**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to ensure the residents had the right to be free from physical abuse and neglect for 3 (Resident #1, Resident #2, and Resident #3) of 9 residents reviewed for abuse and neglect. 1.The facility failed to provide continuous one to one monitoring for Resident #1 after repeated targeted aggressive behavior against Resident #2. An Immediate Jeopardy (IJ) situation was identified on 07/01/25 at 6:55 pm for failure #1.While the IJ was removed on 07/02/25 a 6:42 pm the facility remained out of compliance at a scope of isolated that with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. 2.The facility failed to ensure Resident #3 was not physically abused by MA F on 06/25/2025 when MA F grabbed Resident #3's wrist. These failures could affect the residents by placing them in mental anguish or emotional distress, pain, and physical harm. Findings included: 1.Resident #1 Review of Resident #1's face sheet dated 07/01/25 reflected an [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including other frontotemporal neurocognitive disorder (degeneration of the frontal and temporal lobes of the brain, leading to a range of behavioral, language, and movement difficulties) vascular dementia (a decline in thinking skills caused by conditions that reduce or block blood flow to the brain, leading to brain damage), with other behavioral disturbance, and major depressive disorder (a serious mental illness characterized by persistent sadness, loss of interest in activities, and other symptoms that significantly interfere with daily life). Review of Resident #1's quarterly MDS assessment, dated 05/23/25, reflected a BIMS score of 9, indicating moderate cognitiveimpairmentSection E Behavior reflected physical behavior directed towards others (example hitting, kicking, pushing, scratching, grabbing, abusing others sexually) – behavior of this type occurred every 1 – 3 days. Verbal behaviors directed towards others (example threatening others, screaming at other, cursing at others) – behavior of this type occurred every 1 – 3 days. Review of Resident #1's care plan reflected focus – noted behaviors of physical aggression: 1.05/13/15 resident to resident – Resident #1 was seen holding a fork/spoon like object and was on the verge of trying to stab another resident 2.05/19/25 resident to resident - Resident #1 grazed the other resident in the back of head with remote 3.05/28/25 resident to resident – Resident #1 hit another resident with a broom while sitting in the secure dining room 4.06/01/25 resident was destroying dining room area by overturning table and chair Review of Resident #1's care plan reflected interventions for noted behaviors of physical aggression: 1.05/13/25 document behaviors in the clinical record. 2.05/13/25 let physician know if behaviors are interfering with daily living. 3.05/13/25 refer to psychologist/psychiatrist as needed. Review of Resident #1's care plan reflected focus revised on 05/29/25 indicated Resident #1 had potential to demonstrate verbally abusive behaviors related to vascular dementia, with other behavioral disturbance.Review of Resident #1's care plan reflected focus revised on 05/26/25 indicated Resident #1residedon the facility secured unit related to deemed at risk for elopement. Review of Resident #1's care plan reflected focus revised on 06/30/25 indicated Resident #1 demonstrated behavior symptoms/risk at times such as cursing at other residents who are in the way and following other resident (Resident #2) around telling him to get out from his property. Review of Resident #1's care plan reflected focus revised on 05/26/25 indicated Resident #1 was at risk for behaviors related to demonstrates physically abusive behaviors 05/26/25 – resident to resident, Resident #1 ambulating on hallway with staff member when he hit another resident in the face. Review of Resident #1's care plan reflected interventions dated 05/26/25 indicated psychiatric referral as needed to evaluate and follow in house or outpatient. Observation of the facility secured unit on 07/01/25 at 12:10 p.m., revealed Resident #1 wassitting quietly at a dining table.Residents had finished eating. Two staff members were observed in the diningareaperforming normal work duties. Observation in facility secured unit on 07/01/25 at 2:56 p.m., Resident #1 reflected the door was closed to Resident #1’s room. When surveyor entered with the assistance of RN D, Resident #1 was sitting on his bed. His roommate was laying in his own bed sleeping. Observed no 1:1 monitoring of Resident #1. Review of Resident #1’s Nurses Notedated 05/09/25 written by the ADON reflected Resident #1 was placed on the secure unit due to elopement risk. Review of Resident #1’s Nurses Note dated 05/13/25 written by LPN A reflected aide (name of aide not stated) reported to LPN A that Resident #1, who was the roommate of Resident #2, was seen holding a fork/spoon like object and was on the verge of trying to [stab] Resident #2.The aide was unable to remove the fork/spoon out of Resident #1’s hands.LPN A was called and able to remove the fork/spoon from Resident #1. Both residents were assessed for injury, none at the time will continue to monitor both residents for any complications. Review of Resident #1’s Nurses Note dated 05/20/25 written by RN C reflected Resident #1 was holding a remote in hand and refused to put remote down.Resident #1 picked up broom in the dining room hallway and attempted to hit another Resident #2. CNA (name of CNA not stated) able to redirect and remove broom from Resident #1.Resident #1 was holding remote that he refused to put down. Resident #1 “grazed” Resident #2 in the back of the head with remote. Residents separated for safety. Resident #1 closely monitored post incident. Review of Resident #1’s Progress Note Psychiatric Initial Evaluation dated 05/20/25 by PNP reflected dementia with behavioral disturbances. Patient #1 currently on 1:1 observation, continue current medication regimen. Continue to assess for adverse effects and let medication management associates know. Patient has significant cognitive impairment consistent with Alzheimer’s disease (a progressive neurodegenerative disorder that gradually destroys memory and thinking skills, eventually impacting the ability to carry out even the simplest tasks). Patient with history of becoming easily agitated. Staff report patient was physically aggressive towards another resident with difficulty redirecting over the weekend. No aggressive behaviors noted during evaluation. Seen for initial psychiatric evaluation by request of facility. Consider sending to psychiatric hospital or emergency room if patient is a danger to self or others. Review of Resident #1’s Nurses Note dated 05/20/25 writtenbyRN D reflected PNP saw Resident #1.PNP said she hoped the medications will help calm him down and he will have less behaviors. Review of Resident #1’s Nurses Note dated 05/26/25 written by LVN E reflected Resident #1 walked down the hallway of the secured unit when he hit Resident #2 on the face. Both Resident #1 and Resident #2 grabbed each other’s arms. Residents separated by two staff members (names of staff members no listed).No acute injuries noted. Resident #1 was easily redirected and was calm after being separated from Resident #2. Will continue to monitor. Review of Resident #1 Psychiatry Follow Up from PNP dated 05/27/25 reflected Resident #1 was involved in an altercation with another resident over the weekend, where he was the aggressor. Resident #1 with vascular dementia with behavioral disturbances, currently 1:1 (indicates that one staff member is assigned to continuously observe a single patient. This was often necessary for patients with certain behavioral conditions). Consider sending to emergency room or psychiatric hospital. Dementia in other diseases classified elsewhere, moderate with other behavioral disturbance – Resident #1 with history of becoming easily agitated. Was involved in an altercation with another resident [Resident #2] over the weekend. Resident #1 was the aggressor.Resident #1 continued to be on 1:1, required close monitoring. He appeared to dislike one particular resident (Resident #2). Resident #1 seen in room on 1:1 observation, did not engage much, oriented to self only, significant cognitive impairment consistent with dementia. Resident #1 required 1:1 observation and required close monitoring. Staff were to monitor, redirect, and ensure Resident #1’s safety.It was recommended to keep Resident #1 and Resident #2 in separate locations. Resident #2 Review of Resident #2’s face sheet dated 07/01/25 reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including senile degeneration of brain (decline in cognitive abilities, memory, and behavior associated with old age), Major depressive disorder, wandering in diseases (repetitive, aimless movement from place to place, often without a clear purpose or destination, especially in individuals with dementia or other cognitive impairments). Review of Resident #2's quarterly MDS assessment, dated 04/18/25, reflected a BIMS score of 3, indicating severe cognitiveimpairment. Review of Resident #2's care plan reflected focus revised on 04/12/25, indicated Resident #2 had a behavior problem related to taking other residents’ food off their tray during meals. Review of Resident #2’s Nurses Note dated 05/13/25 written by LPN A reflected Resident #1, who was a roommate with Resident #2, was seen holding a