 PM revealed Resident #11 in the day room with other residents. MSU Mgr asked resident to go to his room for a skin check. Resident #11 had a rash covering his right arm. Observation on 01/11/24 at 3:16 PM revealed Resident #116 had a rash of red dots on left side ribs to hip. He declined any further skin check. Observation on 01/11/24 at 4:40 PM revealed an isolation sign on resident #105's room door. During an interview on 01/10/24 at 2:25 with the Director of Nurses, he stated, he had been in his current position for a few days and prior to becoming the Director of Nurses he was the Infection Preventionist. He stated only one resident (Resident #105) had been tested for scabies and the results were still pending. He stated isolation or transmission-based precautions were not necessary because scabies was not confirmed. He stated they were treating the whole unit prophylactically and were in the process of notifying all the responsible parties . During an interview on 01/10/24 at 2:40 PM with the DCE, she stated she knew Resident #105 went out for an appointment on 01/09/24. She stated she brought up her concerns that the resident was to be placed on transmission-based precautions but was told by the Director of Nurses that it was not necessary because the residents on the unit were being treated and the diagnosis of scabies was not confirmed. She stated if it was any other suspected contagious disease, the resident would be on isolation or transmission-based precautions while they waited for test results. She stated not placing someone on transmission-based precautions could cause spread of infection. During an interview on 01/10/24 at 2:53 PM with CNA A, she stated, she was the aide assigned to work on the hall with Resident #105. She stated the resident goes out to the dining room or sometimes he just sat with other residents and watched television. She stated she was aware that the resident may have scabies, she heard he was tested, but did not know for sure. She stated she was afraid of taking something home to her family, so she had been putting on two pairs of gloves to protect herself. She stated she had not been instructed to wear any other PPE. During an interview on 01/11/24 at 8:25 AM with the MSU Mgr, she stated, Resident #105 had been placed on contact precautions some time before her shift started. She stated PPE should be worn because you didn't want to get people sick or spread something. She stated by not using TBP, everyone could get sick. During an attempted telephone interview on 01/11/24 at 11:20 AM, a message that requested a return call was left at the dermatology clinic visited by Resident #105. During a telephone interview 01/11/24 at 2:39 PM with a certified dermatology technician at the dermatology clinic, she was told the purpose of the call. She placed the call on hold and talked with the provider. She came back to the call and after some discussion, stated she would have the provider call back. The call was not returned prior to exit of the survey. During an interview on 01/11/24 at 3:18 PM with MSU Mgr, she stated all rashes should have been documented in the electronic medical records. During an interview on 01/11/24 at 3:24 PM with the Director of Nurses, he stated he had verified with the doctor that no isolation was needed. He stated Resident #105 was never on transmission-based precautions just standard precautions and gloves were a part of standard precautions. He stated all residents on the unit were treated prophylactically. He stated he read the dermatologists' report this morning. He stated he talked with the doctor both before and after reading the dermatologist report and isolation was not indicated. When asked the protocol for notifying staff or visitors that PPE is needed, he stated, By putting up a sign, we missed that. He stated the facility policy was followed . During a telephone interview on 01/11/24 at 4:15 PM with Resident #105's family member, they stated they took the resident to a dermatologist on 01/09/24. They stated while they were at the office, the dermatologist took the scraping from his hand and looked at it under the microscope and confirmed it was scabies. When they returned to the facility around 1:30 or 2:00 PM, shortly after lunch, they signed him back in at the book at the nurse's station. They stated they gave the Patient Handout including the two prescriptions (permethrin cream and Ivermectin tablets) for treating scabies to the MSU Mgr. During an interview on 01/11/24 at 4:30 PM with MSU Mgr, she stated when Resident #105 and his family member returned from the dermatology appointment on 01/09/24, sometime just after lunch, the family member pulled her aside and told her what the dermatologist said. The family member told her the dermatologist did a scrape and talked about scabies. The family member gave her the paperwork from the dermatologist, she read it and saw that it talked about scabies. She stated she called the Director of Nurses. She stated he read the paperwork form the dermatologist, said he was going to call the doctor, and get right back to her. She stated the paperwork had the order for the two scabies medications. She stated the pharmacy nurse made sure the facility had the medication order. She stated there was an isolation sign on the room door now but it was not there the previous day. During an interview on 01/11/24 at 4:32 PM with the Med Dir, she stated, in general a real infection was confirmed and the resident was treated empirically. She stated it depended on the disease but something like C-diff or scabies, if we suspect it is highly likely, contact precautions would be implemented immediately. She stated she reviewed the facility policies and the policies are all current. Regarding Resident #105, she stated they suspected scabies, but the resident was in a private room and staff used contact precautions right away. She stated, Contact precautions means a gown and gloves are worn for every contact with the resident. If staff did not follow contact precautions, there was the risk of transmission to staff and residents. She stated a resident suspected of scabies should be put on isolation immediately with gloves and gowns. She stated the on-call doctor was notified late in the evening of 01/09/24 and the facility was told to isolate the resident. The Med Dir stated at no point in time did they