**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure residents were free from abuse for 1 (Resident #7) of 6 Residents reviewed for abuse.The facility failed to protect Resident #7 from verbal abuse when Resident #16 made mocking statements and gestures regarding Resident #7's personal hygiene, the Administrator, LVN B, DON and Social Worker were aware of the verbal abuse. The verbal abuse led to Resident #7 being fearful, avoiding Resident #16 and Resident #7's withdrawal from former social patterns in refusing to go to the dining room and activities. An IJ was identified on 08/14/25. The IJ template was provided to the facility on [DATE] at 10:13AM. While the IJ was removed on 08/15/25, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm because the facility was continuing to monitor the implementation and effectiveness of their Plan of RemovalThis failure could result in residents becoming fearful, refusing to go to the dining room, or participate in activities.Findings included: Record review of Resident #7's face sheet, dated 05/28/25, reflected the resident was a [AGE] year-old male, who admitted [DATE] with diagnoses of paranoid schizophrenia (a chronic mental health condition characterized by disruptions in thought, perception, and behavior). Record review of Resident #7's MDS dated [DATE] revealed he had a BIMS score of 10 indicating he had moderate cognitive impairment. Record review of Residents #7's care plan dated 4/23/2025 revealed he was on antipsychotic medications for diagnosis of paranoid schizophrenia. Interventions included administration of medication as ordered.Record review of Resident #16's face sheet, dated 08/01/25, revealed he was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses of depressive, dementia with other behavioral episodes.Record review of Resident# 16's MDS, dated [DATE], revealed he had a BIMS score of 6 indicating severe cognitive impairment.Record review of Resident #16's care plan, dated 08/19/24 and revised 08/12/25, revealed the resident had potential to demonstrate verbally abusive behavior, ineffective coping skills, and yelled loudly at staff, and called them names. Interventions included providing positive feedback for good behavior, assessing, and anticipating the resident's needs. During an interview on 08/12/25 at 12:30PM, Resident# 7 revealed he was scared of what Resident #16 would do to him based on past incidents when Resident #16 pinched his nose, yelled Resident #7 smelled, and followed him around.During an observation on 08/12/2025 at 12:30PM, it revealed the two resident room (Resident #7 and Resident #16) were in proximity/on the same hall/next door to one another. Resident #7 was well groomed, no body odor, or other smells noted. In an interview on 08/12/25 at 12:33PM Administrator revealed he was aware of a previous incident when Resident #7 reported to him Resident #16 said Resident#7 smelled. The administrator stated that he notified the social worker, and the social worker spoke to Resident #7 and Resident #16, and everything seemed to be okay. In an interview on 08/12/2025 at 4:45PM LVN B revealed that Resident #16 and Resident #7 did not like each other. LVN B stated that Resident #16 was the aggressor, he said mean things to people, especially the staff. Resident #7 kept to himself and avoided Resident #16. LVN B stated that he had been in serviced on abuse and neglect. He said the last in service was last pay day on 08/12/2025. He stated that the administrator and the DON were aware of the two Residents not getting along. In an interview on 08/12/25 at 2:58PM the DON revealed she was aware of an incident where that Regional nurse notified the DON that Resident #7 verbalized Resident#16 was holding his own nose yelling that Resident #7 smelled. The DON stated that she spoke with Resident #7 and Resident #16. The DON stated that Resident #16 denied the incident, and Resident #7 acted like nothing happened. No further interventions were implemented. Record review of Grievance, progress notes, social services notes for the dates of 04/01/25 through 08/15/25 reflected no documentation of the incident and interventions for Resident #7 or Resident #16.In an interview on 08/13/2025 at 11:20AM Social Worker revealed a few weeks ago, the Administrator notified her that Resident #7 reported that Resident #16 told Resident #7 that Resident #7 smelled. The Social Worker stated that she spoke with Resident #16 about him being mean to other residents and he denied it, but Resident #7 said that it did happen. Social Worker stated that she talked to both parties and Resident #7 said he was satisfied that she had talked to Resident #16. Social Worker stated that there was not follow up because it was just a passing conversation, and she did not realize that it was going to be a major issue. Social Worker stated Resident #7 was upset enough to bring it up. Social Worker stated that Resident #7 did not appear to have any psychosocial effects, but he must have been upset enough to report it to the administrator'. Social Worker stated that Resident #7's base line was that he got upset sometimes and he was on psych services. Social Worker stated that on 08/13/2025 the administrator notified her that the same issue came up at breakfast. Social Worker stated that the administrator told her that Resident #16 told Resident #7 that Resident #7 smelled. Social Worker stated that when she spoke to Resident #16, he told her he yelled that he spilled his coffee. Resident #7 said that it did happen, that Resident#16 yelled at him that he smelled. Social Worker stated that Resident #7 and Resident#16 were separated. Social Worker stated that after Resident #7 calmed down, Resident #7 was brought back to breakfast. Social Worker stated she documented the incident in EMR. Social Worker stated the facility moved Resident #16 to another hall Social Worker stated she had made a referral for Psych to evaluate both Resident #7 and Resident #16. Social Worker stated that Resident #16 had been discharged for counselling services, but she was going to restart counselling services. No psychosocial assessments done on him. Social Worker stated that Resident #16 was known to have verbal aggression.In an interview on 08/13/2025 at 3:23PM LVN A, revealed that before breakfast Resident #7 refused to go to the dining room when he saw Resident #16 was in the dining room. Resident #7 agreed to go to the dining room if LVN A was going to be in the dining room. LVN A stated at breakfast on 08/13/25, Resident#16 was holding his nose and yelling at Resident #7 stating that Resident #7 smelled. LVN A separated Resident #7 and Resident #16 and then reported to the administrator. She stated that Resident#16 had been moved to a different hall. LVN A stated Resident #16 always bothered Resident #7 and Resident #7 did not like going anywhere close to Resident #16. She stated that she mentioned to the administration before and that most of the staff were aware that the two residents did not get along. She stated that she had been in serviced on abuse and neglect and that was the reason that she reported the incident at breakfast as soon as it happened,In an interview on 08/13/2025 at 4:20 PM Physician revealed he was not aware of any previous Resident to Resident altercation between Resident #7 and Resident #16. He stated that he was notified by the DON on 08/13/2025 that Resident #16 was verbally aggressive to Resident #7 was reportable. The physician stated that if Resident #7 was upset when Resident#16 yelled that Resident#7 stinks then it was verbal abuse. The physician stated that the NP had a better understanding of the Residents. He stated he was notified that the facility had made plans to ensure that Resident#7 felt safe and had moved Resident#16 to a different hall. An interview was attempted 08/13/2025 at 4:30PM with NP Q but was unsuccessful, a voicemail was left with call back number.In an interview on 08/13/2025 at 3:45PM Activity Director, revealed that Resident #7 refused to attend activities when Resident #16 was in attendance because Resident #7 did not want to be in the same space with Resident #16. The activity Director stated that she thought Resident #7 and Resident #16 did not like each other. She stated that she had been in serviced on abuse and neglect on 08/13/2025.In an interview on 08/13/2025 at 6:51PM NP Q revealed that the DON and NP R had told them that the surveyors had inquired about changing Residents # 7s psych medication. NP Q stated that she did not agree to changes to Resident #7s medication because of his diagnosis of schizophrenia. NP Q stated she was concerned that it was the first time she was notified about verbal aggression by Resident #16 to Resident #7. The NP stated that she had known Resident #7 for almost 10 yrs and when she was at the facility Resident #7 always talked to her about what his fears were but had not mentioned Resident #16's verbal aggression. The NP Q stated she had tried to keep Resident #7 on minimum medications to control his paranoia. The NP stated that she was concerned at the number of staff that were aware Resident #7 verbalized verbal aggression from Resident #16 with no interventions. The NP stated that Resident #16 was mean and it would not surprise her that Resident #16 would be verbally aggressive to Resident #7. She stated that verbal aggression could affect Resident #7 psychologically because Resident #7 got fixated on things and he would be fixated on the verbal aggression for a long time. She was concerned the residents' rooms were close to each other. She verbalized the facility should ensure there was no contact between Resident #7 and Resident #16. She stated the staff should be aware to redirect both Residents to avoid them coming into close contact with each other. She stated that she would visit with Resident #7 to assess and give him an opportunity to vent.Record review of the facility policy of undated Abuse/ Neglect revealed: The Resident has the right to be free from abuse, neglect, misappropriation of Resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the Resident's medical symptoms. Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, other Residents, consultants or volunteers, staff of other agencies serving the Resident, family members or legal guardians, friends, or other individuals.An IT was identified on 08/14/25. The IT template was provided to Administrator on 08/14/25 at 10:13 AM and a plan of removal was requested. The plan of removal was accepted 08/14/25 at 5:36 PM. The plan of removal reflected the following: Resident #16 was placed on 1:1 supervision by facility staff. The Administrator is responsible for ensuring Resident #16 remains on 1:1 until Resident is not exhibiting verbal behaviors. Admin/DON will be responsible for ensuring Resident #16 remains on 1:1 supervision as evidenced by documentation on 1:1 form as well as progress notes in [EMR]. Resident #16 will remain on 1:1 supervision until no signs of verbal behaviors are exhibited and the Resident is cleared to step down 1:1 supervision by the attending physician. The facility staff will be designated by the Admin/DON. The physician will provide the 1:1 discharge order when deemed safe. Completed 8/14/25. Resident #7 and Resident #16 were referred to and evaluated by psychological services on 8/13/25. Psych evaluation was completed for Resident #16 and Resident #7 by Senior Psych NP, NP [NAME] on 8/13/25. Resident #7's evaluation shows no concerns or lasting effects at this time. Follow up for Resident #7 will be weekly or as needed by the Senior Psych NP. Resident #16's evaluation shows no concerns or lasting effects at this time. Follow up for Resident #16 will be weekly or as needed by Senior Psych NP. Completed by 8/14/25. The facility social worker interviewed Resident #7 and Resident #16 and completed a trauma informed care assessment, and no new trauma was identified. Social services will visit Resident #7 and Resident #16 for 1-2 times weekly to rule out emotional distress for 4 weeks and on-going as needed. A head-to-toe skin assessment was completed on Resident #7 on 8/13/25 by the Charge Nurse. No signs of injuries were noted. Completed; reviewed on 8/14/25. All Residents in the facility who can be interviewed were interviewed by the social worker for any further allegations of abuse on 8/13/25 and reviewed 8/14/25. No additional allegations were noted. The DON reviewed all safe surveys that were completed by the SW. Completed; reviewed on 8/14/25. All Residents in the facility who are not interview able, will have a head-to-toe assessment completed for any signs of abuse by the DON/ADON/ Charge Nurse. No signs of injuries were noted. Completed; reviewed on 8/14/25. The Administrator and DON were in-serviced 1:1 on the following in-services by the Divisional Director of Clinical Services. Completed; reviewed on 8/14/25.oAbuse and Neglect Policy by the Divisional Director of Clinical Services on 8/13/25. The in-service included reporting immediately to the Abuse Coordinator (Admin) for all allegations of abuse and neglect. The alleged perpetrator will be placed on 1:1 immediately pending investigation. A thorough investigation will be conducted for all allegations of abuse and neglect including verbal abuse. Examples of verbal abuse include yelling and chastising a Resident that causes emotional distress or fear.oTrauma Informed Care Policy- The facility will ensure that Residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for Residents' experiences and preferences to eliminate or mitigate triggers that may cause re-traumatization of the Residents. The interventions will be added to the care plan and available in the POC Kardex. A trauma informed assessment will be completed upon admission based on the past history of trauma that is disclosed on the social history assessment. A trauma informed assessment will also be completed PRN when a Resident is involved in a traumatic event. The assessment will be completed by the social worker or designee. This will begin 8/14/25 and will continue indefinitely. oResident Rights Residents have the right to