folk/spoon like object and was on the verge of trying to stab Resident #2. The aide (name of aide not stated) tried to get the folk out of Resident #1’s hands but Resident #1 was unable to give up the folk. LPN A was called to the scene and was able to remove the folk from Resident #1. Both residents were assessing for any injury, no injuries. Review of Resident #2’s Nurses Note dated 05/26/25 written by LVN E reflected Resident #2’s was walking down the hallway when he was hit on left side of jaw by another resident (Resident #1). Both residents grabbed each other's arms. Resident separated from the other resident by staff x2. No visible injuries noted. Attempted to initiate neurological assessment and vitals, Resident #2 refused at this time. Will continue to monitor. Review of Resident #2’s Nurses Note dated 05/20/25 written by RN C reflected Resident #2 was sitting in chair in dining room. Another resident (Resident #1) attempted to hit Resident #2 with broom and hit the chair. Resident #2 remained seated in dining room chair. Resident #1 grazed Resident #2’s hair on the back of the head with the remote. Resident #2 remained seated, no signs of agitation or aggressive behavior noted. Residents separated for safety. Review of Resident #2’s Progress Note Psychiatric Follow Up Evaluation dated 05/20/25 by PNP reflected Resident #2 was involved in an altercation where he was hit by another resident (Resident #1). Plan was to redirect and keep him safe. Review of Resident #2 Progress Note from PNP dated 05/27/25 reflected Resident #2 was involved in an altercation where another resident (Resident #1) hit him; Resident #2 did not retaliate. Resident #1 required redirection and safety measures. Staff were advised to try to keep Resident #2 and Resident #1 in different locations to prevent further incidents. Review of facility complaint incident report dated 06/01/25 revealed Resident #1 had a problem with Resident #2. Resident #1 is fixated on Resident #2.Resident #1 said, “he thinks resident two broke his family up.” Review of Psychiatry Follow Up from PNP dated 06/10/25 reflected Resident #1 with history of becoming easily agitated and continued to be 1:1 observation, required close monitoring. On and off agitation and aggressive behavior towards one particular resident (Resident #2). Social support – Resident #1 received 1:1 observation and required close monitoring due to aggressive behavior. Follow up – staff to monitor, re-direct and keep safe, continue 1:1 observation due to behavioral issues. Keep Resident #1 and Resident #1 at different locations was encouraged. Continue secure unit placement. Consider sending to the emergency room if identified harm to self or other. Review of Resident #2’s Nurses Note dated 06/17/25 written by RN D revealed Resident #2 would take food when he walked by. Review of IDT (team is composed of various healthcare professionals who collaborate to provide comprehensive care and support for residents) meeting note dated 06/19/25 and attended by the Administrator, ADON, MDS Coordinator and therapy reflected, “Team decided that with information that we reviewed [Resident #1] would be OK off 1:1 monitoring.”No MD or PNP listed as attending meeting and no documentation of information reviewed. Review of Resident #2’s Nurses Note dated 06/20/25 written by RN D revealed Resident #2 seen walking around eating and stealing food from others. Was able to redirect him but he kept walking towards other and grabbing at food or drinks. Other patients are very upset and stating they might hit him if he kept doing it. Review of Resident #2’s Nurses Note dated 06/21/25 written by RN D revealed was going in other rooms and standing over patients while sleeping. Other patients getting upset. Review of Resident #2’s Nurses Note dated 06/26/25 written by RN D revealed continues to take other's food at times. Review of Resident #2’s Progress Note dated 07/02/25 written by MD reflected Resident #2 was the target of another resident’s (Resident #1’s) erratic behavior on 06/28/25, though staff preventedaltercation. Interview on 07/01/25 at 2:42 p.m., with the PNP revealed Resident #1 was a safety concern because he was aggressive. She was concerned about his safety and the safety of the other residents if Resident #1 was not provided 1:1 monitoring.She said he was on the correct medications and if he was not given 1:1 monitoring, the facility needed to find alternative placement for Resident #1. Interview on 07/01/25 at 12:10 p.m., with RN D revealed Resident #1 “targets” Resident #2, but Resident #1 instigates things by taking food and items from residents’ trays (including Resident #1’s tray). RN D said he was not concerned Resident #1 would harm other residents and Resident #1 was currently not 1:1. RN D felt they had enough staff and Resident #1 could be watched. He said some incidents between Resident #1 and Resident #2 have occurred in the past even when Resident #1 was on 1:1 monitoring because staff was not watching.An example was when Resident #1 attempted to hit Resident #2 with a broom. Interview on 07/01/25 at 2:56 p.m., with RN D revealed Resident #1 said he was taken off 1:1 monitoring last Wednesday(06/25/25) and when RN D came to work on the followingThursday (06/26/25), Resident #1 was off 1:1 monitoring and had been off 1:1 monitoring since. Interview on 07/02/25 at 11:29 p.m., CNA G revealed she had not witnessed any physical aggression towards Resident #2 by Resident #1. She said Resident #2 would go around Resident #1’s food tray and take things from his tray. CNA G example gave the example of when Resident #2 took Resident #1’s food cover. CNA G said this would aggravate Resident #1 and said Resident #1 would say something to the affect that Resident #2 was messing with his wife.Resident #1 thought that Resident #2 was in Resident #1’s home. She said Resident #1 would threaten Resident #2 when Resident #2 moved things around and said, “I’m going to kick your ass.”CNA G did not think that 1:1 monitoring was necessary because there were 2 aides in the secured unit she said when staff was there they could re-direct Resident #1.She said that Resident #1 listened to her, but she was not sure if he listened to the staff on othershifts. Interview on 07/02 25 at 2:50 p.m., LVN E revealed she had worked in the secured unit and was familiar with the relationship between Resident #1 and Resident #2. She said that Resident #1 seemed like he would get agitated when he saw Resident #2. She said Resident #1 would get upset and start walking towards Resident #2 getting verbally aggressive and cursing. She said there was an altercation between Resident #1 and Resident #2 with a broom when she was on duty, but she did not see what happened. She said a CNA got in between the residents. She said she was not concerned about resident safety because Resident #1 always received 1:1 monitoring when she was working the secured unit. She said as long as Resident #1 was 1:1 she was not concerned about safety. She said it was the responsibility of the DON and Administrator to decide if a resident received 1:1 monitoring. She said the negative effect of a resident who does not have 1:1 monitoring and needs 1:1 monitoring was that a resident could get hurt. Interview on 07/02/25 at 2:17 p.m., RN C revealed she used to work in the secured unit at night and was familiar with Resident #1 and Resident #2. She said they are physically independent in that they are not in wheelchairs and are able to walk. She said Resident #1 and Resident #2 do not like each other. Resident #1 would say, “it is my house.” She said the residents should be separated. She said Resident #1 should definitely be monitored 1:1. She said if Resident #1 was not monitored 1:1, Resident #2 can get close to him and that irritated Resident #1. She said if Resident #1 is monitored 1:1, he can be re-directed quickly. She said when he received 1:1 monitoring, he was fine but as soon as he was taken off his behaviors go back to what they were previously.She thinks that Resident #1’s behavior could cause harm to Resident #2 or himself if Resident #1 did not receive 1:1 monitoring. Interview on 07/02/25 at 12:46 p.m., with the DON revealed she had not witnessed any disturbances between Resident #1 and Resident #2, but it was reported to her by the overnight nurse (could not remember the name of the nurse) by phone that Resident #1 attempted to hit Resident #2 with a broom. The ADON had heard that Resident #1 thinks that Resident #2 was trying to “break up his family.” She said that Resident #1 found Resident #2 sitting on Resident #1’s bed and Resident #2 had an incontinent episode and Resident #1 had been “fixated” on Resident #2 since this episode. The ADON said the IDT team decided if a resident was going to come off 1:1 monitoring.She said the IDT team consists of the Administrator, the DON, Social Worker, and psychologist. She said she felt like the PNP should have been included in the decision whether to remove Resident #1 from 1:1monitoring. Interview on 07/01/25 at 5:13 p.m., CNR #1 revealed Resident #1 was fixated on Resident #2 and they were both in the secured unit, so it was not like you could keep them separate. She said the facility held an IDT meeting on 06/19/25 and the team reviewed Resident #1’s behaviors and progress note charting and found 1:1 monitoring for Resident #1 was not warranted any longer. She said the facility needed to make sure the provider was consulted and updated. She