tell the Director of Nurses not to isolate the resident. She stated scabies is infectious and should be treated like any contagious disease. She stated, The instant they come back with the paperwork is when it all starts. She stated she did not see the paperwork from the dermatologist until this morning. They suspected scabies and initiated precautions right away. She stated the resident started treatment that night. She stated his rash was diffuse but not on his feet or the palms of his hands. During a telephone interview on 01/11/24 at 5:16 PM with Resident #105's family member, they stated the resident was scheduled for a follow up visit with the dermatologist at the end of January. They stated the Med Dir saw Resident #105's rash and thought the resident should be seen before the end of January. The family member made multiple calls and they were able to secure the appointment on 01/09/24. During an interview on 01/11/24 at 7:05 PM with the Administrator, she stated they follow guidance to keep everyone safe. She stated the policies are based on CDC and CMS guidelines and doctors' recommendations. She stated she was aware Resident #105 was going to the dermatologist for a follow up visit. She stated she was aware he had a scraping done and received prescriptions. She stated, I left it to the medical team. She stated she did not know when he got his treatment. She stated she saw the paperwork from the dermatologist on 01/10/24 . She stated if an infection was not contained it could spread to other residents or staff. Review of the Scabies Identification, Treatment and Environmental Cleaning policy revised 08/16 reflected in part, 8. Affected residents should remain on Contact Precautions until twenty-four (24) hours after treatment. 12. Individuals who come into contact with the infected resident or with potentially contaminated bedding or clothing should wear a gown and gloves or other protective clothing . Review of the CDC's website https://www.cdc.gov/infectioncontrol/guidelines/isolation/appendix/type-duration-precautions.html#S accessed 01/11/24, contact precautions in addition to standard precautions should be used until 24 hours after initiation of effective therapy to prevent the spread of scabies. Review of the CDC's website https://www.cdc.gov/parasites/scabies/gen_info/faqs.html accessed on 01/11/24 reflected The most common symptoms of scabies are intense itching and a pimple-like skin rash. The scabies mite usually is spread by direct, prolonged, skin-to-skin contact with a person who has scabies. Review of the World Health Organization website https://www.who.int/news-room/fact-sheets/detail/scabies accessed 01/11/24 reflected Scabies can lead to skin sores and serious complications like septicaemia (a bloodstream infection), heart disease and kidney problems. This was determined to be an Immediate Jeopardy (IJ) on 01/10/24 at 7:20 PM the Administrator, Director of Nurses, and Regional Nurse Coordinator were notified. The Administrator was provided with the IJ template on 01/10/24 at 7:20 PM. The following POR submitted by the facility was accepted on 01/12/24 at 12:33 PM: F880 - Infection Control The facility failed to follow CMS and CDC guidance addressing infection control in that 7 residents are being treated for a contagious infection without isolation precautions. All residents were at risk of being exposed to scabies, which likely could result in severe itching, rash, sores, thick crusts on skin, and secondary bacterial infections. 1. Action: Immediate The Charge Nurse notified resident #105's MD/NP. The MCU Charge Nurse on duty assessed resident #105. Rash isolated to top of hands, with no other skin irritations present. Date Completed: 1/10/24 Director of Nurses immediately placed resident#105 on contact precautions. Date Completed: 1/10/24 2. Action: The MDS nurse and IDT initiated a review of resident #105's care plan on 1/10/24, and has revised and updated to include the rash area to the bilateral hands. Date initiated: 1/10/24 Date completed: 1/11/24 3. Action: The IDT initiated a review of all residents' care plans who reside on the MCU (secured memory care unit). The MDS nurse updated all care plans for risk for infection. Date Completed: 1/11/24 4. Action: Resident #105's room was cleaned by direct care staff members. Resident #105's clothes, and linens were removed and washed, all no washable items were place on plastic bags as indicated. The Director of Nurses validated that the resident was treated as per physician's orders, and that the room, clothing, and linens were appropriately bagged and laundered. 1. Wash linens in hot water and dry on hot temperature before any use. Follow the isolation practice for contact isolation when handling the contaminated linens or clothing. Bag belongings that cannot be disinfected or laundered in a plastic bag, tied/sealed for up to 3 days. Clean clothing may be returned to the resident's room after the first dose of treatment. 2. Consider washing at least 3-4 changes of clothing in hot water and dry on hot temp prior to providing to resident to be worn while being treated. Completion Date: 1/10/24 5. Action: Risk--All residents who actively reside on the MSU (secured memory care unit) may have been at risk; Therefore, facility implemented prophylactic treatment as recommended by the facility's medical director. The facility's medical director recommended prophylactic treatment for all 30 residents who reside on the MSU. The Director of Nurses will validate that all residents on the MCU received the prophylactic treatment as per physician's orders. Additional measures that were in place to minimize the risk of spreading was keeping resident 105 in a private room on the secured unit, isolated and separated form others, continued consistent staffing to the unit, which minimizes the spread throughout the community, access to supplies, provide PPE ( gloves and gowns) supplies to isolation room, gloves, hand hygiene supplies throughout the secured unit, as well as the deep cleaning and laundering interventions for resident #105 and all others residing in memory care unit. On 1/10/24, following the IJ concern being cited the Director of Nurses implemented contact precautions for resident #105. Date Completed: 1/11/24 6. Action: Nurses conducted a resident skin sweep on residents who reside on the MCU (secured care unit): There