be free from abuse and neglect, including verbal abuse from other Residents. All allegations of verbal abuse should be reported and investigated immediately by Abuse Coordinator (Administrator) with appropriate interventions in place. oDocumentation Policy: The charge nurse or SW will document in the progress note any Resident-to-Resident behaviors or allegations of abuse after it is reported to Abuse Coordinator/Administrator. Completed 8/14/24. The Medical Director was notified of the immediate Threat situation on 8/14/25 by the Administrator. An ADHOC QAPI meeting was completed with the QA committee to include the Medical Director on 8/14/25 to discuss immediate Threat and the plan of removal. The following in-services were initiated by the DON and Regional Compliance Nurse for all staff. All staff not present beginning 8/13/25 and reviewed on 8/14/25 will be in-serviced prior to the start of their next shift. All new hires will be in-serviced during orientation. All agency staff will in serviced prior to the start of their shift. No staff will be allowed to work until they have been in-service. Completion date will be 8/14/25.oAbuse and Neglect Policy The in-service included reporting guidelines (2hrs) for all allegations of abuse and neglect including verbal abuse. The alleged perpetrator will be placed on 1:1 immediately pending investigation. A thorough investigation will be conducted for all allegations of abuse and neglect including verbal abuse. Examples of verbal abuse includes yelling and chastising a Resident that causes emotional distress or fear. oTrauma Informed Care Policy- The facility will ensure that Residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for Residents' experiences and preferences to eliminate or mitigate triggers that may cause re-traumatization of the Residents.Monitoring of the facility's Plan of Removal included the following:Interviews with the following staff from 08/15/25 at 06:56 AM to 3:04 PM who worked all shifts and all days of the week revealed they had been in-serviced on abuse and neglect, Residents Rights, and Trauma informed training: LVN A, LVN B, RN C, CNA D, CNA E, LVN F, LVN G , PTA CNA H, CNA I, RN J, LVN K, LVN L, CNA P, NP Q, , Laundry Aide, housekeeping N, housekeeping O, DON, Business office Manager, Dietary Manager, Maintenance Supervisor, Social Services Licensed, and, the Administrator.Record review of a QAPI Agenda, dated 08/14/25, reflected Administrator, MD, and DON were in attendance. Record reviews reflected that on 8/14/25, the Administrator and DON were in-serviced 1:1 by the Divisional Director of Clinical Services, on the following in-services: Abuse and Neglect Policy, Trauma Informed Care Policy, Resident Rights, Documentation Policy.Record review of in-service sign in sheets, dated 08/13/25, revised 08/14/2025 titled Abuse and Neglect reflected both the DON and Administrator had signed.Record review of Abuse and Neglect policy in-service dated 08/13/25 revised 08/14/2025, reflected 52 staff had been in-serviced. Record review of Trauma Informed policy in-service, dated 08/13/2025 revised on 08/14/25-08/15/2025, reflected 52 staff had been in-serviced.Record review of Residents Rights in-service, dated 08/13/25 revised 08/14/2025 reflected 52 staff had been in-serviced.In an interview on 8/13/2025 at 2:25PM the Administrator revealed that LVN A reported that Resident #16 was holding his nose and told Resident #7 that he smelled. The administrator stated that he was near the dining room, but he did not hear anything. The administrator stated that when he started to investigate Resident #16 stated that he yelled because he got coffee on his clothes. The administrator stated that Resident #7 was fine his only concern was that he was fearful that the state was going to kick him out of the facility. The administrator stated that resident #7 stated that he felt safe and comfortable at the facility, but he was not sure what Resident #16 might do. The administrator stated that he called the cooperate office because once Resident #7 stated that he was fearful the facility had to intervene and make sure he was safe. He stated that Resident #16 was moved to a different hall. He stated that he was reporting the allegation to the state and the facility was meeting the Resident #16's family to discuss finding him a different placement. The administrator stated that psychiatric practitioner had seen both resident and Resident #7 was at his baseline with no psychosocial problems identified.In an interview on 8/15/2025 at 1:34PM with the DON revealed that Resident #16 was in a different hall from Resident #7. She stated that in services on abuse and neglect, Residents rights, and Trauma in formed training were started on 08/13/2025 and revised on 8/14/2025. The in services will continue until all staff have been interviews and no staff will be allowed to start a shift before being in serviced. She stated that staff is aware to make sure that Resident#7 and Resident#16 do not come into close contact. She stated that the facility was trying to find placements for Resident #16 and the family had already been notified. In an interview on 8/15/2025 at 11:30AM Divisional Director of Clinical Services revealed that she was notified by the administrator on 08/12/2025 that Resident #7 had reported that Resident #16 had been verbally aggressive with him. She was again notified of the incident at breakfast on 8/13/2025 that was reported by the LVN A that Resident #16 was holding his nose telling Resident #7 that he smelled. She stated that the facility implemented interventions and moved Resident #16 to a different hall to ensure that Resident #16 and Resident #7 do not come in close contact. She stated that Resident #16 was placed on 1:1 monitoring. She stated that LVN F did a head-to-toe assessment on Resident #7. She stated that the social worker did psychiatric referral for both Resident #7 and Resident #16. Safe surveys were done on all residents and all residents verbalized that they felt safe at the facility. She stated that residents that were not interviewed had skin assessments completed. She stated that in serviced on abuse and neglect, residents right, Trauma informed were initiated and all staff must compete the in-service before returning to their next shift. She stated that she in-service the DON and the administrator on abuse and neglect, trauma informed, residents rights and documentation policies.Record Revies of nurse notes dated 08/13/2025 at 7:30 AM reflected Resident #7 was in DR this morning getting ready to eat breakfast when another Resident started yelling at him and holding his nose telling Resident he stinks. Resident states he is concerned about going in DR when the other Resident is in there. I (LVN A) explained to Resident #7 that as long as am in the DR he has nothing to worry about and then will go eat. Made Administrator aware of the situation this morning. The Adm went and SW the Resident along with SS . This entry was written by LVN ARecord review of Social Service Note dated 08/13/2025 7:40 AM reflected Note Text: LMSW was alerted at beginning of work shift regarding concern of previous verbal altercation between two Residents. LMSW recalled initial incident but was unable to substantiate initial occurrence at the time, where Resident one told [Resident #7] that he had odor emitting from his person. At that time, LMSW had spoken with other Resident, who did not confirm incident and wrapped up conversation, advising Resident one to be cognizant of other's feelings, which other Resident acknowledged. This morning at approximately, 07:20 hours, LMSW was alerted that other Resident was being rude to [Resident #7] in dining room. LMSW approached said Resident, who advised loudly (as he his hard of hearing) that he yelled because he spilled his coffee. LMSW then spoke with [Resident #7] who advised the other Resident was yelling at him because he 'stunk' LMSW advised [Resident #7] that she would speak with other Resident again and discuss utilizing kindness with others at facility. [Resident #7] acknowledged solution. LMSW also contacted NP R from Senior Psych Services via telephone updating her on incident. NP R advised she is en route to facility and would speak to both parties. LMSW will continue to follow up with both Residents to ensure comfortable setting for both parties. this entry was written by social worker.An observation on 8/13/2025 at 4PM revealed Resident #16 was on 1:1 supervision with staff on the 600 hall.In an interview on 8/13/2025 at 2:30PM with Resident #7 he thanked the surveyor and stated that Resident #16 had not bothered him since the surveyors intervened.In an interview on 8/14/2025 at 10:38AM NP Q revealed that she was notified of the Immediate Threat, and she stated that the facility had put sufficient interventions to ensure Resident #7 and other Residents remain safe from abuse. She stated that she had been informed by the social worker that they were sending referrals to find Resident #16 placement in another facility. Record review of Resident #7's Weekly Skin Assessment notes dated 08/13/2025 at 3:48 PM reflected Note Text : Skin Color: Normal, Temperature of skin: Warm. Bruise present: No, Skin Tear Present: No, Abrasion present: No, Laceration present: No, Surgical incision present: No, Rash present: No, Moisture Associated Skin Damage present: No, Pressure, venous, arterial, or diabetic ulcer present: No., Other skin findings present: Yes. Other skin findings: Birthmark on L upper arm. This entry was written by LVN F Record review of Resident #7's of Trauma Informed Assessment notes dated 08/13/2025 3:48 PM Note Text: Has a previously documented diagnosis of Mental Disorder. Have a diagnosis of PTSD: No Experiences: Reports no known negative experiences. Has the Resident been in a situation that was extremely frightening: No Has the Resident witnessed any extremely frightening situations: No Does or has the Resident have a close relationship with someone who experienced any extremely frightening situations: No this entry was written by the social worker.Record review of Resident#16 Psychiatric notes dates 08/13/2025 revealed that (Resident#16 name) is being seen today at the request of the [nursing facility] [social worker] and [DON]. He is seen in his room sitting up on the side of the bed. He has significant hearing loss, and his speech is difficult to understand at time. Some questions are asked by the provider writing down, letting the patient read the questions and the allowing the patient to answer the questions. He says he is doing pretty good and denies any concerns at this time. He reports a good appetite and sleeping well. He denies any physical or verbal aggression towards anyone, and he says he gets along well with others. Staff report the patient told another Resident that he smelled bad. [Resident# 16] admits to holding his nose when another Resident walked by him but denies telling him he smelled bad. He says the other Resident has not showered in 30 days. Discussed actions that can be perceived by others as hurtful, such as holding one's nose when someone walks by, and other alternative actions that can be taken to remove oneself from displeasing odors. Patient v/u and states, I'll be nice and agrees to quietly remove himself from odorous areas. HE denies any problems with depression, sadness, anxiety, or anger. He denies any AVH or SI/HI. this note was written by NP R.Record review of Resident #7's psychiatric notes dated 08/13/2025 revealed that [Residents#7] is being seen today at the request on [DON] and the facility [social worker]. The patient is seen ambulating in his room. He is pleasant and consents to the interview but presents with increase paranoia. The patient often exhibits increased paranoia with any changes in his normal routines and /or schedule. The reports that earlier, another Resident made fun of him and told him he smelled bad Staff report interventions have been put into place to provide space for both parties. discussed their interventions with [Resident#7] who voices appreciation having a good appetite and says he is sleeping well. He denies any AVH or SI/HI.Record review of Residents#7 psychiatric notes dated 08/13/2025 revealed- [Resident#7] is being seen today for a second time due to the request of [DON] of the facility . [DON] reports that the patients were seen by this provider and made statements of being fearful of another Resident. He is seen via audio and video conference with assistance of [DON]. Resident #7 is please and eager to engage. He consents to audio interviewing. He sates he is doing pretty good and says he is not fearful at this time. he states the staff at Country View make him feel safe and treat him well. He reports having times of being fearful of another Resident in the facility. He states the Resident in question has never physically or verbally threatened him. when asked why he is fearful of the Resident he states, because he I'm afraid he is going to come get me. Again, the patient is asked if the Resident in questions has ever verbally threatened him or been physically aggressive towards him. [Resident#7] responds No. Discussed the Resident in question moved to a different hall away from [Resident#7] and being wheelchair bound reminded patient that he [Resident#7] is ambulatory and can quickly get staff member if he feels threatened or fearful patient v/u and agrees to get a staff member when or if he feels fearful to threatened. Again, the Resident stated that the Resident in question has never been physically or verbally aggressive towards him. [Resident#7] has a long history of paranoia schizophrenia with mild paranoia being the patient's baseline. The patient is well managed under current treatment regimen and is able to function well with steady routine. Patient exhibits increased paranoia with any changed in routine such as state surveyors being in the building or changed in administration. In the past the patient returns to his normal baseline of paranoia, the patient responds well to active listening to his concerns addressing his concerns and therapeutic