said if the PNP said Resident #1 needed to have 1:1 monitoring, then Resident #1 needed to be on 1:1 monitoring. She said if you don’t get the approval from the provider, the PNP, you run the risk of more resident-to-resident altercations. Interview on 07/02/25 at 3:15 p.m., CNR #2 revealed that during the IDT meeting on 06/19/25 that concluded that was okay to end Resident #1’s 1:1 a critical component that was missing because the PNP was not included and consulted. He said it was the responsibility of the Administrator make sure that all relevant people are present during an IDT meeting. He said the possible negative outcome of not including the PNP provider at the IDT meeting to provide input regarding the possibility of removing Resident #1 from 1:1 monitoring would be continuing issues with resident-to-resident altercations. Interview on 07/02/25 at 3:06 p.m., the Administrator revealed the PNP should have been kept in the loop when the IDT team made the decision on 06/19/25 to removed Resident #1 from 1:1 monitoring. He said he thought Resident #1 was doing better because Resident #1 did not have any incidents of altercations with Resident #1.He said that the IDT meeting participants should have included a mental health provider to discuss Resident #1’s 1:1 status. He said that Resident #1’s 1:1 monitoring should have remained intact, and he should not have been removed from 1:1 monitoring. He said the negative affect of not having a resident on 1:1 monitoring who should be on 1:1 monitoring would be that it could be unsafe for residents. The Administrator said it was his understanding that Resident #1 only had problems with Resident #2, and Resident #1 was focused on Resident #2.Resident #1 thought that Resident #2 stole his family. He also heard that Resident #2 had an incontinent incident on Resident #1’s bed and Resident #1 had not forgotten about the incident and Resident #1 was still upset about it.The Administrator said the facility was working on getting Resident #1 transferred to another facility because of his fixation on Resident #2 and concerns for Resident #1’s safety and other safety of the other residents in the secured unit. It is the responsibility of the Administrator and the IDT team to make sure that the physical and mental providers are included in the IDT meeting when making decisions about 1:1 monitoring status. Review of facility policy Resident to Resident Altercations dated December 2016 reflected the facility staff will monitor residents for aggressive/inappropriate behavior towards other residents. Occurrences of such incidents shall be promptly reported to the nurse supervisor, director of nursing services, and the administrator. If two residents are involved in an altercation staff will notify each resident's attending physician of the incident, review the events with the nursing supervisor, director of nursing and possible measures to try to prevent additional incidents, make any necessary changes to the care plan approaches to any or all of the involved individuals, document in the resident’s clinical record all interventions and their effectiveness, contract psychiatric services as needed for assistance in assessing the resident, identifying causes, and developing a care plan for interventions and management as necessary or as may be recommended by the attending physician or interdisciplinary care planning team. If after carefully evaluating the situation, it is determined that care cannot be readily given within the facility to transfer the resident. This was determined to be an Immediate Jeopardy (IJ) on 07/01/25 at 5:27 pm.The Administrator was notified at 6:55 p.m.The ADM was provided with the IJ template on 07/01/25 at 6:55 p.m. The following Plan of Removal submitted by the facility was accepted on 07/02/25 at 1:01 p.m. PLAN OF REMOVAL On 07/01/2025 an abbreviated survey was initiated at the facility.On 07/01/2025 the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate threat to resident health and safety. The notification of Immediate Jeopardy states as follows: The facility failed to continuously monitor Resident #1 1:1 for multiple altercations of aggressive behavior targeted against Resident #2. IMMEDIATE JEOPARDY PLAN OF REMOVAL for F600 – Failure to Protect Residents from Abuse Tag Number: F600 Regulation: The resident has the right to be free from abuse. Deficient Practice: The facility failed to ensure that Resident #1 was continuously monitored as ordered for 1:1 supervision following multiple episodes of physical aggression toward Resident #2, placing Resident #2 at risk for harm. 1. Corrective action(s) taken for resident(s) found to be affected: Who: The Administrator/Designee and Secure Unit Charge Nurse. What: Immediately reinstated 1:1 monitoring for Resident #1 to ensure Resident #1 and Resident #2 are separated. 1:1 monitoring to include direct 24-hour eyes on supervision by dedicated/assigned staff member. In-service education provided clarification to staff to ensure Resident #1 is not left alone at any time and the protocol for providing breaks and adequate replacement for assigned staff member. When: Initiated on 07/01/2025, following incident review. Where: On the secured memory care unit, where both residents reside. Additionally: Resident #2 was assessed by the ADON/Designee for injury and psychosocial impact—no acute injury found, no acute psychosocial impact. Referral was made to [MD]on 07/01/25 to conduct follow up visit on 7/2/2025. No other residents identified during review of R-to-R altercations with Resident #1 Psychiatric Nurse Practitioner (NP) re-evaluated Resident #1 on 07/01/2025, recommending need to reinstate 1:1 due to continued aggression. The interdisciplinary team (IDT) met on 07/01/2025 and updated Resident #1’s care plan to reflect behavior management strategies, permanent 1:1 status, and physical separation plan from Resident #2 through direct 1:1 supervision. Finding alternate placement. 2. How the facility will identify other residents who could be affected: Who: ADON/Designee. What: Conducted a review of all residents on the secured unit with active or recent aggressive behavior or R-to-R altercations within the last 30 days. Facility wide incidents were reviewed and are currently ongoing starting on 7/1/25 When: Audit began 07/01/2025 and will be completed by 07/02/25. Where: Secured unit. The audit includes: Review of behavior monitoring orders. Validation of 1:1 interventions being documented and implemented. Documentation is assigned to the Charge Nurse on the MAR/TAR every shift and paper monitoring, which includes location, behavior/activity and supervising staff initials, is ongoing with 1 hour frequency. Confirmation of care plan updates for any additionally identified resident and interdisciplinary review of any behavior incidents in the last 30 days. 3. Systemic changes made to ensure the deficient practice does not recur: Who: Staff Development Nurse, in coordination with Administrator/Designee and Regional Nurse Consultant. What: Regional Nurse provided education to the Assistant Director of Nursing and Administrator on 07/01/2025 by in-service education. Assistant Director of Nursing and Administrator will conduct Facility-wide in-service education and posttest for all licensed nurses, CNAs, agency and direct care staff prior to the start of assigned shift. New staff will receive training during orientation: Abuse prevention Resident to Resident altercation policy Requirements for initiating, documenting, and discontinuing 1:1 supervision. In-service provided clarification to staff outlining the expectations of 1:1 supervision, including, 24-hour eyes on supervision; not leaving Resident unsupervised at any time; providing adequate coverage of assigned staff member. Importance of timely IDT reviews and documentation in the MAR/TAR and care plan. When: Initiated on 07/01/2025 and completed by 07/02/2025 with all current and oncoming staff/agency prior to start of shift worked; new staff will receive this training during orientation. Where: In-person training held in facility and documented with sign-in sheets. Additional changes: Continue 1:1 Supervision Monitoring Log, to be maintained at the point of care (resident’s room or nearby nurse station), requiring hourly initials by assigned staff. Verification of completion of monitoring log will be done by ADON/designee daily. 1:1 supervision will be reviewed by IDT within 24 hours of initiation and will be reviewed daily for continued appropriateness of 1:1. 4. How the facility will monitor to ensure compliance and prevent recurrence: Who: Administrator/designee. What: Weekly audits of 100% of residents with 1:1 orders for compliance with documentation, monitoring logs, and MAR/TAR entries. Monthly reviews of incident reports involving R-to-R contact, focusing on behavioral care planning and response follow-through. When: Weekly audits for 8 weeks starting 07/02/25, followed by monthly audits for 4 months. Where: Monitoring will occur facility wide for any identified R-to-R altercations. Audit results will be reported to the QAPI Committee monthly, and immediate corrective action will be taken for any missed 1:1 interventions or breakdowns in IDT communication. 