were no findings or indication of infectious outbreak. All residents on the MCU have the skin results documented in each of the resident's electronic health record progress. Date Completed: 1/10/24 7. Action: The Regional Nurse conduct re-education to the Director of Nurses, Assistant Director of Nurses, and Infection Preventionist prior to them proceeding with in-service training. In-service provided: Scabies Information, Scabies response guide, Infection Control and Prevention- Isolation Practices, Preventing the Spread of Infection of Communicable Disease/Conditions, Utilizing Isolation Precautions to include PPE(gown and gloves) and Hand Hygiene Practices. Date Completed: 1/11/24 8. Action: The Director of Nurses, Assistant Director of Nurses, and Infection Preventionist conducted in-service education to all staff prior to assuming their next shift. The Director of Nurses, Assistant Director of Nurses, and Infection Preventionist will conduct in-service education to all newly hired staff during orientation. The Director of Nurses, Assistant Director of Nurses, and Infection Preventionist will conduct in-service education to all agency staffers upon entrance to facility prior to assuming their assignment. Inservice training provided: o Scabies Information o Scabies response guide o Infection Control and Prevention- Isolation Practices, Preventing the Spread of Infection of Communicable Disease/Conditions, Utilizing Isolation Precautions to include PPE (gloves and gown) and Hand Hygiene Practices Date Completed: 1/11/24 and on-going 9. Action: The Director of Nursing and Infection Preventionist conducted staff education consisting of the identification and reporting of s/s scabies, infection control practices and hand hygiene practices. All staff assigned to that designated area have received the education and the in-servicing was also extended to all staff and no staff will work their next shift unless the staff member has received the scabies related in-service. regarding infection prevention and control measures to include but not limited to: o Scabies Information o Scabies response guide o Infection Control and Prevention- Isolation Practices, Preventing the Spread of Infection of Communicable Disease/Conditions, Utilizing Isolation Precautions to include PPE (gown and gloves) and Hand Hygiene Practices Completion Date: 1/11/24 10. Action: The Administrator, Director or Nurses conducted and Ad Hoc QAPI review of this situation and IJ Plan of Removal with the facility's Medical Director. Completion Date: 1/11/24 The Survey team monitored the Plan of Removal on 01/12/24 as followed: Record review of Resident #105's progress notes revealed a note, documented by MSU Mgr on 1/10/24 at 5:24 PM, stated, This writer, DON, DCO assessed skin. Resident has itchy rash and scaly. Resident recieves schedule clobetasol propionate cream, ketoconazole shampoo, fluocinonide external cream. Resident denies itching at this time. Will continue plan of care. All parties notified about skin condition. Note, documented by Pharmacy Nurse on 1/9/24 at 3:53 PM, stated, Resident seen by dermatology, new order for permethrin 5% topical cream and Ivermectin 3mg x 6 tablets for one time dose. MSU Mgr was attempted to be contacted on 01/12/24 at 5:41 PM. A voicemail was left with call back number. Med Dir and Attending Physician were attempted to be contact on 01/12/24 at 5:42 PM but the office was closed. Record review of Resident #105's skin and wound assessment, documented by RN N on 1/10/24, revealed he had good elasticity turgor, normal skin color, warm temperature, normal moisture, normal condition, and no new wounds. Record review of Resident #105's skin and wound evaluation, documented by RN N on 1/11/24, revealed he had a rash on left upper abdomen, acquired in-house, wound been present since 12/14/23, wound bed epithelial, 100% of wound covered with surface intact, no evidence of infection, pink or red color and scab, exudate none, periwound attached: edge appears flush with wound bed or as a sloping edge, intact with unbroken skin, no induration present, no swelling or edema present, normal periwound temperature, no pain frequency, healable for goals for care, no dressing appearance, cleaning solution or debridement, no dressing applied, topicals for care, stable progress, practitioner and RP notified. Record review of Resident #105's Dermatology consult, dated 1/9/24, revealed orders and instructions for applying permethrin 5% topic cream on neck down to feet, ivermectin 3mg tablet 6 by mouth at once, expectations, contaminated clothing, contacting office if scabies fails to resolve, and skin education. Record review of Resident #105's care plan revealed staff reviewed the care plan and included a revision, documented by Regional Nurse Coordinator on 1/11/24, that noted Resident #105's had rash to hand. Goal was to assess redness, blisters, or discoloration through review date and skin injury will resolve without associated complications through review date. Interventions included apply treatment as ordered and follow community's practice for assessing skin, reporting skin concerns to charge nurse, doctor, resident, or RP, and follow skin protocol in place as indicated. Record review of Resident #105's order summary report, dated 1/12/24, revealed the following orders: Contact Isolation Precautions: Strict Isolation required in which all care, therapy and other services are provided in private room r/t an active infection. Every shift for 7 days. Permethrin External Cream 5% apply to neck down to feet topically at bedtime every 7 day(s) for scabies leave on for 8 hours/wash off in AM. Repeat in one week. Record review of all residents' care plans who resided on MCU (secure memory unit) revealed staff updated all care plans to include risk for infection. Record review of all MCU residents' progress notes and order summary report revealed they were ordered and received prophylactic treatment as recommended by MD. Record review of all MCU residents' progress notes and skin assessment results revealed they were assessed by nurses for skin issues and had findings documented on assessments in EHR. Record review of in-services revealed the DON, the ADON, and the IP were re-educated on contact precautions by the regional nurse and Abuse and neglect by the ADM on 1/10/24. Visual aids for contact precautions and