communication. An interview was attempted on 08/15/2025 at 11:24 AM to interview MD was unsuccessful his office was closed.An IT was identified on 08/14/25. The IT template was provided to the facility on [DATE] at 10:13 AM. While the IT was removed on 08/15/25, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm because the facility was continuing to monitor the implementation and effectiveness of their Plan of Removal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents the right to be free from abuse and/or neglect for 1 (Resident #1) of 7 residents reviewed for abuse and/or neglect. The facility failed to ensure Resident #1 was free from physical abuse. CNA A grabbed Resident #1's arm and twisted it and then CNA A put her hands on Resident #1's neck and choked her. The incident occurred on 03/03/25. An IJ was identified on 4/22/25. The IJ began on 03/03/25 and removed on 03/03/25. The facility took action to remove the IJ before the survey began. While the IJ was removed on 03/03/25, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm because all staff had not been trained on behavior management procedures, abuse, and trauma informed care plans. These failures could place residents at risk of physical or emotional harm. Findings included: Record review of Resident #1's face sheet, dated 04/21/25, indicated she was a [AGE] year-old female, initially admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included hemiplegia (complete paralysis on one side of the body) and hemiparesis (refers to a weakness on one side of the body) following cerebral infarction (condition where a brain tissue area dies due to a lack of blood supply and oxygen) affecting right dominant side, vascular dementia (a type of dementia caused by brain damage due to impaired blood flow), bipolar disorder (a mental illness characterized by significant mood swings, ranging from extreme highs to extreme lows), and anxiety disorder (a group of mental health conditions characterized by excessive worry, fear, and anxiety that significantly impair daily functioning). Record review of Resident #1's Quarterly MDS assessment, dated 02/21/25, indicated she had a BIMS score of 11, which indicated moderate cognitive impairment. She was usually able to make herself understood and she was able to understand others. She did not exhibit behaviors of rejection of care or wandering. She had impairment on one side of both her upper and lower extremities. She used a cane/crutch and a wheelchair for mobility. She was able to independently complete activities of eating, oral hygiene, toileting hygiene, lower body dressing, putting on/taking off footwear, personal hygiene, sit-to-standing, and chair/bed-to-chair transfers, and toilet transfers. She required supervision or touching assistance with showering/bathing and tub/shower transfers. She required moderate assistance with upper body dressing. She was able to independently walk 150 feet. Record review of Resident #1's care plan, last revised on 03/03/25, indicated a focus of Resident #1 has a history of trauma that may have a negative impact. The trauma is related to domestic abuse, Resident #1 prefers not to talk about incident. Resident #1 has a history of trauma related to physical assault, she indicates she is ok and does not wish to continue talking about it. The goal was staff will assist in avoiding triggers through next review. Interventions included: *Consult with family regarding resident's condition as appropriate *If the resident has escalated, if at all possible do not touch the resident unless absolutely necessary for resident's or others safety *Monitor for escalating anxiety, depression or suicidal thought and report immediately to the nurse *Psych consult ordered *Social worker or designee to follow up for 3 days. The care plan addressed another focus of Resident #1 has a communication problem related to expressive aphasia. The goal was the resident will be able to make basic needs known on a daily basis through the review date. Interventions included: * Anticipate and meet needs * Ensure/provide a safe environment: Call light in reach, Adequate low glare light, Bed in lowest position and wheels locked, Avoid isolation. * Monitor/document frustration level. Wait 30 seconds before providing resident with word. * Use communication techniques which enhance interaction: Allow adequate time to respond, repeat as necessary, do not rush, Request feedback, clarification from the resident, to ensure understanding, Face when speaking and make eye contact, Turn off TV/radio as needed to reduce environmental noise, ask yes/no questions if appropriate, use simple, brief, consistent words/cues, Use alternative communication tools as needed, such as communication book/board, writing pad, gestures, signs, and pictures. Record review of Resident #1's progress notes, dated 03/03/25 - 03/06/25 indicated the following: *03/03/25 at 5:30PM, by the ADON, indicated, .NP notified of altercation between resident and staff member. NP notified of scratches to residents left arm, bruising to both sides of neck, abrasion to left arm, and bruising to left arm. NP also notified of resident's refusal to go to ER for further evaluation. New orders received to clean scratches to left arm with [normal saline], apply TAO, cover with dry dressing if resident allows, if not leave open to air and monitor for changes. Notify MD/NP of changes. Monitor bruising to left arm and both sides of neck . *03/04/25 at 07:45AM, by the SW, indicated, LMSW spoke with resident concerning incident that occurred on 3/3/2025. Resident advised she was assaulted by CNA. Resident is unable to speak but showed LMSW that CNA had pulled her left arm behind her person while squeezing/placing pressure of left forearm. Resident then advised CNA grabbed her by the neck and squeezed, causing pain. LMSW observed what appeared to injuries sustained by nail markings and blue/green bruising to resident's left forearm and nail marking to both the right and left side of resident's neck. LMSW contacted/made referral .Psych services to follow up with resident, ensuring care of mental health. LMSW also asked if she feels safe at facility with remainder of staff or if there was anything needed to help with safety concerns. Resident advised she currently feels safe and advised she did not have further concerns at this point. Physical Therapy .also met with resident, resident advised [Rehab Director] that she is doing well and will participate in physical therapy on today's date (03/04/2025) LMSW will continue to follow-up with resident, ensuring she continues to feel safe and addressing if any other concerns present. *03/06/25 at 10:28AM, by the MDS Coordinator, indicated This nurse and administrator followed up with resident regarding incident with staff member .she is pleased that staff member is no longer employed here at facility, indicates that she feels safe, and that she is appreciative of the actions taken by management in this incident. No other concerns voiced/indicated. Record review of Resident #1's Initial Skin Assessment, dated 02/28/25, indicated she had normal skin color, with no bruising, skin tears, abrasions, lacerations, incisions, rashes, or ulcers. Record review of Resident #1's Weekly Skin Assessment, dated 03/03/25 at 05:08PM, and completed by the ADON, indicated she had right inner forearm- circular, dime-sized beginning of purplish bruising. She also had an abrasion to the right inner forearm - 0.5cm x 0.5cm. Further, she had other skin findings: scattered scratches to the right inner forearm: 1). 0.5cm x 0.5cm 2). 0.3cm x 0.5cm 3). 0.8cm x 0.3cm 4). 1.3cm x 0.3cm 5). 0.5cm x 0.2cm 3 red areas to right side of neck: 1). 1.2cm x 0.2cm 2). 0.5cm x 0.2cm 3). 2cm x 1cm 1.5cm x 0.5cm red area to left side of neck. Record review of a Physician's progress note, dated 03/06/25, indicated: .On 3/3 resident [and] staff had physical altercation in hallway. [patient] [care of] multiple scratches . scratches [and] bruising to [left] neck. States [left] arm sore but better. Tearful and quiet / states safe now . The note further indicated the resident had a skin tear, and a bruise to the left forearm and neck. Resident #1 was also anxious. During an interview and observation on 04/21/25 at 10:28AM, Resident #1 was lying in bed in her room. She was unable to verbalize most words, but she was able to point and act out her story with motions. She mostly spoke with no and nodded or shook her head to indicate yes or no. This surveyor asked her yes or no questions to gather the story. When asked if CNA A grabbed her arm she said yes. She made a motion to indicate that CNA A grabbed her arm and twisted it behind her back. When asked if it was the left arm she said no and pointed to her right arm. When asked if CNA A touched her neck she said yes, and then put her hands on her neck in a choking motion. When asked if CNA A choked her, she said yes. When asked if she could not breathe when CNA A choked her, she said yes. When asked if CNA A left marks and bruising on her, she said yes, and pointed to her right arm and neck. When asked if it was painful, she said yes. When asked if she had seen CNA A since the incident, she said no. When asked if she was upset and tearful by the incident she said yes. When asked if she felt safe at the facility now, she said yes. When asked who witnessed this event this surveyor gave several names of staff members and residents. She said yes that CNA B and Resident #2 had witnessed the incident. When asked if the police came to the facility she said yes. When asked if she pressed charges against CNA A she said yes. When asked if any other staff have tried to abuse her, she said no. Record review of Resident #2's face sheet, dated 04/21/25, indicated she was a [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included hemiplegia (complete paralysis on one side of the body) and hemiparesis (refers to a weakness on one side of the body) following cerebral infarction (condition where a brain tissue area dies due to a lack of blood supply and oxygen) affecting unspecified side, dementia (a general term for the loss of memory and other thinking abilities that are severe enough to interfere with daily life), and major depressive disorder (a mental illness characterized by persistent low mood, loss of interest or pleasure in activities, and other symptoms that significantly impair daily functioning). Record review of Resident #2's quarterly MDS Assessment, dated 01/17/25, indicated she was sometimes understood, and sometimes able to understand others. Her vision was marked as adequate, indicated she was able to see fine detail, such as regular print in newspapers/books. She had a BIMS score of 12, which indicated moderate cognitive impairment. During an interview and observation on 04/21/25 at 11:58AM, Resident #2 was lying in bed in her room. She was unable to form some words. She was able to use hand motions to tell her story. This surveyor also asked yes or no questions. When asked if she remembered the incident with Resident #1 and CNA A she said yes. When asked if CNA A grabbed Resident #1, she said yes. When asked what happened, Resident #2 made a motion with her right arm and moved it behind her back. When asked if CNA A grabbed Resident #1's arm and twisted it she said yes. When asked if Resident #1 was swinging and trying to hit staff she said yes. This surveyor asked her to point at the arm that CNA A grabbed on Resident #1 she pointed to her right arm. When asked if she saw bruises and scratches, she said yes and pointed to her right arm. When asked what else CNA A did to Resident #1, she put her hand up towards her neck and made a choking sign. This surveyor asked her if CNA A used her hands, or her arms and the Resident pointed to her hand. When asked if Resident #1 hit CNA A and then CNA A choked Resident #1 she said yes. When asked if she had seen CNA A since the incident, she said no. When asked if she had observed any other abuse in the facility, she said no. Record review of an undated witness statement by the MDS coordinator indicated on [03/03/25] at approximately 3:15[PM], this nurse heard yelling, I went to the nurses station to investigate and noted [Resident #1] in front of the 500 hall with several staff members standing around her. When I asked her what was going on, she showed me her left forearm, at that time I noted several dark, half moon shaped indentions, a dark blue circular mark, and a scratch with a small amount of red blood. Resident was upset, had tears in her eyes and indicating towards hall 600. I looked up and saw [CNA A] coming from the 600 hall, who went to the time clock and I witnessed her walk out the front door. On seeing her, resident became even more upset, yelling and pointing at her. At that point, I assisted resident to the administrator's office. While talking with her with the administrator, she indicated that her arm was pulled backwards and that her neck was grabbed. When looking at her neck, I noted a bright red mark going from under her chin in the middle of her neck, to just below the corner [of] her jawbone noted a small abrasion with no bleeding, resident also had a small circular abrasion to her chin. This nurse stayed with resident in administrator's office talking with her and reassuring her until she calmed down and was no longer crying. She indicated that she wanted to leave the office, and headed to her room, she had her phone and indicated that she wanted to make a phone call. Record review of a witness statement by CNA B, dated 03/03/25, indicated [CNA B, CNA A, and CNA C] were in the linen room. [Resident #1] approached us and said 'no no' and was rubbing her body to let her aide know she wanted a shower. [CNA A] [continued] grabbing her linen. I walked away to answer one of my lights. When I came out [of] my resident room [CNA A] was at the end of the hall with her linen cart. [Resident #1] was blocking [CNA A] from passing by. [CNA A] asked her to move [and] she would not. [Resident #1] was hitting [CNA A]. [CNA A] was allowing it. After a while [CNA A] grabbed [Resident #1's] arm and told her to stop [and] she would not. [Resident #1] put her wheelchair in lock [and] stood up to hit [CNA A]. [CNA A] .put her hands on [Resident #1's] neck to calm her down. I grabbed [CNA A] and told her to walk away. Record review of a witness statement by CNA A, dated 03/03/25, indicated I was loading my linen cart when [Resident #1] stopped and asked for a shower. (after checking my computer chart I had my shower sheets available.) I informed [Resident #1] I had to prioritize those residents first before I take on the other responsibilities. After closing the linen closet, I asked her if she needed anything else - bed linen changes, a snack? She refused. Trying to get back to my hallway, I begin to push my cart. I thought I bumped her, so I stopped and apologized. Only to realize she was actively pushing my cart as she was rolling down the hall. She stopped near the nursing station and blocks my path. (another resident is no the other sides, so I wasn't able to fit with my linen cart). I pushed [Resident #1's] wheelchair slightly to the right after asking for space repeatedly. When I feel I have enough space I pull my linen cart between the residents. [Resident #1] locks her wheelchair and begins swinging at me. I grabbed her wrist to keep from getting hit. I informed her that she was about to hit another resident after releasing her wrist. She's still trying to attack me and elbows me and hits me in the face. I give her a hug and told her I love my job! When releasing from my embrace I grab my linen closet and take it back to my hall. During an interview on 04/21/25 at 1:09PM, the MDS Coordinator said she did not witness the incident between CNA A and Resident #1. She said she did hear yelling and went down to where the resident was. The incident was already over when she made it to the area. She said she did not see CNA A. She checked on Resident #1 and saw marks and scratches on her arm. She said she did not see blood. She said she also saw red marks on Resident #1's neck. She said Resident #1 was visibly upset and crying. During an interview on 04/21/25 at 1:12PM, the Treatment Nurse said she heard the screaming at the time of the incident. She said she came out and saw marks on Resident #1's arm. She said she saw dug in fingernail marks that were beginning to bruise. She said she saw 4-5 marks. She said she asked CNA A what had happened, and CNA A said she did not remember. During an interview on 04/21/25 at 1:21PM, CNA D said she heard the commotion of the incident. She said when she walked outside of the facility, she saw CNA A leaving the facility. She said did not see the Resident. She said it seemed out of character for the CNA. She said she had worked with the CNA in the past. She said the CNA seemed like something was wrong that day. During an interview on 04/21/25 at 1:28PM, CNA B said she witnessed the incident between CNA A and Resident #1. She said she was near the linen room with CNA A. She said Resident #1 came by and made a gesture that she wanted a shower. She said CNA A asked Resident #1 to give her a minute. She said at this point she had to walk away and complete a task with another resident. She said she then heard yelling. She said when she came back out to the hall, she saw Resident #1 standing out of her wheelchair and Resident #1 slapped CNA A. She said CNA A was holding Resident #1's arm to keep her from swinging and hitting her. She said CNA A then reached out and put her hands on Resident #1's neck and choked her. She said she intervened and split up the altercation and asked CNA A to walk away. She said she had not really worked with CNA A before, so she was unsure if this was out of character for her. She said it was not okay for a CNA or any health care staff to do this to a resident. She said she did not look at the resident's skin. She said at this point there was a bunch of people around and the nurses were assessing her. She said someone reported it to the Administrator. She said she wrote a statement. During an interview on 04/21/25 at 2:00PM, CNA A said on the day of the incident she was loading one of her hallway linen carts. She said another aide saw Resident #1 saying that she needed something. She said when she addressed Resident #1, she motioned that she needed a shower. She said she checked her shower sheets, and Resident #1 was not on her sheets for that day so she would take care of her after her scheduled showers were completed. She said the resident remained in the hallway. She said after she finished stocking her cart, the resident then asked again for a shower. She said she offered to strip Resident #1's bed so she would have clean linens. She said the resident refused. She said she started moving her linen cart down the hallway and she thought she ran into Resident #1 with the linen cart, so she stopped and apologized. She said she looked over and noticed Resident #1 had her hand up and was pushing the linen cart. She said she stopped walking and let the resident move away from her cart. She said she waited a few minutes and then tried to move again. She said Resident #1 blocked the end of the hallway from her leaving with the cart. She said she asked Resident #1 to move so she could pass. She said Resident #1 had a hard time communicating. She said Resident #1 was ignoring her request to move so she could get through and out of the hall. She said Resident #1 tried to swing at her. She said she was trying to protect herself from the resident hitting her. She said there was also another resident nearby she was trying to keep Resident #1 from hitting. She said Resident #1 elbowed her in the stomach and then hit her in the face. She said she hugged the resident and then clocked out and left. She said she did not hold Resident #1's hand. She said she was making contact with her wrist. She said she held Resident #1's shoulder when she gave her a hug. She said she did not grab Resident #1's arm and twist it. She said she did not put her hands on Resident #1's neck. She said she clocked out because she was afraid the situation would upset her and make her lose her job. She said she felt she had to leave the environment because she was not safe. She said CNA B was not around when she was talking to Resident #1. During an interview on 04/23/25 at 10:26AM, the Social Worker said she did a trauma assessment the next day following the incident for Resident #1. She said she spoke with the resident and the injuries lined up with her story. She said she observed bruising and scratches on Resident #1's arm. She said she saw a nail mark on the resident's neck at the time of the trauma assessment. She said the resident appeared to be in an okay state. She said the resident was relatively calm. She said she assured the Resident that she would be safe in the facility. She said the resident has a history of being a victim of domestic violence and sexual assault. She said she was unsure if the CNA abusing her could have been triggering for her considering that the resident had a history of being a victim of domestic violence and sexual abuse. She said she started the resident on psychological services to check on her. She said she was not in the facility at the time of the incident. During an interview on 04/23/25 at 10:35AM, the ADON said she was not in the facility on the day of the incident. She said she felt like CNA A abused Resident #1. She said she expected the CNA to not abuse the resident. She said the resident was calm the next day when she saw her. She said it was possible that due to the resident's history of being a victim of domestic violence and sexual abuse it could have been triggering for her. She said the CNA never showed any indication that she would hurt a resident. She said all the residents liked CNA A and she was shocked when it happened. She said Resident #1 had bruising and scratches on her arm and she had red marks on her neck after the incident. She said Resident #1 also had fingernail indentions on her arm. During an interview on 04/23/25 at 10:48AM, the DON said she was not in the facility when the incident between CNA A and Resident #1 occurred. She said she was sick with the flu and came back later that week. She said she did visit with the resident when she was able to come back. She said she could not remember if she saw anything on her neck when she came back, but she did have bruising and scratches on both arms. She said she felt like CNA A abused Resident #1. She said she expected her staff to not abuse residents. She said the measures to correct the noncompliance were in place on 03/03/25. She said this incident was probably triggering to Resident #1 considering she had a history of being a victim to domestic violence and sexual abuse. She said she checked on the resident on 04/22/25 and the resident was crying because she felt like she was reliving the incident when talking to this surveyor on 04/22/25. During an interview on 04/23/25 at 11:08AM, the Administrator said he was in the facility at the time of the incident between CNA A and Resident #1. He said his door was open and he was in his office. He said there was a bunch of noise in the common area. He said he came out and the other staff were gathered around Resident #1. He said he asked the staff what had happened. He said at this time CNA A had already walked out the front door of the facility. He said he initiated an investigation and checked on the resident's safety. He said CNA A had already removed herself from the facility. He said he took a statement from CNA A and suspended her. He said he called the police and notified them. He said several staff followed up with the resident. He said he ultimately substantiated abuse and terminated CNA A. He said after the incident he noticed the red marks to Resident #1 on both sides of her neck. He said there was a red mark that looked like a hand on her neck. He said he conducted in-services on abuse and neglect and behavior management. He said Resident # 1 felt better after he notified her that the CNA was not going to return. He said he felt like this incident could be triggering for the resident considering her history of being a victim of domestic violence and sexual abuse. He said it was 100% physical abuse of a resident. He said he did not expect the staff to abuse the residents. He said he has a zero tolerance for abuse or neglect. During an interview on 04/23/25 at 12:04PM, the MDS Coordinator said she conducted a trauma assessment on Resident #1 shortly after the incident between her and CNA A. She said at first when she checked on Resident #1, she was crying and visibly upset. She said the resident had crescent moon indentions on her arm and bruising. Her neck had a red mark that went from her back of her neck in a line towards the front. She said there were marks on the other side of her neck as well. Record review of the facility's policy, Abuse/Neglect, last revised 03/29/18, indicated: The Resident has the right to be free from abuse .as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion .Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. The facility will provide and ensure the promotion and protection of resident rights . .1. Abuse: abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish .Instance of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It included verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm . The administrator was notified of the IJ on 04/22/25 at 11:30AM due to the above failures. The administrator was provided with the IJ template on 04/22/25 at 11:32AM. The surveyor confirmed the following measures had been implemented sufficiently to remove the Immediate Jeopardy on (03/03/25) by: - Reviewed completed facility self-reported incident to HHSC for Resident #1 dated 03/03/25 - This surveyor interviewed Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6 on 04/21/25. Each resident indicated they had not been abused, and they enjoyed the facility staff. - Reviewed paperwork which indicated CNA A was suspended until completion of investigation which indicated the following: *dated 03/03/25 indicated .Type of Disciplinary Action: Investigatory Suspension .[CNA A] will be placed on an investigatory suspension pending an investigation into allegations of abuse .ADM .HR Director . - Reviewed paperwork which indicated CNA A was terminated after the allegation of abuse was investigated, which indicated the following: *dated 03/05/25 indicated .Type of Disciplinary Action: Discharge .[CNA A] failed to adhere to the Corporate Code of Conduct. [CNA A] was placed on an investigatory suspension pending an investigation into allegations of abuse; allegations were substantiated. [CNA A] is aware of all policies and procedures via their signature on the employee handbook acknowledgement. [CNA A] meets criteria for immediate termination .DON .ADM .HR Director . - Reviewed paperwork which indicated CNA A had a criminal history check before hire. CNA A had a criminal history check on 02/01/24 and her date of hire was 02/01/24. - Reviewed paperwork which indicated the incident between CNA A and Resident #1 was reported to the local police department. The local police were notified on 03/03/25. - Reviewed documented safe survey resident interviews conducted on 03/03/25 during the course of investigation. They indicated no residents complained of resident abuse/neglect or misappropriation. The sampled residents verified they felt safe in the facility, were treated well by the staff, they did not have any concerns to report, and that any concerns were to be reported to the abuse coordinator. - Record review of a facility conducted in-service, Abuse and neglect dated 03/03/25, indicated 26 of 49 facility staff were provided education on the topic. - Record review of a facility conducted in-service, Behavior Management dated 03/03/25, indicated 26 of 49 facility staff were provided education on the topic. - During interviews on 04/22/25, starting at 8:54AM, the MDS Coordinator, PTA F, the Rehab Director, the Maintenance Director, the Dietary Manager, Dietary [NAME] G, RN H, LVN K, CNA L, LVN M, CNA D, CNA N, the ADON, the Activity Director, the HR Director, the DON, CNA O, LVN P, CNA Q, and LVN R had been in serviced on abuse and neglect. They were able to identify an example of abuse and were able to verbalize to report any abuse to the abuse coordinator, (Administrator). They were also able to verbalize an understanding of behavior management, and proper de-escalation techniques for a resident that was trying to hit another staff or resident. - Record review of Resident #1's Trauma Informed PRN Assessment, dated 03/03/25, indicated a trauma assessment was completed by the MDS Coordinator.altercation with employee in this facility. Was handled by other facility staff, and feels safe now that the offending employee is no longer in the building . - Record review of Resident #1's Psych Visit Note, dated 03/04/25, indicated the resident was added to psych services and saw a provider this day. [Resident #1] is seen in her room. She is calm, pleasant and consents to the interview .The patient is unable to elaborate on what happened but reports feeling safe now that the staff member in question is no longer working at the facility. She reports no issues with any of the remaining staff and says they all treat her well. She denies being fearful . The noncompliance was identified as Past Immediate Jeopardy. The IJ began on 03/03/25 and was removed on 03/03/25. While the IJ was removed on 03/03/25, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm because all staff had not been trained on behavior management procedures, abuse, and trauma informed care plans.