5. Date of completion: All corrective actions and training will be fully implemented by: July 02, 2025 Monitoring: Review of Resident #1’s MAR and TAR reflected 1:1 supervision continuous 24hr monitoring with every hour checks every hour for physical behaviors every shift documented every hour with no behavioral issues reflected. Observation 07/02/25 at11:25 a.m. of Resident #1 with 1:1 monitoringdedicated/assigned staff member. Observation 07/02/25 at 1:00 p.m. of Resident #1 with 1:1 monitoringdedicated/assigned staff member. Observation on 07/03/25 at 11:40 am of Resident #1 with 1:1 monitoringdedicated/assigned staff member. Interview on 07/02/25 with CRN #1 stated she assessed Resident #2 for any psychosocial impact and no acute injury found. Review of PNP documentation dated 07/01/25 re-evaluation of Resident #1 recommended need to reinstate 1:1 monitoring due to continued aggression. Review ofinterdisciplinary team (IDT) meeting document dated 07/01/2025 and review of updated Resident #1&rsqu[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 (Resident #1) of 3 residents reviewed for accidents and hazards. The facility failed to ensure there was appropriate supervision on [DATE] when Resident #1, who resided on the secure unit, exited the secure unit, after RN A left the unit (to respond to a code after not being familiar with the CPR policy), and then one of the facility's side exits and got into the passenger seat of a parked fire truck in the parking lot. An Immediate Jeopardy (IJ) was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 4:28pm. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. These failures placed residents at risk of elopement, falls, or injuries and not having their end-of-life wishes followed. Findings included: Review of Resident #1's quarterly MDS assessment dated [DATE] reflected he was an [AGE] year-old-male who was admitted to the facility on [DATE] with diagnoses including dementia (memory loss), major depressive disorder with severe psychotic symptoms (loss of contact with reality) (extreme sadness), anxiety (extreme worry), unsteadiness on feet, and frontotemporal neurocognitive disorder (when nerve cells in the brain are lost). Section E - Behavior, revealed that he had physical and verbal behavior directed toward others in the last 1-3 days, and wandering had occurred in the last 4-6 days in the last week. His BIMS score was a 9, indicating he was moderately cognitively impaired. Review of Resident #1's elopement risk assessment dated [DATE] revealed a score of 6, which indicated he was a high risk of elopement. Review of Resident #1's care plan dated [DATE] revealed that he was to reside in the secure unit due to risk of elopement and to have elopement risk assessments per facility protocol. Review of progress note dated [DATE] at 10:00am by RN A reflected, Patient was brought back to unit by staff up front. Stated he was seen at the front door. Patient came back very calm and was even pushing another patient with him. Patient stated, I was just wanting to look at the fire truck. He was unable to state how he exited. All areas were checked. Side and back door are locked. All windows are secured shut and unable to open. Management informed and looked at cameras and noted he went out secure main door when it did not secure properly behind me as I was exiting to respond to a code on the other side of the building. DON contacted family. Patient was put on 1:1 (monitoring where a staff member is directly responsible for one resident) And q15 minute checks was started also immediately. Reminded all staff to ensure door is locked when going out. Review of progress note dated [DATE] at 10:00am by the DON reflected, at 0939, this nurse received a phone call from charge nurse {RN A}, stating that this resident was found at the front door of facility during a time of a code on another resident on one side of the building, and an emergency on the other. {RN A} verbally stated as he was exiting the doors of the secure unit to go assist, he stated that, the resident must have followed me out of the secure unit and that is how he ended up in the mix of the facility due to the nature of the emergency and situation. Admissions coordinator was at the front of the building and seen resident as he was at the front door of the building holding his remote and was with the EMS staff and firemen and immediately redirected resident back to the secure unit. Resident was approachable and easily willing to go back to the secure unit. He pushed another resident in his wheelchair to the south station of the building, in good spirits, hugging everyone and, glad to be a help to others. No injuries were reported on resident. This nurse instructed charge nurse, {RN A} to immediately initiate one on one monitoring on this resident to indefinite timing, 24 hours a day, as resident is a high elopement risk with good understanding verbalized. {The DON} instructed {RN A} to ensure that anytime the secure doors are opened by any staff member or at any time, that they need to make sure they are completely closed and locked to where no resident in a secure unit can exit. There are two other doors on secure unit that have been tested and do work; alarms will sound and go off if they are pushed. This nurse spoke with daughter, and explained to her the situation and she thanked nurse for the phone call and update and stated she was at a funeral and wouldn't be back up to the facility for the rest of the day. This nurse and {daughter} discussed this residents' disease process, and she expressed her feelings about it and how she is sad seeing the rapid decline in her father, cognitively, and she and her brother are coming to realization to acceptance about it. She stated that resident used to be a Life support educator, and that in his mind, he probably really did think he was a part of the emergency he seen happening and followed the nurse/EMS staff, thinking he was helping save someone's life. I informed {daughter} that I had re-initiated one on one monitoring on her dad due to safety measures, and it would be a 24-hour monitoring, and she tearfully expressed her appreciation. I told her to contact this nurse at any time with any questions, concerns, or needs and she verbalized understanding. In an attempted interview on [DATE] at 9:10am with Resident #1, the HHSC surveyor attempted to ask him about recent events, but he stated he did not remember the events in question. During an interview on [DATE] at 11:16am with RN A he stated that on [DATE] he was the RN assigned to the secure unit and was assisted by CNA B. He was aware that CNA B was off the unit for lunch at the time a code (indicating a resident had stopped breathing and needed CPR) was called, but he thought it was just him and 1 other nurse working in the building during that time, so he said he had to respond to the code. He stated that he was only off the unit for a couple of minutes. He stated that when he left the unit the door did not lock behind him and that the door got stuck unless it was pushed shut. He stated that a code was never called over the loudspeaker, and he had heard through word of mouth from another CNA there was a code. When he arrived to the code, the RN told him the resident collapsed, so she started CPR and never had a chance to call the code. He stated they (EMS/Nurse) were already working on the resident and didn't need any help, so he went back to the secure unit. He stated he knew his CNA was off the unit and he knew he was leaving the residents unattended/unsupervised. His stated his priority was the emergency when he found out about it. He could not recall who told him about the code. He stated that he received no notification other than CNA word of mouth. He stated that based on experience as a nurse he was to respond to all codes, and he had no direction from the facility on responding to codes. He stated he did not see Resident #1 was by the doors when he went off the unit and didn't know he was followed. He stated he had received no training on CPR response teams and no training on the team or identifying who responded or not. During an interview on [DATE] at 11:36am with the DON she stated that she was not aware CNA B was off the unit when RN A responded to the code. She thought there was an additional agency staff present on the secure unit that day. She later confirmed there was no agency staff present on the secure unit on [DATE] and just RN A and CNA B were working on the secure unit. She stated 2 other nurses were working on the other side of the building and there was no reason for RN A to leave the secure unit. During an interview on [DATE] at 1:19pm with the AC, she stated that RN A never attended the code. She also stated that she was at the front door of the facility when Resident #1 had made his way to the door, and that she had redirected him back to the secured unit. She was unable to verify if Resident #1 had made it outside the front door or just to the front door of the building. During an interview on [DATE] at 3:22pm with the RNC he stated that if a code happened on a certain hall, the staff that worked that hall should respond, and that all direct care staff were CPR trained and certified. During an interview on [DATE] at 6:30pm with RN A, he stated that based on experience as a nurse he was to respond to all codes, and he had no direction from the facility on responding to codes. He stated he had received no training on CPR response teams and no training on the team or identifying who responds or not. He stated that for that incident there was no code called over the loudspeaker, he was just notified through CNA word of mouth. During an interview on [DATE] at 8:36am with MA C, she