washing hands were included. The DON, the ADON, and the IP were also re-educated on scabies, scabies response guide, infection control and prevention isolation practices, preventing the spread of infection of communicable disease/conditions, utilizing isolation precautions, which included PPE and hand hygiene practices on 1/10/24 by the regional nurse. Record review of in-services revealed the ADON, the DON, and the ADM re-educated staff prior to assuming their next shift, newly hired staff[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #244's face sheet revealed Resident #244 was a [AGE] year-old male admitted to the facility on [DATE] with a diagnoses of cancer of the esophagus, atrial fibrillation (irregular heartbeat), history of lower leg amputation, high blood pressure, depression, chronic kidney disease. Review of Resident #244's quarterly MDS assessment dated [DATE] revealed Resident #244 had a BIMS score of 15 to indicate intact cognition. Resident #244 did not require a pain assessment. Review of Resident #244's discharge MDS assessment dated [DATE] revealed Resident #244 received a scheduled pain medication regimen and the pain assessment interview was not completed. Review of Resident #244's readmission Assessment completed 10/19/2022 revealed Resident #244's pain assessment portion of the assessment was blank. Resident #244 was noted to have a terminal condition related to cancer and required end of life/hospice/pallative plan of care. Under vital signs it was noted Resident #244 had a pain level of 0 on 10/19/2022 at 3:10 AM. Review of Resident #244's MAR dated 10/19/2022 revealed on 10/22/2022 Resident #244 had a pain level of 9 when the fentanyl patch was administered. Review Resident #244's nursing progress note dated 10/19/2022 at 10:03 PM revealed Resident #244 returned from the hospital, VSS. Resident #244 had a new order for 15 mg morphine every four hours as needed for pain. Review of Resident #244's nursing progress note dated 10/20/2022 at 9:15 AM revealed Resident #244 refused hydrocodone and morphine was administered. Review of Resident #244's nursing progress dated 10/20/2022 at 9:28 AM revealed a new order was entered for Fentanyl patches ordered every 72 hours 75 mcg/hr with instructions to apply one patch transdermally one time a day every three days. In an observation on 10/19/2022 at 3:00 PM, Resident #244's RP notified LVN J that Resident #244's pain medications including morphine and fentanyl patches had been sitting on his bed side for over an hour, unsecured, and that someone should probably lock them up before they went missing. LVN J took the medications and exited the room. In an interview on 10/19/2022 at 3:05 PM, Resident #244's RP stated he wanted Resident #244 to be comfortable and as pain free as possible due to his terminal cancer diagnosis. He stated Resident #244 required strong pain medication due to the cancer spreading all over his body and into his bones. He stated Resident #244 had a fentanyl patch on and it was due to be changed tonight at midnight. He stated he spoke with LVN J and notified him of the need for the patch change and that Resident #244's RP did not want it missed because Resident #244 would be in pain. He stated prior to Resident #244's recent hospitalization, it was not uncommon for the nursing staff to run late with Resident #244's pain medication. He stated he was in the process of setting up hospice care at his home for Resident #244, so they could ensure he received the pain medications as ordered and so Resident #244 would be more comfortable. In an interview on 10/20/2022 at 9:35 AM, Resident #244 stated his new fentanyl patch was not put on until 9:00 AM that morning and his pain level had reached a 9; at that time, it was at a 7. He stated he asked for his morphine pill and LVN D brought him hydrocodone. He said she told him the facility did not have his morphine filled. He said he told her he returned from the hospital with it filled and then LVN D left to find it. He stated he told her he needed the morphine because his pain was so bad. He said she returned and gave him the morphine. He said the whole thing was screwed up. He said MD Q saw him yesterday and assured him all of his pain medications would be ready at his request. He said his pain medication was not ready and they could not apply the new fentanyl patch because there was no physician order. In an interview on 10/20/2022 at 10:55 AM, LVN D stated she gave Resident #244 his morphine pill at 9:11 AM and his previous dose was at 4:45 AM. She stated the fentanyl patch was replaced at 9:20 AM as there was no order for the patch until then. She stated she did not know why the order was not in yesterday. In an interview on 10/22/2022 at 10:20 AM, the DON stated there was confusion over Resident #244's fentanyl patch. She stated Resident #244's RP told the admitting nurse he had the patch on and it needed to be replaced that night (10/19/2022) at midnight. She stated the fentanyl patch was removed by the hospital staff prior to his discharge and when Resident #244 returned to the facility, he was not wearing a fentanyl patch. She said no one checked for the patch sooner. They clarified the order with the physician the morning of 10/20/2022 and the charge nurse placed the patch on 10/20/2022 at 9:11 AM. Review of the facility's policy Pain Management dated 03/14/2019 reflected Compliance Guidelines: to assess the resident pain control and management needs at admission/ readmission, quarterly, annual and when a change of condition indicates a need for initiating or modifying a pain management program for the residents. Pain screening is conducted upon admission using the UDA: Nursing: admit/ Re-admit nursing review .Residents who experience a change in condition or have a suspected new onset of pain are evaluated for pain. Residents are also evaluated for pain regularly by team members inquiring if they have pain and observation of the resident for non-verbal signs and symptoms of pain . An Immediate Jeopardy (IJ) was identified on 10/19/2022 at 3:55 PM, due to the above failures. The Administrator was notified of the IJ and the IJ template was provided. The Administrator verbalized understanding of the IJ and a Plan of Removal was requested. The Plan of Removal was accepted on 10/21/2022 at 8:43 PM and is as follows: Plan of Removal Immediate Jeopardy On 10/18/2022 an annual survey was initiated at facility. On the evening of 10/19/2022 the surveyor provided an Immediate Jeopardy Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate jeopardy to a resident's health and safety. F697 Pain Management r/t the resident stated to surveyor on 10/18/2022 that he was in pain at the time of the interview and had not received pain medication for five hours. The notification of Immediate Jeopardy states as follows: On 10/18/2022 The surveyor indicated that the resident reported during an interview on 10/18/2022 that he had returned to the community on the night before (10/17/2022) and was currently in pain and had reported his pain to the nurse but had not received any pain medication and has been in pain all morning for about 5 hours. All residents who currently reside at the facility (152 active residents) may have the potential to be affected. 