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the resident environment remained free of accident hazards as possible, and each resident received adequate supervision and assistance devices to prevent elopement for 1 of 5 residents (Resident #1) reviewed for accident hazards and supervision. 1. The facility failed to ensure Resident # 1 had adequate interventions to prevent elopement on 04/08/24 after he had verbalized and or attempted to leave the facility on 03/15/24, 03/17/24, 03/18/24, and 03/31/24. 2. The facility failed to prevent Resident #1 from eloping from the facility on 04/08/24. Resident #1 wheeled himself approximately 0.3 miles from the facility. An Immediate Jeopardy (IJ) situation was identified on 07/09/24 at 5:51 p.m. While the IJ was removed on 07/10/24, 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, due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk of serious injury or harm. Findings include: Record review of Resident #1's face sheet, dated 07/09/24, reflected Resident #1 was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #54 had diagnoses which included Dementia (loss of memory), stroke, diabetes (a disease that occurs when your blood glucose, also called blood sugar, is too high), and seizures. Resident #1 was his own responsible party. Record review of Resident #1's comprehensive care plan dated 08/28/23, reflected Resident #1 had behavior issues because he would decide at times that he wanted to leave the facility and go homeless. Resident #1 was educated on safety and allowed to vent and express his frustrations. Resident #1 attempted multiple times to exit the building. Resident #1 voiced he wanted to leave. The staff interventions were if reasonable, to discuss the resident's behavior. Explain/reinforce why the behavior was inappropriate and/or unacceptable and praise for any indication of the resident's, progress/improvement in behavior. Record review of Resident #1's quarterly MDS assessment, dated 03/21/24, reflected Resident #1 understood and was understood by others. Resident #1's BIMS score was 03, which indicated he was severely cognitively impaired. Resident #1 required assistance with bathing and was independent with toileting, personal hygiene, transfer, dressing, bed mobility and eating. Record review of Resident # 1's Elopement assessment, dated 03/14/24, reflected Resident #1 was at risk for elopement. Record review of the progress noted, dated 03/15/24, written by LVN A, reflected Resident #1 attempted to leave the facility twice. He was redirected and brought back to the lobby. Record review of the progress noted, dated 03/17/24, written by LVN A, reflected Resident #1 attempted to leave the facility by the emergency exit on hall 500 when he was stopped by a CNA. He was later seen crawling toward the front door to leave the facility. LVN A notified the NP, DON, and Administrator and obtained orders to send him to the hospital. Record review of Resident #1's hospital visit, dated 03/17/24, reflected Resident #1 had a diagnosis of altered mental status (a disruption in how your brain works that causes a change in behavior). Record review of the progress noted, dated 03/18/24, written by LVN A, reflected Resident #1 was on the floor crawling toward the front door again after the hospital visit. Record review of Resident # 1's Elopement assessment, dated 03/20/24, reflected Resident #1 was at risk for elopement. Record review of the progress noted, dated 03/31/24, written by LVN A, reflected Resident #1 said he was going to leave the facility. Record review of an incident report, dated 04/08/24, written by LVN C at 5:52 p.m., reflected the MDS nurse was driving by the facility and noticed Resident #1 was in his wheelchair in the parking lot of the shopping center a few hundred yards away from the facility. LVN B and the MDS nurse assisted Resident #1 back to the facility. According to LVN B Resident #1 was last seen in the dining room eating supper about 20 minutes earlier. Record review of the progress noted, dated 04/08/24, written by LVN C, reflected she notified a family member of Resident #1's elopement and the family member stated she knew he had been trying to escape for over a month now. Record review of Resident #1's comprehensive care plan, dated 04/08/24, reflected Resident #1 was at risk for wandering related to history of attempts to leave the facility and voiced he wanted to leave the facility. Resident #1 tore the gate in the fenced-in smoke area and propelled himself about a block from the facility where staff observed him and assisted him back to the facility. The intervention was to place Resident #1 on 1:1 monitoring, apply a wander guard, and distract the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, and books. Resident #1's care plan did not address Resident #1's risk for elopement prior to 04/08/24. Record review of the consolidated physician orders, dated 04/08/24, reflected Resident #1 to have a wander guard for wandering and staff to monitor every shift for the function of the wander guard. Resident #1 did not have an order for a wander guard before he eloped on 04-08-24. Record review of Resident #1's electronic medical record, dated 02/25/24 through 04/05/24, did not reflect any documentation of changes in his condition that could have caused Resident #1 to make statements or attempt to leave the facility. Resident #1's electronic medical record did not reflect any interventions to prevent elopement except for redirection prior to his elopement on 04/08/24. During an interview on 07/08/24 at 1:06 p.m., the RCN said she was the traveling DON and started with this facility on 03/25/24, and Resident #1 eloped on 04/08/24. She said she was in the facility on the day Resident #1 had eloped. She said she left the facility before he eloped. She said staff called her at home to notify her of his elopement and they had located him and brought him back to the facility with no visual injuries noted. She said Resident #1 escaped out of the 400 hall exit door. She said the way he broke the door; the alarm did not go off to alert staff. She said she was amazed at how he escaped, she said he was determined by the way the door looked. She said she was unaware of any statements Resident #1 made before his elopement. She said she saw where he had a lot of falls according to the fall log and was trying to find out why. She said she had ordered labs, talked with the NP, and asked the pharmacist to review his medication. She said it was only after his elopement that she looked further into his medical records and realized he did not have sufficient documentation in his chart to show what the facility had done to prevent his elopement. She said she wrote orders for his wander guard and called the psychiatrist. She said he had a telehealth visit with the NP psychiatrist on 04/09/24. She said the staff had already implemented the 1:1. She said they continued 1:1 until he was discharged from the facility on 05/19/24. During an interview on 07/08/24 at 2:36 p.m., the MDS nurse said she was on her way home from the store when she noticed Resident #1 between the facility and the shopping center. She said she called the facility, spoke with LVN B, and told him what she saw. LVN B said he was not aware Resident #1 had left the facility. She said she parked her car and by then LVN B was outside of the facility. She said by the time she parked her car Resident #1 was in the shopping center parking lot a few hundred yards away. She said she and LVN B brought Resident #1 back to the facility. She said he did not have any injuries but was laughing and said he was going to leave again. She said she was aware of his threats to leave the facility and his going to the front door and pushing on the door. She said she did not think he was serious because he would wait until staff was around and then make the statement he was going to leave. She said I thought he did it more for attention. She said she had not care planned his attempts or statements of elopement before he eloped. She said she thought it was a behavior and had care planned his behaviors. During an interview on 07/08/24 at 3:16 p.m., the Psychiatrist NP said she had been seeing Resident #1. She said she knew he had behaviors but was not aware of his statements or attempts to leave the facility. She said they called her after he eloped on 04/08/24 and she did a telehealth visit (online doctor's visit) on 04/09/24. She said her husband had been sick and she had missed the last few scheduled visits for Resident #1. She said she missed his 03/13/24, 03/21/24, and 04/04/24 visits. She said if she had known about his statements or attempts to leave the facility, she could have changed her visits, done a telehealth visit, or made medication adjustments. During an interview on 07/08/24 at 5:15 p.m., LVN A said she was aware of Resident #1's threats and attempts to leave the facility. She said she notified the Administrator, DON, and NP about most of Resident #1's attempts to leave the facility but was not sure about all his attempts. LVN A said on some occasions she was instructed to send him to the hospital but on other occasions, she monitored him closely. LVN A said she had not completed and did not know she needed to complete an elopement assessment, place him on every 30-minute checks, or update his care plan when he attempted to leave or made threats that he wanted to leave the facility. LVN A said Resident #1 could have injured himself on the uneven road or even died if a car had hit him. During an interview on 07/08/24 at 5:30 p.m., LVN C said she was the charge nurse when Resident #1 eloped on 04/08/24. She said the MDS nurse notified her that Resident #1 was outside the facility between the facility and the shopping center. She said she was not aware Resident #1 had left the facility grounds. She said when she went outside LVN B and the MDS nurse were bringing Resident #1 into the facility. She said LVN B assessed Resident #1 with no visual injuries noted. She said she called the Administrator, the DON, and his family. She said Resident #1 was in the dining room eating his supper around 5:30 p.m. which was the last time she had seen him. She said without the staff knowing Resident #1 had left the facility he could have been injured or hit by a car. She said Resident #1 had attempted to leave the facility before but nothing like this. She said they just redirected him mostly. She said she did not do an elopement assessment or update his care plan on his attempts to leave the facility because she was not aware she needed to do them. She said she believed she told the Administrator and DON of his prior attempts. During an interview on 07/08/24 at 5:50 p.m., LVN C said he received a call from the MDS nurse on 04/08/24, but he was unable to recall at what time the phone call was received. He said the MDS nurse reported Resident #1 was outside the facility between the facility and the shopping center. He said he went outside and when he saw Resident #1, he was in the shopping center parking lot. He said he and the MDS nurse brought Resident #1 back to the facility. He said he assessed him with no visual injuries. He said Resident #1 made the statement he was going to do it again (leave the facility). He said he then went to see how Resident #1 left the facility. He said it appeared he unscrewed the bolts with his hands on the door and then kicked the door open. He said the magnetic hardware was still attached to the door therefore the alarm did not go off. He said he found the screws and screwed them back in. He said the maintenance staff was called, and they returned to the facility and retightened the screws. He said the door had been properly repaired since Resident #1's elopement. During an interview on 7/9/24 at 12:34 p.m., LVN D said she had been employed at the facility for about 6 months. She said Resident #1 had some changes in his behavior since mid-February and had escalated since that time. She said Resident #1 pulled on the front door several times before he eloped on 04/08/24. She said she was instructed by the ADON and DON to redirect Resident #1 when she saw him near the exit doors and she instructed the aides to do the same. She said she was not aware of any elopement assessments, or how to update a care plan. She said she was a new nurse, and this was her first job. During an interview on 7/9/24 at 2:34 p.m., CNA EE said she knew Resident #1. She said Resident #1 was quiet when he came to the facility but over the last few months, he changed. She said he was coming out of his room and saying he wanted to leave the