stated that she did not recall any recent in-services on elopement or resident supervision. During an interview on [DATE] at 8:43 am with RN B, she stated they had not received in-serving on elopement since the incident on [DATE]. During an interview with the MD on [DATE] at 10:30am she stated that her expectation for staffing in the secure unit was that there would be somebody working in the unit to make sure residents could not harm themselves or others, to provide medications and help during meals. For staffing, she stated that there were times when the residents were stable, and the environment varied based on the patients' behaviors. She said if they were poorly staffed or things happened, more staff could be needed, but in general somebody needed to be always back there with the residents. She stated she had concerns if all staff left the secure unit for an extended amount of time, but if someone was stepping out to get help or something quick, that should be allowed. In the situation on [DATE] she stated that RN A was a very well-trained nurse, and she thought it was appropriate that he stepped out to check on things and then returned. She stated that a resident would be ordered to live on the secure unit due to Alzheimer's disease, not being aware of his surroundings, and not being aware of potentially dangerous situations. The MD stated she had no more concerns with Resident #1 getting around the fire truck than any other residents. She stated she did not think Resident #1 had the capacity to drive, pick up heavy things, or move equipment anymore. The MD stated there was potential for injury, but she didn't know that the fire truck would sit much higher than the bed in his room or a table in the secure unit, so the MD did not know that it would be more of a fall risk. She stated it wouldn't be good if Resident #1 got into any hoses and the MD did not know if Resident #1 had any strength to pull heavy equipment. In an interview with the RNC on [DATE] at 11:17am he stated that the facility did not have any policies specific to the secure unit. In an interview on [DATE] at 12:20 pm with the DON, she stated that every staff member had a code legend on their badge, and that if there was a resident coding, someone would get on the loudspeaker/intercom and call a code blue, which would alert everybody, so staff could respond. She stated they did not designate teams; the nurses would just respond. The expectation of responding nurses would be that they call 911 and get crash cart to help out. In an interview with MA C on [DATE] at 12:31pm she stated that she was working on the south hall on [DATE] as a medication aide. She stated that the south side entrance door alarm went off (meaning that the exit door had been opened) so she responded to the door. She looked outside and did not see any residents outside. She stated she was able to see out into the driveway where the fire truck was parked. She stated that she thought the door alarm may have been triggered by the in and out of the emergency personnel on the other side of the building, and that the emergency personnel took the coded resident out of the facility's main front door. She stated she worked until 2:00pm on [DATE] and was never informed of Resident #1's elopement, and that she did not receive in-service for elopement until [DATE], even though she had worked another shift on [DATE]. She stated that a negative outcome of a resident leaving out of the south door unsupervised was that they could potentially walk into traffic, get lost, get injured, or die. Review of video footage provided by the facility revealed RN A leaving the secure unit on [DATE] at 9:22:37am and returning at 9:24:18am. Resident #1 could be seen on camera peeking out from his bedroom door and watching RN A leave the unit, and then Resident #1 ambulated to the secure unit door and pushed it open at 9:22:42 and began walking down the south hallway. Resident #1 was then seen through a different camera view, pushing open and walking out of the building's south side entrance and walking into the driveway and ambulating into the passenger side of the fire truck with its lights on, that was parked there. There were no facility staff or emergency personnel in view of the camera. Review of a different camera view of the facility outside the front main entrance revealed Resident #1 approaching the ambulance that was parked in the driveway in front of the main entrance. Resident #1 was seen observing the ambulance but did not open any of the doors, and no facility staff or emergency personnel were in view of the camera. Resident #1 was observed making his way to the facility front door on his own. In a different camera view of the facility inside the main entrance at 9:25:27 the AC can be seen making her way from the entrance, down the hallway toward the dining area at 9:25:57., At this time her back was toward the main entrance, and she went out of the camera's view until she reappeared at 9:28:01 and began her way back toward the front entrance doors. At 9:28:40 she came back into the camera view and was observed guiding Resident #1 down the hallway with their hands intertwined. Resident #1 was returned to the secure unit at 9:30:52am. Review of the facility's Safety and Supervision of Residents policy dated 2018 revealed, Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified needs and identified hazards in the environment. Review of the facility's policy titled 'Emergency Procedure - Cardiopulmonary Resuscitation' last revised February 2028 reflected, Select and identify a CPR Team for each shift in the case of an actual cardiac arrest. To the extent possible, designate a team leader on each shift who is responsible for coordinating the rescue effort and directing other team members during the rescue effort. The ADM, DON, and RNC were notified on [DATE] at 4:18pm that an Immediate Jeopardy had been identified due to the above failure and an IJ template was provided. The following POR was accepted on [DATE] at 11:43am: On [DATE] an abbreviated survey was initiated at the facility. On 5-30-25 the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate Jeopardy to resident health and safety. The notification of Immediate Jeopardy states as follows: The facility failed to ensure there was appropriate supervision on [DATE] when Resident #1, who resides on the secure unit, exited the secure unit, after RN A left the unit, and then one of the facility's side exits (approximately 160 feet from the secure unit) and got into the passenger seat of a parked fire truck (approximately an additional 220 feet from the exit door) in the parking lot. Immediate Jeopardy Plan of Removal - F689 (Supervision to Prevent Accidents) 1. Resident #1 (Affected Resident): Resident #1 was safely returned to the secure unit by the medication aide on [DATE] after exiting the unit unsupervised. The elopement was self-reported to HHSC on [DATE] by the Administrator. Immediate actions taken included: o Initiation of 1:1 supervision by the CNA on 5-24-25 for 24 hours from the time of the incident. o The charge nurse updated the elopement risk assessment on 5-25-25, reviewed and updated the care plan as needed. o The interdisciplinary team review was initiated by the Administrator and the interdisciplinary team on 5-25-25. o CNA B and RN A were instructed on 5-24-25 by the DON to not leave residents unattended, especially those on secure unit, even for a moment. o Door hardware on the secure unit was repaired by the maintenance director to ensure door latched when closing and signage placed (Please make sure the door is closed and latched behind you!) on 5-26-25. All staff were in-serviced by the DON/designee on 5-30-25 to ensure that the door is closed and latches when exiting. New hire employees will be in serviced during orientation and prior to the start of their first shift. PRN employees and agency staff will be in-serviced prior to the start of their next assigned shift. 2. Identification of At-Risk Residents (Facility-Wide Review): On [DATE], the MDS coordinator initiated a full audit of all the residents on the secure unit to identify additional elopement risks. All current elopement risk assessments were reviewed and updated as needed on 5-30-25 by the MDS coordinator. Care plans were reviewed by the MDS coordinator on 5-30-25 to ensure they reflect current interventions. All staff were in-serviced by the DON/designee on 5-30-25 to immediately notify administration by phone of any breaks or coverage issues. Door alarm systems and locking mechanisms for all exit doors were checked by maintenance on 5-26-25 and documented on a log and will be reviewed by the administrator daily. 