1. Action: At approximately 5:30 pm, on 10/19/2022 Administrator and Registered Nurse rounded to confirm resident was comfortable and without distress. There were no negative outcomes identified at that time, as in no pain or discomfort noted. Nurse re-assessed resident on 10/19/2022 at 19:21, noted a pain score of 8 out of 10 and the nurse medicated resident with oxycodone as ordered. Nursing will continue to monitor for s/s of pain. 10/19/2022 Director of Nurses confirmed that the Oxycodone 10mg Q8 hrs. was available to be administered as ordered. Start Date: 10/19/2022 Completion Date: 10/19/2022 and on-going monitoring continues every shift and as needed until fracture resolved. Pain monitoring will be continued every shift throughout duration of stay. Responsible: Director of Nursing Services / Licensed Nurses The electronic health record has a pain monitoring order scheduled for Q-shift (every shift) on the LNAR (licensed nurses administration record) to indicate the pain assessment is scheduled to be completed and the nurse will document the pain assessment findings. 2. Action: Administrator/Director of Nursing Services conducted rounds and interviewed resident and team members who provided direct care to resident, which included a licensed vocational nurse on duty at time of resident's admission, the licensed vocational nurse taking over at shift change at 6pm 10/17/2022, and two certified nurse's aides to identify additional pain concerns noted. Outcome: There were no associated negative findings noted. As indicated in action # 7, the Administrator / Director of Nursing Service /Director of Clinical Education/Register Nurse Supervisor will conduct random, at least weekly rounds on all residents to ensure the comfort and well-being of our residents is maintained and if pain present, it is managed and being addressed. This has commenced 10/19/2022 and will be an ongoing activity added to weekly tasks. Start Date: 10-19-2022 Completion Date: 10-19-2022 Responsible Administrator/Director of Nursing Services 3. Action: The Director of Nursing Services was immediately re-educated by the Regional Registered Nurse following the IJ being cited. The Director of Nursing Services then re-educated the Director of Clinical Education and RN supervisor so that they may assist with educating licensed nurses, medication aids and nurses aids alike. All licensed nurses and aids, full time and part time, on duty and off, were re-educated by Director of Nursing Service /Director of Clinical Education/Register Nurse Supervisor on Prevention of Abuse & Neglect identifying and anticipating and meeting pain management as well as the care to include monitoring and provide care in a gentle manner to prevent pain and discomfort during care related to care of a patient with a known fracture without surgical intervention, as well as communicating patient needs to ensure staff (licensed nurses, medication aids and aids) are aware of patient care needs upon return from the hospital. Additionally, all nursing staff to include licensed nurses, medication aids and aids have been re-educated as indicated in action #4 as indicated below. The education provided regarding assessing pain needs, addressing pain needs and providing gentle and appropriate care to prevent discomfort and pain, was regarding the issue identified as well as other residents who have injuries such as fractures and any resident experiencing pain. Start Date: 10-19-2022 Completion Date: 10-20 -2022 Responsible Administrator/Director of Nursing Services 4. Action: Director of Nursing Services/Director of Clinical Education/RN Supervisor initiated Inservice training & re-education will be provided to all nursing team members ( (licensed nurses, medication aids and aids) and those team members who were identified as assigned to the resident during the time in question as indicated above in action #3, regarding topics: (this education was extended to other nursing team members (licensed nurses, medication aids and aids) in order to ensure that the team is aware of how to assess pain, address pain management needs and to provide care in a gentle and careful manner in order minimize pain and discomfort especially for those with fractures). Prevention of Abuse & Neglect identifying and anticipating and meeting pain management as well as the care to include monitoring and provide care in a gentle manner to prevent pain and discomfort during care related to care of a patient with a known fracture without surgical intervention, as well as communicating patient needs to ensure staff is aware of patient care needs upon return from the hospital. Current full time and PRN nursing team members will be re-educated prior to assuming next shift. Nursing team members (LVNs/RNs/Certified Med Aids and Certified nurse aids and non-certified nurse aids in training), both full time and PRN and those (LVNs/RNs/Certified Med Aids and Certified nurse aids and non-certified nurse aids in training), who are absent have been re-educated via telephone communication. The in-service attendance page with signatures indicates in person re-education received and the team member names, and role listed indicates the telephone communication provided. The team members re-educated consists of LVNs/RNs/Certified Med Aids and Certified nurse aids and non-certified nurse aids in training, future team members will be educated during on boarding prior to working their assignment. This education has been provided through