facility and he attempted to leave a few times before he eloped on 04/08/24. She said the nurses were aware and they monitored him mostly. She said she remembered one time they sent him to the hospital because he would not leave the front door but when he returned, he was still saying he was going to leave the facility. The nurses on duty were aware, but she was unable to recall their names. During an attempted phone interview on 07/09/24 at 3:00 p.m., with the previous ADON was unsuccessful, a message was left. During an attempted phone interview on 07/09/24 at 3:10 p.m., with the previous Administrator was unsuccessful, a message was left. During a phone interview on 7/9/24 at 3:44 p.m., the facility NP said she was seeing Resident #1. She said she was aware of his threats to leave the facility, and of his previous attempts to leave the facility. She said he told her before he would rather be homeless or go to prison than reside at the facility. She said he received psychiatric services, and they were adjusting his medications. During an interview on 7/10/24 at 1:33 p.m., the previous ADON said Resident #1 was aggressive and an elopement risk. She said Resident #1 attempted to leave the facility on several occasions before he eloped on 04/08/24. She said she had consulted psychiatric services, and she instructed staff to stay with the resident or call the police if needed when he attempted to leave the facility. She said she could not recall them making referrals to other facilities even after he had made statements and/or attempts to leave the facility. She said after Resident #1 eloped they placed him on 1:1, and shortly afterward gave him a 30-day notice. She said they started making referrals to other facilities and notified the Ombudsman. She said she did not know the facility's elopement policy. During an attempted phone interview on 07/10/24 at 2:00 PM, Resident #1 was unable to be reached. During an interview on 7/10/24 at 5:00 p.m., the previous Administrator said she was the Administrator when Resident #1 eloped. She said she was notified the MDS nurse drove by the facility and saw Resident #1 going towards the shopping center away from the facility. She said after they brought Resident #1 into the facility, they placed him on 1:1. She said there were times when Resident #1 said he wanted to leave the facility before he eloped on 04/08/24. She said during the times Resident #1 attempted to leave the facility or made statements he wanted to leave the facility; they did not have a social worker; so, she was doing the best she could. She said looking back they should have placed him on 1:1 after he started making statements or attempted to leave the facility. She said she could not recall the elopement policy for the facility. Record review of the facility's policy, Elopement Prevention , dated 01/23, reflected, Policy Statement Every effort will be made to prevent elopement episodes while maintaining the least restrictive environment for residents who are at risk for elopement. 1. The Elopement Risk Assessment will be completed upon admission. The assessment should be completed by reviewing the resident's medical history and social history. Information may be obtained by reviewing current medical records, if available, an interview with the resident/family, or a conference with the interdisciplinary team member. The assessment tool should be completed, and interventions implemented as indicated. The Elopement Risk Assessment is to be completed at least quarterly, after an elopement attempt, upon new exit-seeking behavior, and upon change of condition. 3. The resident's current chart and assessments will be reviewed to determine what changes have occurred that would trigger elopement episodes. 4. The resident's care plan will be modified to indicate the resident is at risk for elopement episodes. 5. Interventions into elopement episodes will be entered into the resident's care plan and medical record. Staff Training: Staff will receive training during their orientation process and then annually regarding: o Elopement prevention o Operation of all exit devices o Actions to take if elopement occurs effective transition of care. Record review of the facility's policy, Elopement Response, dated 01/23, reflected Policy Statement: Nursing personnel must report and investigate all reports of missing residents. When an elopement has occurred or is suspected, our elopement response plan will be immediately implemented. Policy Interpretation and Implementation: 1. It is the responsibility of all personnel to report any resident attempting to leave the premises, or suspected of being missing, to the charge nurse as soon as practical. 4. Should an employee discover the resident is missing from the facility (Code Orange), he/she should: A. Report to the charge nurse 7. Post-return resident evaluation and care: C. The facility will evaluate its elopement prevention program and all residents will be reassessed for elopement risk. 8e Documentation: An event note is to be made out on all residents who, without knowledge of the staff, leave the facility. Including the following: o Date o Time resident was first determined missing o Responsible party notified and time o Attending physician notified and time o Emergency Personnel o Condition of resident when located o Where located and time located Complete and file an incident report and o Make appropriate entries into the resident's medical record. o After an elopement the care plan coordinator will reevaluate the resident's care plan. This was determined to be an Immediate Jeopardy (IJ) on 07/09/24 at 5:51 p.m. The Administrator was notified. The Administer was provided with the IJ template on 07/09/24 at 6:05 p.m. The following Plan of Removal submitted by the facility was accepted on 07/10/24 at 2:30 p.m.: 1. As of 7 /9/24, Resident #1 no longer resides in the facility. 2. Elopement risk assessments for all residents in the facility were completed and reviewed by the DON/ADON/Designee on 7/9/24. No additional concerns were identified. 3. All elopement risk care plan interventions were reviewed on 7/9/24 by the Regional Compliance Nurse, DON, and ADON. All interventions are in place and care planned. 4. The Administrator, DON, and ADON were in-serviced 1:1 by the Regional Compliance Nurse on 7/9/24 on the following: a. Elopement Prevention Policy to include implementing interventions for residents at risk. b. Elopement Response Policy 5. The Medical Director was notified of the immediate jeopardy on 7/9/24. 6. An additional QAPI meeting was conducted on 7/9/24 to discuss the immediate jeopardy citation and subsequent plan of correction. In-services: 1. The Regional Compliance Nurse, Administrator, DON, and ADON will in-service all staff on the following topics below. All staff not present for the in-services will not be allowed to work their next shift until the in-service are completed. All new hires will be in-serviced during orientation prior to working their shift. All agency staff will be in-serviced prior to assuming their scheduled shift. a. All staff were in-serviced on the elopement response policy by the Compliance Nurse, Administrator and DON on 7/9/24. b. All staff were in-serviced on elopement prevention by the Compliance Nurse, Administrator, and DON on 7/9/24. Monitoring of the POR included the following: Observation of the 400 hall exit door revealed it was repaired. During Interviews on 07/10/24 from 9:26 a.m. until 2:30 p.m. with 1 RN 6 am-6 pm (RN L), 1 PRN RN (RN FF), 6 am-6 pm 4 LVN (LVN B, LVN D, LVN E, and LVN F), 3 PRN LVNs 6p-6a (LVN A, LVN Z, LVN CC), 3LVNs PRN (LVN X, LVN Y, and LVNAA), and 6 am-2 pm 4 CNAs (CNA G, CNA V, CNA H and CNA S), 2 pm-10 pm 1 CNA (CNA EE), 10 pm-6 am 2 CNAs (CNA R, CNA DD, ) 6 am-10 pm 1 CNA (CNA BB), 3 PRN CNAs (CNA J CNA W and CNA I), Dietary staff 4 Cooks (Cook O, [NAME] N, [NAME] M, and [NAME] Q), housekeeping department 2 housekeepers (Housekeeper L, Housekeeper K), Therapy Department 2 therapist (T and P) and the ADON, MDS, BOM, HR, Dietary manager, Maintenance supervisor, Housekeeping Supervisor, and activity director all who indicated they received a written in-service regarding the process of elopement prevention and response. Staff was able to state what to do if a resident made statements or attempts to leave the facility and what to do if a resident eloped from the facility. During a phone interview on 07/10/24 at 1:30 p.m., the facility medical doctor said he was aware of the IJ received and attended a QAPI meeting via phone. During an interview on 7/11/24 at 2:36 p.m. the DON said when a resident starts making statements, such as I want to leave, we do not dismiss the statements. Staff should report any statements or attempts to leave the facility to their management. She said even if staff believed a resident was joking, they should take any statements or attempts to leave the facility seriously. Staff should do another elopement assessment, update the care plan, and be thorough on what interventions they put in place. Resident #1 had a traumatic brain injury also known as TBI (damage to the brain which could affect the way a person thinks or behaves) so she said she would have done an in-service with staff about his disease process. She said she would educate staff on making sure they kept their eye on him and placed him on every 30-minute check. She said as management, she would coordinate with psychiatric services, the doctor, and any other outside resources. She said then she would have made referrals to a more equipped facility. She said the Administrator and herself were responsible for the safety and well-being of all residents. During an interview on 7/11/24 at 2:41 p.m., the RCN said the facility failed to follow its policy on prevention. She said when the facility became aware of Resident #1's statements to leave the facility or his attempts to leave the facility staff should have followed the policy on prevention and elopement. She said after he eloped the staff told her they tried to find him placement and other things but when she looked in his electronic medical records, she could not locate the information. She said during the POR they educated all staff on the facility's policy and felt if this situation ever happened again staff would implement their policy. She said the DON and the Administrator should have been responsible for following up on the statements and ensuring they had things in place to prevent the elopement. During an interview on 7/11/24 at 2:56 p.m., the Administrator said whenever a resident made statements about wanting to leave the facility staff should have done an elopement assessment, elopement drill, elopement in-service, staff education, and resident assessment. He said he would have placed Resident #1 on every 30-minute check until they could have placed him in a secure unit. He said his goal would have been to keep him safe until he was placed in a secure unit. He said staff were in-serviced on what to do if this situation ever arose again. Record review of the Elopement risk assessments for all residents in the facility completed on 7/9/24 revealed 5 residents at risk of elopement. Record review of the 5 identified residents at risk of elopement revealed their care plans and interventions were updated. Record review of the Elopement Response and Prevention in-service, dated 07/09/24, given by RCN, to the Administrator, Administrator in training, and DON revealed the policy on elopement response and prevention. Record review of the Elopement Response and Prevention in-service, dated 07/09/24, given by RCN, Administrator, and DON signed off by staff who attended or were phoned revealed they were instructed on the policy for elopement response and prevention. Record review of the sign-in sheet for the additional QAPI meeting conducted on 7/9/24 revealed, the QAPI team will update the elopement system with new interventions discussed to ensure compliance with the recommendations implemented as well as a plan in place for sustainability. An In-service was given to all staff including the Administrator, DON, and ADON on the following policies: 1. Elopement Prevention 2. Elopement Response. Once compliance was established Administrator and DON/ADON would monitor the system weekly, to ensure continuous compliance was met. The Administrator was informed the Immediate Jeopardy was removed on 07/10/24 at 2:30 p.m. The facility remained out of compliance at a scope of isolated and a severity level of no actual harm with a potential for more than minimal harm that is not immediate jeopardy and due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide pharmaceutical services including procedures to ensure the accurate acquiring, receiving, dispensing, and administering of all drugs to meet the needs of each resident for 1 of 3 Residents reviewed for pharmaceutical services. (Resident #1) The facility failed to follow physician order to give Resident #1 Invega Sustenna prefilled syringe 234 MG/1.5ML injection once a month. Resident #1 missed Invega in October and began hearing voices telling him to harm himself and Resident #1 had to be admitted to a psychiatric facility. The facility failed to ensure their Medication Administration Policy was followed where a resident's medication will be administered in an accurate, safe, timely and sanitary manner. The facility failed to ensure Resident #1's script for Invega Sustenna prefilled syringe 234 MG/1.5ML injection medication were acquired from pharmacy. The noncompliance was identified as PNC. The Immediate Jeopardy (IJ) began on 10/18/2023 and ended on 11/3/23. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of not receiving the intended therapeutic benefit of the medications. Findings included: Record review of Resident #1's face sheet printed on 11/3/23, indicated Resident #1 was a [AGE] year-old male who originally admitted on [DATE] and readmitted on [DATE] and transferred on 11/01/23 to a psychiatric hospital with diagnoses including schizoaffective disorder (a mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania) and major depressive disorder (so known as clinical depression, is a mental disorder characterized by at least two weeks of pervasive low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities). Record review of Resident #1's physician order printed on 11/3/23 indicated an order for Invega Sustenna prefilled syringe 234 MG/1.5ML injection once a month for psychosis related to schizoaffective disorder; Start Date: 8/23/23. During an interview on 11/4/23 at 3:51 p.m., at the acute psychiatric hospital, Resident #1 was escorted to the visitation area. He said he started hearing voices real bad telling him to hurt himself and he said he did not want to hurt himself. Resident #1 said he had a history of hearing voices but whenever he took his medications the voices were not that bad. Resident #1 said the facility explained he missed a psych medication, and they were going to send him to the psychiatric hospital to be evaluated and treated. Resident #1 said he felt better and was ready to return to the facility. During an interview on 11/14/23 at 2:31 p.m., The DON said in October 2023 she was working the floor as charge nurse and was giving meds to her assigned hall. She said she recalled that she could not locate Resident #1's Invega medication, so she placed an order and did not notify staff to administer Resident #1's medication when it arrived and as a result Resident #1 missed his October's Invega dosage because mediation was not available. During an interview with on 11/14/23 at 4:23 p.m., Doctor D said it was too hard to tell, and could not tell State Surveyor if it was possible the missed dosage of Invega Sustenna medication led to Resident #1's hallucinations telling him to harm himself. He said he was not 100% sure. Record review of Resident #1's revised care plan initiated 8/25/23 indicated Resident #1 required anti-psychotic medications. Goal: The resident will be/remain free of drug related complications, including movement disorder, discomfort, hypotension, gait disturbance, constipation/impaction, or cognitive/behavioral impairment. Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness; Monitor/record occurrence of for target behavior symptoms pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others and document per facility protocol. Record review of transfer form dated 11/1/23 indicated Resident #1 was transferred to an in-patient psychiatric hospital on [DATE] at 2:00pm. Reason for transfer: Resident #1 was having command hallucinations and voices telling him to hurt himself. Current primary diagnosis: schizoaffective disorder. Record Review of Resident #1's September's TAR revealed Invega Sustenna prefilled syringe 234 MG/1.5ML injection once a month for psychosis related to schizoaffective disorder, was administered on 9/20/23. Record Review of Resident #1's October's TAR revealed Invega Sustenna prefilled syringe 234 MG/1.5ML injection once a month for psychosis related to schizoaffective disorder, was coded 9 for 10/18/23. Per chart code 9 means other/ see nurse notes. Record review of Resident #1's Progress Note revealed the following: -On 10/18/23 at 6:59pm; Completed by DON: Invega Sustenna Intramuscular Suspension Prefilled Syringe 234 MG/1.5ML Inject 1 syringe intramuscularly one time a day every 28 day(s) for psychosis related to schizoaffective disorder was not available. -On 11/01/23 at 1:49pm; Completed by RN G: Resident #1 spoke with psych nurse and told her that he was having feelings of hurting himself. He spoke with nurse and said the same. Called the DON and she stated to call the police and they will take him to the psychiatric hospital for evaluation. Police was called and picked up x2 police officers. No acute distress noted. -On 11/01/23 at 2:05pm; Completed by DON: Resident #1 was transferred to hospital on [DATE] 2:00 PM related to Resident #1 was having command hallucinations and voices telling him to hurt himself. -On 11/02/23 at 12:04pm; Completed by Administrator: Called psychiatric hospital; Resident #1 was admitted with schizoaffective disorder and Bipolar. Informed they increased Lexapro for depression, increased Trazadone for insomnia, added Vistaril for anxiety PRN, Continue Invega. Informed staff that Resident #1 missed Invega injection in October. -On 11/7/23 at 9:30am; Completed by LVN H: Resident #1 returned from psychiatric hospital. Record review of Resident #1's psych individual therapy visit note revealed the following: Encounter date: 11/01/23; Content/Assessment: The purpose of psychotherapy was to alleviate emotional disturbance and improve function. Insight Oriented and Supportive psychotherapy was/were used in the session. Utilized cognitive-behavioral therapy, person centered therapy, rapport building, reflective listening, relaxation techniques, supportive therapy and validation therapy in session. Clinician met the client in a private area. Clinician reflectively listened as the client discussed the voices in his head and how they have gotten worse since he did not receive the medication he needs once a month to keep the voices at bay. Clinician went over the client's coping skills with him and what he does to manage the voices. Client spoke about how the voices tell him to hurt himself. Clinician checked the client for safety who stated that he did not feel safe. Clinician reported this to the facility who called 911 and the client was transported to the hospital. Patient's compliance had been good. Patient's mood was not changed after the session. Record review of undated written statement completed by The DON revealed the following: On October 19th, the Invega injection appeared on TAR to be given, and after several minutes of looking for the medication, she was unable to find it. At that time, she immediately reordered the medication. During an interview via email on 11/13/23 at 3:42 p.m., The Administrator said Resident #1's September dose was administered by a LVN who no longer was employed with facility. She said he should had reordered the Invega Sustenna prefilled syringe 234 MG/1.5ML injection med the same night he administered the last dose. That did not occur. The DON was working as Charge Nurse in October when the dose should have been administered again. It was not available, so she ordered it that evening. The DON did not note what had occurred. She did not communicate to anyone the need to administer the dose when it arrived. She did not obtain an order to administer it when it arrived or make a change in the program so it would alert on the MAR to administer it when it arrived. Therefore, when Resident #1's Invega Sustenna prefilled syringe 234 MG/1.5ML injection arrived, it was placed in stock for the November dose. The DON was suspended pending investigation. She was returned to work but received a written Employee Disciplinary Report for this. Interviews and record reviews were conducted on 11/3/23 from 12:15 p.m. through 5:00 p.m. and on 11/14/23 from 10:00 a.m. through 5:00 p.m., and included 2 LVNs, 1RN, and DON. Staff were able to explain the proper medication administration process, community's expected process for proper medication administration process, ensuring the correct resident, the correct medication, correct dose to be administered, correct route to be administered, correct documentation of administration. This included verifying the medication administered record to the actual medication. As well as documentation of medication administration, medication availability to include - receiving and accessing new medications and refilled medications in order to ensure that the medications were available on the carts for administration as ordered. Staff had knowledge on what to do if the medication was not on the cart and not available for administration. Nurses should also respond by contacting the dispensing pharmacy in order to order and/or re-order the medication timely to ensure a 5-7 days supply is present. Record review of the facility's plan to correct the noncompliance dated 11/1/23 indicated Problem: pharmacy services. Resident #1 was transferred to the Psychiatric hospital on [DATE] after notifying psych services that he was hearing voices that are telling him to harm himself. All medications ordered for Resident #1 were audited and verified that adequate supply is present. Audit completed by ADON/MDS nurse as of 11/1/23. Administrator/ADON reviewed Medication Reorder policy and Medication administration policy as of 11/1/2023. ADON or designee will review all orders daily to assure policies and procedures are being followed. Interventions: *As of 11/1/2023, 100% audit was completed on all resident medications including antipsychotics to ensure residents are receiving the physician ordered dose. The audit was completed by ADON and MDS Nurse. No additional omissions were discovered. *All resident medications including antipsychotic medications were verified that they match the ordered dose as of 11/1/2023 by ADON and MDS Nurse. All resident antipsychotic orders match current physician orders. *A Medication error completed as of 11/1/2023 by ADON utilizing the medication error form. *Pharmacy Consultant was called to notify of med error as of 11/1/2023 by ADON. A message was left for a return call. Consultant returned call on 11/2/23 and came to facility on 11/3/23. *QAPI meeting was completed with MD and IDT team as of 11/2/2023 to review med error and root cause analysis, and plan of removal. *The following in-services were initiated by the ADON/MDS completed as of 11/1/23 at 9pm. All Licensed Nurses not in serviced by 11/1/23 will be in-serviced prior to starting their next shift. In-services will be ongoing for all new hires before they assume their duties. The DON/ADON are responsible for conducting these in-services. Licensed Nurses will be in-serviced on: -5 Rights of Medication administration -Reporting Medication error that has occurred or found immediately to Physician and DON -Re-ordering medications timely to ensure a 5-7 day supply is present. Charge nurses are responsible for the re-ordering of medications. Charge nurses will be responsible for auditing carts and reviewing medication supply three times a week to ensure medications are ordered when needed. Medications need to be re-ordered as indicated on the medication card. The Charge nurse will review the order status in PCC under the residents MAR for medications needing to be reordered and reorder if needed. -Notification of the MD and ADON immediately for any resident medications that will not be administered as ordered. *The DON and ADON was in-serviced by the regional nurse on 11/3/23 on pulling the electronic transmission report to show which medications have been reordered and the status of the pharmacy refilling the medication. *The medical director was notified of missed medication. On 11/1, Admin called and left message for return. MD called back at 6am on 11/2 and spoke with Admin about the specifics. Monitoring: The DON / designee will review the med administration audit report 5 days per week to ensure all meds are administered as ordered. The DON/designee will review new pharmacy orders 5 days per week to ensure medications are available to be administered as ordered. The DON/ADON/Designee will audit medications on two carts per week to ensure an adequate supply of resident medications are available. Record review of employee disciplinary report dated 11/3/23 revealed the following: Staff: DON; Date of Infraction: 11/01/23; Specific reasons for disciplinary action: DON had failed to follow medication administration policies and procedures. On 11/01/23 the DON failed to administer medication to Resident #1 resulting in potential harm to the resident. The DON was aware of all facility policies and job duty expectations as indicated by her signature on her Employee Handbook Acknowledgement and job description. This was the first disciplinary action for the DON within a 12-month period. Record review of intake worksheet created and received on 11/01/2023 revealed the following: Date and time of incident: 11/1/23 at 6:00pm; Date facility first learned of incident: 11/1/23 at 6:00pm. Immediate action taken to protect client: Resident #1 transferred to psychiatric hospital to be evaluated and treated as indicated. *Results of hospital evaluation: admitted for Schizoaffective Disorder and Bipolar *What treatment was provided: Increased Lexapro for depression, increased Trazadone for insomnia, added Vistaril for anxiety PRN, Continue Invega. Narrative of The Incident: Resident #1 reported to staff that he was hearing voices telling him to harm himself and was having trouble controlling them. In a review of his medications, it was determined that he did not receive his Invega injection as ordered last month. Actions and Notifications: Resident #1 was transferred to acute psychiatric Hospital for evaluation and treatment as indicated. Allegation: Pharmaceutical Services. Record review of revised Medication Administration Procedure/Policy dated 10/25/17 revealed the following: .20) the 10 rights of medication should always be adhered to 1.Right patient 2. Right medication 3. Right dose 4. Right route 5. Right time 6. Right patient education 7. Right documentation 8. Right to refuse 9. Rights assessment 10. Right evaluation *Handwritten 21) Notify the MD and ADON or designee immediately of any resident medications that will not be administered as ordered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide pharmaceutical services including procedures to ensure the accurate acquiring, receiving, dispensing, and administering of all drugs to meet the needs of each resident for 1 of 3 Residents reviewed for pharmaceutical services. (Resident #1) The facility failed to follow physician order to give Resident #1 Invega Sustenna prefilled syringe 234 MG/1.5ML injection once a month. Resident #1 missed Invega in October and began hearing voices telling him to harm himself and Resident #1 had to be admitted to a psychiatric facility. The facility failed to ensure their Medication Administration Policy was followed where a resident's medication will be administered in an accurate, safe, timely and sanitary manner. The facility failed to ensure Resident #1's script for Invega Sustenna prefilled syringe 234 MG/1.5ML injection medication were acquired from pharmacy. The noncompliance was identified as PNC. The Immediate Jeopardy (IJ) began on 10/18/2023 and ended on 11/3/23. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of not receiving the intended therapeutic benefit of the medications. Findings included: Record review of Resident #1's face sheet printed on 11/3/23, indicated Resident #1 was a [AGE] year-old male who originally admitted on [DATE] and readmitted on [DATE] and transferred on 11/01/23 to a psychiatric hospital with diagnoses including schizoaffective disorder (a mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania) and major depressive disorder (so known as clinical depression, is a mental disorder characterized by at least two weeks of pervasive low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities). Record review of Resident #1's physician order printed on 11/3/23 indicated an order for Invega Sustenna prefilled syringe 234 MG/1.5ML injection once a month for psychosis related to schizoaffective disorder; Start Date: 8/23/23. During an interview on 11/4/23 at 3:51 p.m., at the acute psychiatric hospital, Resident #1 was escorted to the visitation area. He said he started hearing voices real bad telling him to hurt himself and he said he did not want to hurt himself. Resident #1 said he had a history of hearing voices but whenever he took his medications the voices were not that bad. Resident #1 said the facility explained he missed a psych medication, and they were going to send him to the psychiatric hospital to be evaluated and treated. Resident #1 said he felt better and was ready to return to the facility. During an interview on 11/14/23 at 2:31 p.m., The DON said in October 2023 she was working the floor as charge nurse and was giving meds to her assigned hall. She said she recalled that she could not locate Resident #1's Invega medication, so she placed an order and did not notify staff to administer Resident #1's medication when it arrived and as a result Resident #1 missed his October's Invega dosage because mediation was not available. During an interview with on 11/14/23 at 4:23 p.m., Doctor D said it was too hard to tell, and could not tell State Surveyor if it was possible the missed dosage of Invega Sustenna medication led to Resident #1's hallucinations telling him to harm himself. He said he was not 100% sure. Record review of Resident #1's revised care plan initiated 8/25/23 indicated Resident #1 required anti-psychotic medications. Goal: The resident will be/remain free of drug related complications, including movement disorder, discomfort, hypotension, gait disturbance, constipation/impaction, or cognitive/behavioral impairment. Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness; Monitor/record occurrence of for target behavior symptoms pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others and document per facility protocol. Record review of transfer form dated 11/1/23 indicated Resident #1 was transferred to an in-patient psychiatric hospital on [DATE] at 2:00pm. Reason for transfer: Resident #1 was having command hallucinations and voices telling him to hurt himself. Current primary diagnosis: schizoaffective disorder. Record Review of Resident #1's September's TAR revealed Invega Sustenna prefilled syringe 234 MG/1.5ML injection once a month for psychosis related to schizoaffective disorder, was administered on 9/20/23. Record Review of Resident #1's October's TAR revealed Invega Sustenna prefilled syringe 234 MG/1.5ML injection once a month for psychosis related to schizoaffective disorder, was coded 9 for 10/18/23. Per chart code 9 means other/ see nurse notes. Record review of Resident #1's Progress Note revealed the following: -On 10/18/23 at 6:59pm; Completed by DON: Invega Sustenna Intramuscular Suspension Prefilled Syringe 234 MG/1.5ML Inject 1 syringe intramuscularly one time a day every 28 day(s) for psychosis related to schizoaffective disorder was not available. -On 11/01/23 at 1:49pm; Completed by RN G: Resident #1 spoke with psych nurse and told her that he was having feelings of hurting himself. He spoke with nurse and said the same. Called the DON and she stated to call the police and they will take him to the psychiatric hospital for evaluation. Police was called and picked up x2 police officers. No acute distress noted. -On 11/01/23 at 2:05pm; Completed by DON: Resident #1 was transferred to hospital on [DATE] 2:00 PM related to Resident #1 was having command hallucinations and voices telling him to hurt himself. -On 11/02/23 at 12:04pm; Completed by Administrator: Called psychiatric hospital; Resident #1 was admitted with schizoaffective disorder and Bipolar. Informed they increased Lexapro for depression, increased Trazadone for insomnia, added Vistaril for anxiety PRN, Continue Invega. Informed staff that Resident #1 missed Invega injection in October. -On 11/7/23 at 9:30am; Completed by LVN H: Resident #1 returned from psychiatric hospital. Record review of Resident #1's psych individual therapy visit note revealed the following: Encounter date: 11/01/23; Content/Assessment: The purpose of psychotherapy was to alleviate emotional disturbance and improve function. Insight Oriented and Supportive psychotherapy was/were used in the session. Utilized cognitive-behavioral therapy, person centered therapy, rapport building, reflective listening, relaxation techniques, supportive therapy and validation therapy in session. Clinician met the client in a private area. Clinician reflectively listened as the client discussed the voices in his head and how they have gotten worse since he did not receive the medication he needs once a month to keep the voices at bay. Clinician went over the client's coping skills with him and what he does to manage the voices. Client spoke about how the voices tell him to hurt himself. Clinician checked the client for safety who stated that he did not feel safe. Clinician reported this to the facility who called 911 and the client was transported to the hospital. Patient's compliance had been good. Patient's mood was not changed after the session. Record review of undated written statement completed by The DON revealed the following: On October 19th, the Invega injection appeared on TAR to be given, and after several minutes of looking for the medication, she was unable to find it. At that time, she immediately reordered the medication. During an interview via email on 11/13/23 at 3:42 p.m., The Administrator said Resident #1's September dose was administered by a LVN who no longer was employed with facility. She said he should had reordered the Invega Sustenna prefilled syringe 234 MG/1.5ML injection med the same night he administered the last dose. That did not occur. The DON was working as Charge Nurse in October when the dose should have been administered again. It was not available, so she ordered it that evening. The DON did not note what had occurred. She did not communicate to anyone the need to administer the dose when it arrived. She did not obtain an order to administer it when it arrived or make a change in the program so it would alert on the MAR to administer it when it arrived. Therefore, when Resident #1's Invega Sustenna prefilled syringe 234 MG/1.5ML injection arrived, it was placed in stock for the November dose. The DON was suspended pending investigation. She was returned to work but received a written Employee Disciplinary Report for this. Interviews and record reviews were conducted on 11/3/23 from 12:15 p.m. through 5:00 p.m. and on 11/14/23 from 10:00 a.m. through 5:00 p.m., and included 2 LVNs, 1RN, and DON. Staff were able to explain the proper medication administration process, community's expected process for proper medication administration process, ensuring the correct resident, the correct medication, correct dose to be administered, correct route to be administered, correct documentation of administration. This included verifying the medication administered record to the actual medication. As well as documentation of medication administration, medication availability to include - receiving and accessing new medications and refilled medications in order to ensure that the medications were available on the carts for administration as ordered. Staff had knowledge on what to do if the medication was not on the cart and not available for administration. Nurses should also respond by contacting the dispensing pharmacy in order to order and/or re-order the medication timely to ensure a 5-7 days supply is present. Record review of the facility's plan to correct the noncompliance dated 11/1/23 indicated Problem: pharmacy services. Resident #1 was transferred to the Psychiatric hospital on [DATE] after notifying psych services that he was hearing voices that are telling him to harm himself. All medications ordered for Resident #1 were audited and verified that adequate supply is present. Audit completed by ADON/MDS nurse as of 11/1/23. Administrator/ADON reviewed Medication Reorder policy and Medication administration policy as of 11/1/2023. ADON or designee will review all orders daily to assure policies and procedures are being followed. Interventions: *As of 11/1/2023, 100% audit was completed on all resident medications including antipsychotics to ensure residents are receiving the physician ordered dose. The audit was completed by ADON and MDS Nurse. No additional omissions were discovered. *All resident medications including antipsychotic medications were verified that they match the ordered dose as of 11/1/2023 by ADON and MDS Nurse. All resident antipsychotic orders match current physician orders. *A Medication error completed as of 11/1/2023 by ADON utilizing the medication error form. *Pharmacy Consultant was called to notify of med error as of 11/1/2023 by ADON. A message was left for a return call. Consultant returned call on 11/2/23 and came to facility on 11/3/23. *QAPI meeting was completed with MD and IDT team as of 11/2/2023 to review med error and root cause analysis, and plan of removal. *The following in-services were initiated by the ADON/MDS completed as of 11/1/23 at 9pm. All Licensed Nurses not in serviced by 11/1/23 will be in-serviced prior to starting their next shift. In-services will be ongoing for all new hires before they assume their duties. The DON/ADON are responsible for conducting these in-services. Licensed Nurses will be in-serviced on: -5 Rights of Medication administration -Reporting Medication error that has occurred or found immediately to Physician and DON -Re-ordering medications timely to ensure a 5-7 day supply is present. Charge nurses are responsible for the re-ordering of medications. Charge nurses will be responsible for auditing carts and reviewing medication supply three times a week to ensure medications are ordered when needed. Medications need to be re-ordered as indicated on the medication card. The Charge nurse will review the order status in PCC under the residents MAR for medications needing to be reordered and reorder if needed. -Notification of the MD and ADON immediately for any resident medications that will not be administered as ordered. *The DON and ADON was in-serviced by the regional nurse on 11/3/23 on pulling the electronic transmission report to show which medications have been reordered and the status of the pharmacy refilling the medication. *The medical director was notified of missed medication. On 11/1, Admin called and left message for return. MD called back at 6am on 11/2 and spoke with Admin about the specifics. Monitoring: The DON / designee will review the med administration audit report 5 days per week to ensure all meds are administered as ordered. The DON/designee will review new pharmacy orders 5 days per week to ensure medications are available to be administered as ordered. The DON/ADON/Designee will audit medications on two carts per week to ensure an adequate supply of resident medications are available. Record review of employee disciplinary report dated 11/3/23 revealed the following: Staff: DON; Date of Infraction: 11/01/23; Specific reasons for disciplinary action: DON had failed to follow medication administration policies and procedures. On 11/01/23 the DON failed to administer medication to Resident #1 resulting in potential harm to the resident. The DON was aware of all facility policies and job duty expectations as indicated by her signature on her Employee Handbook Acknowledgement and job description. This was the first disciplinary action for the DON within a 12-month period. Record review of intake worksheet created and received on 11/01/2023 revealed the following: Date and time of incident: 11/1/23 at 6:00pm; Date facility first learned of incident: 11/1/23 at 6:00pm. Immediate action taken to protect client: Resident #1 transferred to psychiatric hospital to be evaluated and treated as indicated. *Results of hospital evaluation: admitted for Schizoaffective Disorder and Bipolar *What treatment was provided: Increased Lexapro for depression, increased Trazadone for insomnia, added Vistaril for anxiety PRN, Continue Invega. Narrative of The Incident: Resident #1 reported to staff that he was hearing voices telling him to harm himself and was having trouble controlling them. In a review of his medications, it was determined that he did not receive his Invega injection as ordered last month. Actions and Notifications: Resident #1 was transferred to acute psychiatric Hospital for evaluation and treatment as indicated. Allegation: Pharmaceutical Services. Record review of revised Medication Administration Procedure/Policy dated 10/25/17 revealed the following: .20) the 10 rights of medication should always be adhered to 1.Right patient 2. Right medication 3. Right dose 4. Right route 5. Right time 6. Right patient education 7. Right documentation 8. Right to refuse 9. Rights assessment 10. Right evaluation *Handwritten 21) Notify the MD and ADON or designee immediately of any resident medications that will not be administered as ordered.