3. System Correction: o The DON/designee in-serviced all staff on elopement protocol, and supervision protocols, on [DATE] and are ongoing until all staff have completed training on 5-31-25. Mandatory in-services will be completed on 5-31-25 with all current and oncoming staff prior to the start of shift worked. The regional nurse provided education to the director of nursing and the administrator on 5-30-25 regarding supervision protocols, elopement prevention, and response expectations for secure unit. Agency staff and PRN staff will not be assigned to the secure unit unless they have completed the facility's elopement prevention and supervision in-service. This will be verified through the human resources and staffing coordinator prior to working their shift. This will be validated by the DON/designee. o A revised policy on code response was implemented by the regional nurse on [DATE] to require designated responders to any emergency or code being called, ensuring secure unit staff do not leave residents unattended. o Daily door audits were implemented on 5-30-25 by the maintenance director for all secure unit exits for 14 days and then weekly thereafter. This will be documented by the maintenance director on a daily audit form and reported to the Administrator daily. o The DON/designee in-serviced staff on 5-30-25 when assigned to the secure unit staff are now required to formally sign out when taking a break or leaving the unit to verify designated coverage is in place prior to leaving the unit ensuring continuous supervision of residents in accordance with facility protocols. Agency staff and PRN staff will not be assigned to the secure unit unless they have completed the facility's elopement prevention and supervision in-service. This will be verified through the human resources and staffing coordinator. This will be validated by the DON/designee. o Each staff member attending the in-service will complete a verbal return demonstration to confirm comprehension of the content presented, and once the staff verbalizes understanding by repeating back the information then the in-service will be signed at that time. o Verbal return demonstrations will include scenario-based questions, policy clarification, and role-specific expectations (e.g., code response protocol, secure unit coverage requirements). o Competency will be assessed in real time by a licensed nurse, department manager, or clinical educator. o Staff who do not successfully complete the verbal return demonstration will receive immediate re-education and follow-up assessment to ensure understanding. 4. Administrative Oversight/Monitoring: oThe DON/designee is completing daily visual checks on secure unit supervision and door status for 14 days starting [DATE]. o The Maintenance Director will check the secure unit door latch and magnetic locking mechanism daily starting 5-30-25 for 14 days, then weekly thereafter, to ensure the door closes and secures properly. If there is a malfunction to the door the maintenance will fix it and if unable the location will be monitored directly by designated staff member until repaired. o QAA Committee will review supervision compliance and elopement documentation monthly for 3 months. ADHOC QAPI meeting was held on 5-30-25 by the Administrator and IDT team to review the deficiency and the process of when the POR will be completed. 5. Completion Date: [DATE] The surveyor monitored the POR on [DATE], [DATE], and [DATE] as follows: During observation on [DATE] between 9:00am-9:50am revealed the south side entrance door working properly, it had a delayed egress mechanism, signage that stated Emergency Exit Only Push Until Alarm Sounds. Door Can Be Opened in 15 Seconds. When tested, the door did not immediately open, and after 15 seconds a loud alarm sounded and the door opened to the outside. An exit door in the secure unit revealed a sign that read Do not use door. An alarm code was used by facility staff to enter/exit the secure unit main entrance as well as the back exit door, the back exit door also had a delayed egress mechanism and sounded a loud alarm when opened without the door code. During an observation on [DATE] at 9:47am revealed signage placed on secure unit doors advising staff to ensure door closure and latching. The surveyor tested the secure unit door to ensure its latching. Review of Resident #1's progress note dated [DATE] reflected, One on one monitoring, indefinite timing, 24 hours a day, on this resident continues due to resident being a high elopement risk. Resident sitting up in bed. Resident attempting to wake up roommate and easily redirected back to bed. Resident alert and oriented to self. Review of Resident #1's elopement risk assessment dated [DATE] revealed he was scored at a 13, indicating high risk for wandering. Review of secure unit resident list revealed 2 additional residents whose elopement risk assessments were updated on [DATE] and the other 13 were done prior to [DATE]. Review of Resident #1's care plan updated [DATE] reflected he was a high risk for elopement, was to maintain 1:1 supervision until behavior stabilized and IDT determined it was safe to discontinue. Review of a document titled Systemic Issues No real-time staff assignment to monitor unit during dual emergencies revealed the regional nurse provided education on the following topics, 1:1 supervision maintained, door security protocol re-education completed with staff on secure unit, mock drill to assess emergency-response door security codes, secure unit alarms re-tested and validated, resident's care plan and elopement risk assessment updated, QAPI follow-up scheduled in 30 days for reassessment and was signed by the DON, ADM and the RNC. Review of 15 residents who resided on the secure unit revealed updated elopement risk assessments and care plans with assessment and/or updated dates of [DATE]. Review of a log titled Daily Secure Doors Door Monitoring Log reflected dates of: [DATE]-10am Checked Door Functions [DATE]-10am Checked Door Functions [DATE]-10am Checked Door Functions [DATE]-10am Checked Door Functions [DATE]-10am Checked Door Functions [DATE]-10am Checked Door Functions Review of the facility's QAPI meeting agenda, dated [DATE], titled Unauthorized Exit from Secured Memory Care Unit revealed the MD, MS, MDS, DOR, ADON, DON, RNC, and ADM were all in attendance. Review of the facility's in-service dated [DATE] and [DATE], and conducted by the RNC, ADON, and DON titled Elopement Prevention and Supervision In-Service Packet revealed all staff (CNA B, MA C, and RN A's signatures were visible) were in-serviced on the following: 1. Supervision Protocols for Residents on Secure Units -Never leave residents on a secure unit unsupervised. -Ensure coverage is confirmed before leaving for any reason. -Document any staff hand-offs. -Notify supervisor immediately if understaffed. 2. Elopement Prevention Strategies -Know which residents are at risk (review care plans and risk assessments). -Ensure resident doors and alarms are operational at the beginning of each shift. -Report and document any unsafe conditions immediately. 3. Door Security and Exit Door Monitoring -Check that doors latch and alarms sound properly at the start and end of each shift. -Ensure signage remains visible on all secure exits. -Never prop open doors to the secure unit. -Report door malfunctions to maintenance immediately. 4. Code Response Expectations and Designated Response Team Procedures - Secure unit staff must not respond to codes unless alternate staff has assumed coverage. -Follow the designated code response team assignments. -If you're not assigned to respond, remain at your post. -Call for assistance if help is needed, but do not leave residents unattended. 5. Reporting and Documentation of Coverage Breaks -Notify supervisor or nurse manager prior to leaving your post for break or emergency. -Ensure a staff handoff is documented. -Use the assignment sheet or staff coverage log. -Report and document any observed lapses in supervision. Review of 2 sign out sheets titled Secure Unit Staff Break Sign Out revealed 1 sheet dated [DATE] with 3 staff members clock in times and clock out times handwritten. A sheet dated [DATE] with 5 staff members clock in times and clock out times handwritten. Review of in-servicing post tests in employee files in the HR office reflected staff completed question/answer tests to verify their comprehension of the in-services provided with dates observed of 5/30 and 6/1. Review of a log titled Daily Administrative Oversight Log reflected columns titled Observer (DON/Designee), Supervision in place on secure unit? (Yes/No), Any gaps in coverage (yes/no), Door functional and locked? (Yes/No), Corrective actions taken if issues found. The logs had dates of [DATE]-[DATE] with yes and no answers and the ADON's signatures next to each date. Review of the revised CPR Policy dated [DATE] reflected, It is the policy of this facility to adhere to residents' rights to formulate advance directives. In accordance with these rights, the facility will implement guidelines regarding cardiopulmonary resuscitation (CPR) in accordance with accepted clinical standards and federal regulations. Emergency Preparedness and Code Response (Added [DATE]) - A revised Code Response Protocol was implemented by the Regional Nurse on [DATE] to ensure resident safety during emergency situations. - Designated emergency responders will be pre-identified for each shift and are responsible for responding to codes and medical emergencies. - Staff assigned to the secure unit are prohibited from leaving the unit unattended under any circumstance, including to respond to a code, unless relieved by appropriate coverage. - This measure ensures continuous supervision of high-risk residents and aligns with regulatory requirements under F689 (Supervision to Prevent Accidents) and F678 (CPR). - Staff have been educated and a log of designated code responders is maintained at each nurse's station for reference. Review of handwritten staff unit assignments dated 6/12 and 6/13 revealed a CR next to 2 nurses per shift indicating they were the code responders for their shift. During an interview on [DATE] at 9:47am with the MS, he stated that he was notified of the elopement on [DATE] and