current date, upon new hire on-boarding, annually and as needed. Start Date: 10/19/2022 Completion Date: 10/20/2022 Responsible Director of Nursing Services/Director of Clinical Education/RN Supervisor 5. Action: Director of Nursing Services requested that physician assess resident to ensure condition stable and pain needs are being managed appropriately. Physician's assessment and review of plan of care was conducted on 10/19/2022 The plan of care was reviewed on 10/19/2022 and will be updated as clinically indicated. Start Date: 10-19-2022 Completion Date: 10-19 -2022 Responsible Director of Nursing Services & Dr. [NAME] 6. Action: Administrator conducted an AdHoc QAPI meeting (additional, specific quality assurance meeting) with the MD and Director of Nursing Services to review identified concern and response plan. (Plan of removal) Start Date: 10-19-2022 Completion Date: 10-19 -2022 Responsible Administrator, Director of Nursing Services & MD 7. Action: The Administrator / Director of Nursing Service /Director of Clinical Education/Register Nurse Supervisor will conduct random, at least weekly rounds to ensure the comfort and well-being of our residents This has commenced 10/19/2022 and will be an ongoing activity added to weekly tasks. Director of Nursing Services/Director of Clinical Education/RN Supervisor have reviewed the 24-hour report, progress notes, risk management reports and changes in condition, to identify any new onset or worsening pain and validated interventions are in place. Date Completed: 10-19-2022 Start Date: 10-19-2022 Responsible: Director of Nursing Services The Survey team monitored the plan of removal as follows: In an interview on 10/21/2022 at 12:30 PM CNA M stated she was educated on notifying the charge nurse immediately if a resident had new onset of pain or worsening pain. She stated she was to notify the charge nurse immediately of any change in condition or injury to a resident for assessment by the charge nurse. She stated if a resident's pain was not relieved she would speak with the charge nurse again or notify the DON. In an interivew 10/21/2022 at 9:30 AM CNA E stated she was inserviced on notifying the charge of a resident change in condition or increased pain. She stated sh was educated regarding reading the shift report log for updated information regarding a resident's condition or change in condition. She stated she was to notify the charge nurse of any new or worsening pain in a resident. In an interview on 10/22/2022 at 9:25 AM, LVN K stated she received education/in-servicing regarding pain management, comprehensive pain assessment under assessments tab and reporting any incident to DON. She stated CNA's should report any incident to charge nurse and then she would report to DON. She stated if a resident was injured in any way, staff were to assess the injury and assess for pain immediately and frequently to ensure resident was not in pain. She stated she was to notify the doctor if needed if current pain management medication was not effective. She stated she was not aware of any resident currently in pain and continuing to do pain assessments on Resident #244 who required morphine as needed every 4 hours. In an interview on 10/22/2022 at 9:40 MA N stated she received in-service regarding pain management for residents with acute or chronic pain. She stated she was to notify the nurse immediately if a resident complained of pain and required PRN pain medication. She stated if a resident was injured during care or a fall, notify the nurse immediately. She stated she was instructed to check in with residents regularly to ensure pain did not continue to be an issue. She stated there were no residents currently complaining of pain to her this morning. In an interview on 10/22/2022 at 9:47 AM, Resident #244 stated he was not currently in bad pain. He stated his pain level was a 9 that morning but now it was down to a 3. He stated the staff were bringing his pain medication as requested. In an interview on 10/22/2022 at 9:55 AM, LVN A stated she was in-serviced on pain management and conducting comprehensive pain assessments upon readmission. She stated she was educated on follow up for effectiveness of pain medication. She stated she was educated on the use of the pain assessment under assessment tab each time assessing for acute pain or new onset of pain. She stated if a resident experienced any changes or if pain medication was not effective, she was to notify the doctor for further instructions. She stated she was to notify the DON if a pain medication was not available. She stated they were to notify the DON of any changes or incidents with residents. She stated they were to give any new or changed information on shift report regarding pain or new injury or issue with a resident and ensure the aides knew as well. In an interview on 10/22/2022 at 10:00 AM, LVN L stated she was educated on addressing resident pain needs as soon as possible and if pain medication was not effective with current medication, they were to notify the physician. She stated they were to notify the physician of new onset of pain. She stated they were to notify oncoming charge nurse and aides of any changes or new incidents with a resident so all were aware of changes in care needs for residents. She stated in addition to medication they were re-educated regarding other forms of pain relief like repositioning residents to more comfortable or offer heat/cold pack as requested. She stated they were instructed to complete the comprehensive pain assessment under the assessment tab. In an interview on 10/22/2022 at 10:05 AM, Resident #69 stated his pain was at baseline and he received medication as requested. He stated he felt his pain needs were adequately addressed and he would report to the DON or the Administrator, if not. In an interview on 10/22/2022 at 10:20 AM, the DON stated in addition to the education provided regarding pain management they implemented the procedure that aides would also review the shift report log. So they were familiar with new resident issues or changes. She stated the staff were not communicating well and having agency staff was the reason for lack of knowledge for new patient issues. Review of Record of Inservice dated 10/19/2022 at 6:00 PM revealed staff were educated regarding handling veterans with care, pain management, pain assessments, documentation, abuse and neglect. Permanent staff, agency staff and PRN staff currently on the schedule were noted to have completed the in-service as required by the POR. Review of Resident #69's Progress noted dated 10/19/2022 revealed Resident #69 completed an assessment of Resident #69 and confirmed Resident #69 was stable and pain management needs were met. Review of Resident #69's MAR dated 10/22/2022 revealed Resident #69 was assessed for pain each shift as required. On 10/22/2022 at 10:45 AM, the administrator was notified that the Immediate Jeopardy (IJ) was removed. However, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy with a scope of isolated, due to the facility needed to evaluate the effectiveness of the corrective systems. Based on observation, interview and record review, the facility failed to ensure that pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 2 of 30 residents (Residents #69 and #244) reviewed for pain management. 1. The facility failed to ensure Resident #69 was assessed, monitored and received pain medication after Resident #69 suffered a displaced transverse femur fracture on 10/12/2022 with the fracture not being identified by the facility until 10/13/2022. 2.The facility failed to ensure Resident #69, who was determined to not be a surgical candidate after his femur fracture, was assessed, monitored and received pain medication upon his return to the facility from the hospital on [DATE] until 10/18/2022. 3. The facility failed to assess, provide effective pain treatment, and address pain promptly for Resident #244 with terminal cancer, who was assumed to be wearing a fentanyl patch upon readmission to facility, but was not and did not receive a new fentanyl patch for 17 hours. An immediate Jeopardy (IJ) situation was identified on 10/19/2022. While the IJ was removed on 10/22/2022 at 10:45 AM, the facility remained out of compliance at a scope of isolated with actual harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. These failures placed residents at risk of experiencing significant pain and discomfort. Findings include: 1. Review of Resident #69's face sheet dated 10/18/2022 reflected he was admitted on [DATE] with the following diagnoses Malignant neoplasm of prostate (prostate cancer), Transient Ischemic Attack and cerebral infarction (a brief episode of neurological dysfunction caused by loss of blood flow; Infarction refers to death of tissue) and Hemiplegia affecting left side (paralysis of one side of the body.) Review of Resident #69's quarterly MDS assessment dated [DATE] reflected Resident #69 was assessed to have a BIMS score of 15 indicating he was cognitively intact. Resident #69 was assessed to require extensive assist with two person assist with transfers and ADLs. Resident #69 was assessed to have scheduled pain medication regimen. Review of Resident #69's comprehensive care plan reflected a focus area self-care deficit related to hemiparesis left side with contractures causing limited physical functioning related to stiff or limited joint range of motion. Review of Resident #69's interventions did not reflect how the resident was to be transferred. Review of Resident #69's nursing progress notes reflected an entry dated 10/13/2022 Resident had complaints of pain in his left hip, Resident stated that when he got back from his appointment his leg got stuck in between the machine and he heard a crack. Nurse called in an order of the x-ray at 12:00 PM on 10/13/2022 the results came back and found a transverse fracture through the proximal left femoral diaphysis with superior displacement of the distal fracture fragment of approximately 3.5 cm MD was notified and EMS is on their way to transfer the resident to the hospital. Review of Resident #69's incident report dated 10/13/2022 reflected Nursing Description: Resident had complaints of pain in his left hip. Nurse called in an order for the x-ray at 12:00 PM on 10/13/2022. Results came back and found a transverse fracture through the proximal left femoral diaphysis with superior displacement of the distal fracture with fragment of approximately 3.5 cm. The MD was notified, and EMS was on their way to transfer the resident to the hospital. Resident Description: Veteran stated that when he got back from his appointment his leg got stuck between the Hoyer and he heard a crack. Review of Resident #69's X-ray report dated 10/13/2022 at 3:25 PM reflected a transverse fracture through the proximal left femoral diaphysis with associated superior displacement of the distal fracture fragment of approximately 3.5 cm and apex lateral angulation . Review of Resident #69's consolidated physician orders dated 10/18/2022 reflected an order dated 06/16/2022 to assess the residents' level of pain every shift, on a 0-10 scale, every day and night shift. Further review of the consolidated physician orders reflected an order dated 03/01/2022 for Acetaminophen 325 mg two tablets by mouth every 4 hours as needed for pain, an order for Acetaminophen 500 mg two tablets by mouth every 8 hours for 14 days related to displaced transverse fracture of shaft of left femur with a start date of 10/19/2022, and an order for oxycodone HCL 10 mg tablet by mouth every 8 hours as needed for pain related to displaced transverse fracture of shaft of left femur with a start date of 10/18/2022. Review of Resident #69's MAR dated October 2022 reflected no pain medication was administered on 10/12/2022 or 10/13/2022. Review of Resident #69's re-admission assessment dated [DATE] at 7:43 PM reflected under the pain section that resident was able to verbalize pain and had no history of or current signs of pain. The assessment further stated Resident #69's location of pain was left hip dislocation (non-surgical) with the type of pain being acute. The pain assessment did not rate Resident #69's pain only described it hot/ burning and his acceptable or tolerable level of pain was a 2 out of 10. Review of Resident #69's nursing progress note dated 10/17/2022 at 8:21 PM Facility supervisor was informed unable to input narcotic oxycodone 10 mg, they took care of order, the on call that verified orders stated to let facility MD know to obtain triplicate and contact pharmacy to order medication . In an interview on 10/18/2022 at 1:23 PM, LVN A stated she sent Resident #69 to the hospital on [DATE] after an x-ray confirmed he