went to the facility at 10am that day to begin door checks on all facility doors to ensure latching/security. He stated that he was to be responsible for secure unit door checks for 2 weeks from [DATE], and then weekly. He stated the protocol was to check the doors behind him and ensure proper latching/locking. During an interview on [DATE] at 5:24pm with CNA C, she stated that she was providing 1:1 supervision to Resident #1 due to his elopement that occurred on [DATE]. She stated that she received in-service training on elopement, door safety and security, supervision instructions specific to Resident #1, and keeping the door code private. During interviews on [DATE] from 5:13pm-5:40pm with 1 MA, 4 CNA's, 1 LVN, and 1 SC from multiple shifts revealed they were all in-serviced between [DATE]-[DATE] on elopement, ensuring door safety/security, visual checks if doors alarm, supervision of residents, keeping door codes private, not leaving residents alone in the secure unit, and who the abuse coordinator is. They stated they were to immediately go to the door that alarmed to see who exited, and ensure they see the person that exited before leaving the door to ensure it was not a resident. During an interview on [DATE] at 10:47am with the MS, he stated that he repaired the secure unit doors so they would close without rubbing on [DATE]. He also stated that he adjusted the timing on the doors so they have 3 seconds, from the time the code is input on the keypad, meaning whoever is trying to gain entry, would have 3 seconds to open the door after inputting the code on the keypad, and if they don't open it within the 3 seconds it would re-engage the magnetic lock. He confirmed he conducts daily audits of all secured exit doors and turns them into the ADM. During an interview on [DATE] at 11:25am with the MDSC she stated that she was given instructions to update/view all care plans and ensure elopement risk assessments were completed. She stated that the secure unit RN completed the elopement risk assessments, but she verified all assessments were done on [DATE]. She also went into each care plan and made sure they all had problem/focus areas for elopement risk. During an interview on [DATE] at 11:37am with RN A he stated he got in-serviced after the elopement on needing to make sure there was always staff on the secure unit. He stated that during his shifts he made sure all doors were working properly and alarms were working, if they were not, he was to notify the DON or the ADM immediately. He stated that Resident #1 was still residing at the facility and on 1:1 monitoring. He stated he had not had any issues with the secured unit door not closing or latching. He stated if a code were called or something else happened, he was to stay on the unit. If there was a code, he was to page the code and start CPR. He confirmed he had to take a posttest to confirm his comprehension of the topics presented.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, observations, and record review the facility failed to ensure each resident receives adequate supervision and assistive devices for one of twenty residents (Resident #1) reviewed for accidents. The facility failed to ensure Resident #1's coffee cup was positioned properly at the upper right of his plate which led to him knocking it over. Resident #1 sustained 2nd degree burns to his bilateral inner thighs from the hot coffee. An IJ was identified on 01/11/2024 at 4:10 PM. While the IJ was removed on 01/12/2024, the facility remained out of compliance at a severity level of actual harm and a scope of isolated harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. These failures placed all residents at risk for injuries, pain, and mental anguish. Findings include: Record review of Resident #1's face sheet dated 01/11/2024, reflected Resident #1 was a [AGE] year-old man admitted on [DATE] with diagnoses of unspecified glaucoma (build-up of fluid in the eye, which presses on the retina and optic nerve), unspecified cataract (a condition in which the lens of the eye becomes cloudy), muscle weakness (lack of physical or muscle strength), and type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, left eye (central part of the retina, swells from the leaking fluid and causes blurred vision). Record review of Resident #1's quarterly MDS assessment dated [DATE] reflected Resident #1 had a BIMS score of 09, which indicated moderate cognitive impairment. Section B (Hearing, Speech, and Vision) reflected Resident #1's vision was highly impaired. Section GG (Functional Abilities and Goals) reflected Resident #1 required setup or clean-up assistance for eating. Record review of Resident #1's care plan dated 01/11/ 2024 reflected Resident #1 was care planned for impaired visual function related to cataracts, glaucoma, and diabetic retinopathy. Resident #1 was care planned for ADL self-care performance deficit related to confusion, impaired balance, and limited mobility with interventions of eating self-performance (limited assist) support provided (x1 assist). Resident #1 was also care planned for blisters to medial thighs bilaterally related to coffee spillage in his lap. Record review of the facility nursing progress note dated 12/29/23 reflected, At approximately. 10:00 am the nurse was called to the dining room; the nurse notified the resident was yelling. Resident reported he had spilled coffee on himself, the nurse returned to his room to assess injury. I wasted coffee in my lap Record review of the facility nursing progress note dated 01/02/24 reflected, Nurse practitioner there to see resident today and assess blisters to inner thighs bilaterally. New orders noted by the charged nurse and entered into the computer. Care plan updated to reflect the following: Focus: Resident #1 had blisters to medial thighs bilaterally related to coffee spillage in his lap. Goal: Resident #1's blisters would heal without complications in the next 30 days. Interventions: Administer treatment as ordered by the physician, assist Resident #1 with his coffee and provide Kennedy cup (non-spill cup) as needed while drinking his coffee, for closed blister on left inner thigh: spray with skin prep or betadine and cover with foam dressing daily, for opened blister on inner right thigh: clean with NS, apply Silvadene to red base wound, calcium alginate to the slough are and cover with foam dressing, change daily, monitor blisters to legs bilaterally for signs of infections or swelling, and notify physician with any concerns. Record review of the facility nursing progress note dated 01/02/24 reflected, received new order for wound care to change orders for care of burns to residents bilateral thighs, New order to clean open blisters to bilateral thighs with NS/WC, pat dry, apply petrolatum gauze to wound beds, and cover with dry gauze type dressing daily and PRN. Resident advised of new orders to start 01/11/2024. Record review of the wound care progress note dated 01/03/24 reflected, Resident #1's wound #1 status was Open. The date acquired was: 1/1/2024. The wound was classified as a Partial Thickness wound with etiology (the cause or cause of a disease) of 2nd degree Burn and was located on the right, Anterior Upper Leg. The wound measured 8cm length x 8.5cm width x 0.1cm depth; 53.407cm2 area and S.341cm3 volume. There was no tunneling or undermining noted. There was a non-present amount of drainage noted. There was no necrotic tissue within the wound bed. The periwound skin appearance did not exhibit: Callus (a region of thickened skin that develops from increased friction), Crepitus (popping, clicking or cracking sound in joints), Excoriation (health condition where you compulsively pick at your skin), Induration (thickening or hardening of soft tissues of the body), Rash (irritated or swollen skin), Scarring (the body's natural way of healing and replacing lost or damage skin), Dry/Scaly (small, hard, dry area that fall of in small pieces), Maceration (skin softening and breaking down due to prolonged contact with moisture that is usually not present on the skin), Atrophie Blanche (a chronic condition that presents as recurrent, painful, ulcers of the lower leg, ankle, or dorsal foot), Cyanosis (bluish color in the skin, lips, and nail beds caused by a shortage of oxygen in the blood), Ecchymosis (bruises), Hemosiderin Staining (areas of discolored skin that usually affect the lower leg, typically on the ankle and the top of the foot), Mottled (marked with spots of different colors), Pallor (skin paleness), Rubor (redness to skin), Erythema (skin rash). Periwound temperature was noted as No Abnormality. Wound #2 status was Open. The date acquired was: 1/1/2024. The wound was classified as a Partial Thickness wound with etiology (the cause or cause of a disease) of 2nd degree Bum and was located on the left,Medial Upper Leg. The wound measures 0.5cm length x 3cm width x 0.1cm depth; 1.178cm2 area and 0.118cm3 volume. There was no tunneling or undermining noted. There was a non-present amount of drainage noted. The wound margin was flat and intact. There was no necrotic tissue within the wound bed. The periwound skin appearance did not exhibit: Callus (a region of thickened skin that develops from increased friction), Crepitus (popping, clicking or cracking sound in joints), Excoriation (health condition where you compulsively pick at your skin), Induration (thickening or hardening of soft tissues of the body), Rash (irritated or swollen