had a broken hip. She stated Resident #69 told her it happened the day before on 10/12/2022 when he was being transferred with the Hoyer lift. LVN A stated he told her his leg got caught on the mechanical lift and as they turned him, he heard a pop. LVN A stated he was in pain when she checked on him and she looked at left hip and saw swelling. She stated the MD requested an x-ray then confirmed the fracture. She stated the doctor was notified and said send him to hospital. LVN A stated Resident #69 returned last night 10/17/2022. LVN A stated she notified the DON immediately upon Resident #69's reporting injury and pain. LVN A stated the staff nurses did not do incidents that the DON would have done the incident report and subsequent investigation. LVN A stated she was not sure if Resident #69 had surgery on his hip while hospitalized . LVN A stated she was the nurse in charge of Resident #69 on 10/12/2022 and CNAs (CNA B & CNA C) did not report any incident or injury regarding Resident #69 to her on 10/12/2022 or 10/13/2022. LVN A stated Resident #69 was out of bed on 10/12/2022 due to MD appointment and they would have been transferring him back to bed when it happened. She said staff are supposed to report to charge nurse and/or DON immediately of a resident injury. LVN A stated Resident #69 normally doesn't require treatment for pain and had only had PRN Tylenol ordered for pain. LVN A stated Resident #69 had to be treated with something stronger for pain when he returned to the facility on [DATE] at 5:34 PM but his pain medicine was not in the building last night when he arrived. LVN A stated they were having trouble filling the medication because they did not have triplicate for the prescription which was a controlled medication. LVN A stated she had not administered any pain medication to him that morning because he had not asked for any. LVN A stated she was unaware of any change in his care plan. She said in response to his hip being broken, the facility did an in-service on abuse/neglect reporting and mechanical lifts on Thursday 10/13/2022. LVN A stated she was not aware of any other staff education done regarding Resident #69 and his broken hip or care and pain needs. Observation and interview on 10/18/2022 at 10:35 AM revealed Resident #69 was in bed, Resident #69 was observed to have a contracture of his left arm. Resident #69 was also observed to have bruises on his arm. Resident #69 stated they were from his transfer to the hospital a week ago. Resident #69 stated he was still in pain and stated the staff went to the nurse but had not come back. He stated he has been in pain all morning. Resident #69 stated he didn't know when he could take his medication and stated nobody has advised him on his medication. He stated the doctor at the hospital said he could take it every 4 hours, but the doctor here said every 8 hours. Review of Resident #69's MAR dated October 2022 reflected Resident #69 was assessed to not have pain on the night of 10/17/2022. Further review of Resident #69's MAR reflected he was medicated for pain for the first time on 10/18/2022 at 1:30 PM with oxycodone HCL 10 mg and was medicated with Tylenol 325 mg two tabs at 3:55 PM for continued pain rated at a 4/10. In an interview on 10/18/2022 at 2:16 PM, Resident #69 stated the nurse finally did give him some pain medication . In an interview on 10/18/2022 at 3:39 PM, the DON stated they should have made sure the resident had pain medication in house when Resident #69 returned from the hospital. An interview and observation on 10/19/2022 at 8:40 AM revealed CNA E was outside of Resident #69's room preparing to perform incontinent care for the resident. CNA E stated she was not sure what leg was broken on resident and went up and down the hall multiple times to find someone to help her. CNA H arrived to assist CNA E. The CNAs began incontinent care, Resident #69 grimaced while the CNAs were preforming front peri care was done. The CNAs rolled Resident #69 to his left side to do care his left leg was shaking CNA E asked Resident #69 if he was in pain and he stated yes. The CNAs then turned Resident #69 to his back and his leg and left side was shaking and Resident #69's facial expressions indicated he was in pain. In an interview on 10/19/2022 at 11:45 AM, CNA F stated she worked the 2:00 PM to 10:00 PM shift on 10/17/2022. She stated she was aware of his accident. She stated she answered Resident #69's call light and he stated he needed a pain pill that he was in pain. CNA F stated she communicated to the nurse, the resident was in pain and she stated she did not know her name she was an agency staff . CNA F stated she did not see if the nurse medicated him and stated the resident was sleepy, so she didn't check on him frequently and stated CNA G took care of him. In an interview on 10/19/2022 at 1:15 PM, CNA G stated she went to Resident #69's room to get him water and he asked her if she could let the nurse know that he needed pain medication . CNA G stated she told the nurse, who was agency, that Resident #69 need pain medication. She stated she did not know if he got the medication. CNA G stated around 9:30 PM 10/17/2022, the agency nurse was making her way down the hall, but she did not see what room she went into or if she gave Resident #69 any medication . In an interview on 10/20/2022 at 8:50 AM, LVN I stated she worked the night of 10/17/2022 and her shift ended at 6:00 AM. LVN I stated Resident #69's pain medication was not available on her shift and was not given to resident. She stated she did not do the re-admission assessment another nurse (she did not know the name of) did the assessment. When asked why her name was on the assessment, she stated she did not know. LVN I, stated she did not get the report from the hospital when Resident #69 was readmitted from the other nurse. She further stated she was not told if he had been medicated for pain prior to discharge from the hospital . She stated she did go and check on the resident and took his vital signs but was not able to say at what time the assessment occurred. She stated it was documented in the progress notes (review of notes reflected no assessment or vital signs, review of MAR revealed no vital signs). She stated no one reported to her about the resident having pain and was not able to say when she performed a pain assessment on Resident #69.