skin), Scarring (the body's natural way of healing and replacing lost or damage skin), Dry/Scaly (small, hard, dry area that fall of in small pieces), Maceration (skin softening and breaking down due to prolonged contact with moisture that is usually not present on the skin), Atrophie Blanche (a chronic condition that presents as recurrent, painful, ulcers of the lower leg, ankle, or dorsal foot), Cyanosis (bluish color in the skin, lips, and nail beds caused by a shortage of oxygen in the blood), Ecchymosis (bruises), Hemosiderin Staining (areas of discolored skin that usually affect the lower leg, typically on the ankle and the top of the foot), Mottled (marked with spots of different colors), Pallor (skin paleness), Rubor (redness to skin), Erythema (skin rash). Periwound temperature was noted as No Abnormality. A Record Review of Coffee temp log reflected there was no documentation of coffee temperatures before January 2024. There were missing coffee temperatures for the PM shift on 01/07/24, 01/08/24, and 01/09/24. The coffee temperature log only has one AM and one PM column for documentation. During an observation on 01/10/24 at 1:15 pm of Resident #1's injuries, it was observed Resident #1 had two bandaged areas on both his right and left inner thighs. Observation of the upper right inner thigh area was observed to be pink in color, skin missing. No observation of Resident's #1 left thigh due to Resident #1 yelling out in pain. During an interview on 01/10/24 at 10:30am with Resident #1 stated his plate was placed in front of him and his cup of coffee placed beside the plate (right side), but near the edge of the table. Resident #1 states that his vision was impaired, and he can see objects, shadows, and movement, but not clearly. Resident #1 stated that typically his cup of coffee would have been placed near to the center of the table. Resident #1 stated that his cup was usually at the upper right of his plate with the handle turned out so that he could easily manage his grip on the cup. Resident #1 stated that while he was attempting to take a bite of his food, his hand/arm knocked over his cup of hot coffee directly into his lap. Resident #1 stated he yelled out in pain when he spilled the hot coffee. Resident #1 states that he was wearing sweatpants at the time. During an interview on 01/10/24 at 11:45 am with the CNA, he stated that Resident #1 needs his food and drink positioned to his liking, so he doesn't knock it over. CNA stated that Resident #1 liked his coffee positioned near the center of the table so could see it. Attempted an interview on 01/10/24 at 1:20 pm with LVN #1. No answer but voicemail was left. No return call was made from LVN #1. During an interview on 01/10/24 at 2:45 pm with the DON, she stated she was notified of Resident #1 injuries but there was no redness or blistering at the time. Resident #1 was given a cold towel to place in his lap and the MD was notified. The DON stated LVN #1 and NA #1 gave Resident #1 a shower after the incident and no redness or blistering was observed at that time. DON stated that Resident #1 sustained 2nd degree burns to his left and right thigh because of the incident. During an interview with Dietary Supervisor on 01/10/24 at 3:15pm, a request was made for the coffee/hot liquid temperatures for the calendar year of 2023. Dietary Supervisor stated the facility had not taken any coffee/hot liquid temps prior to January 2024. During an interview on 01/10/24 at 4:15 pm with the ADM, he stated hot liquid temps should be taken after batch of coffee was made. The ADM stated if no temperatures are taken then there would be potential for the coffee/hot liquid to be too hot for the residents. If the coffee/hot liquid was too hot, then there would be risks for resident to sustain injuries from the coffee/hot liquid. During an interview on 01/10/24 at 4:30 pm with the Dietary supervisor, she stated coffee was made 7 times a day. There was a coffee pot for both halls and one for the dining area. The Dietary supervisor stated that the dishwashing staff was responsible for checking the temperature of the coffee. The Dietary supervisor stated she was not aware the temperature of the coffee needed to be checked after each batch was made. During an interview on 01/11/24 at 9:45 am with dishwashing staff #1, he stated he checked the temperature of each coffee pot before each meal. Dishwashing staff #1 stated he only checked the temperature for breakfast and before lunch. The dishwashing #1 stated he did not remember when he was in-services on hot liquids. Attempted an interview on 01/11/24 at 10:15 am with NA #1. No answer but voicemail was left. No return call was made from NA #1. Attempted an interview on 01/11/24 at 2:15 pm with LVN #1. No answer but voicemail was left. No return call was made from LVN #1. Attempted an interview on 01/11/24 at 12:55 pm with NA #1. No answer but voicemail was left. No return call was made from NA #1. Review of the facility's Safety of Hot Liquids Policy dated 2001 reflected Residents will be evaluated for safety concerns and potential of injury from hot liquids up admission, readmission and on change of condition. Appropriate precautions will be implemented to maximize choice of beverage while minimizing the potential of injury. Policy interpretation and implementation 1. The potential for burns from hot liquids is considered an ongoing concern among residents with weakened motor skills, balance issues, impaired cognition, and nerve or musculoskeletal condition. 2. Residents with these or other conditions may suffer from accidental burns and related complications stemming from thinner, more fragile skin that may burn quickly and severely and take longer to heal. 3. Residents who prefer hot beverages with meals (i.e. coffee, tea, soups, etc.) will not be restricted from these options. Instead, staff will conduct regular Hot Liquid Safety Evaluations as indicated, and document the risk factors for scalding and burns in the care plan. 4. Once risk factors for injury from hot liquids are identified, appropriate intervention will be implemented to minimize the risk from buns, such interventions may include: A. Maintaining a hot liquid serving temperature of not more than 155 degrees Fahrenheit: B. Serving hot beverages in a cup with a lid: C. Encouraging residents to sit at the table while drinking or eating hot liquids: D. Providing protective lap coverage or clothing to protect skin from accidental spills, and E. Staff supervision or assistance with hot beverages. 5. Food service staff will monitor and maintain food temperatures that comply with food safety requirements but do not exceed recommended temperatures to prevent scalding. This was determined to be an Immediate Jeopardy on 01/11/24 at 4:10 pm. The ADM was notified. The ADM was provided with the IJ template on 01/11/24 at 4:10 pm. The Plan of Removal was accepted on 01/12/2024 at 10:20 AM and included the following: All listed items will be completed by 01/12/24 with continued follow-up: 1. On 1/11/2024, Resident #1 was assessed by the Director of Nursing/Designee to validate that the resident was not exhibiting signs or symptoms of physical or psychosocial distress related to the deficient practice and to ensure that measures were in place to minimize the risk of future burns related to hot liquids. Care Plan was reviewed to validate all current interventions in place. On 1/11/2024 The Director of Nursing/Designee notified resident #1's responsible party and physician of the identified deficient practice. 2. On 1/11/2024, dietary log was initiated to monitor and temp all brewed batches of coffee throughout the day. Total of 13 dietary staff, 9 of which have received education, the remaining 4 will be completed on 1/12/2024, prior to start of shift, on the process to monitor and temp all batches and requirement to be 155 degrees or less prior to making available for residents consumption. 3. The Director of Nursing/Designee completed a sweep of all facility residents' hot liquid assessment, validated they were current and applicable for all residents on 1/11/2024. Director of nursing/designee then validated for appropriate interventions to be in place and that care plans are updated as applicable related to risk assessment. 3 residents with visual deficit/legally blind were identified including Rresident #1 All 3 identified were supplied with specialty mugs with handles, non-slip bases and lids on January 4, 2024. 4 residents identified as needing assist with all hot liquids, these care plans were updated to reflect necessary need. 5 residents identified with need to be seated at table to securely place hot liquids while drinking. Those care plans updated to reflect the need for this intervention on 1/11/2024. 4. Director of Nursing completed education with all dietary staff on requirements to monitor and log temperature of all batches of coffee, and requirement that temperature before serving or making available to resident be 155 degrees or less 5. The Director of Nursing/Designee provided education to all facility staff on policy for hot liquids and list of specific residents that require additional interventions for hot liquid safety. This education included the requirement to implement appropriate interventions to prevent burns for residents consuming hot liquids. To monitor for compliance: Director of Nursing/Designee will review residents identified with safety concerns from hot liquid assessment daily x 7 days, beginning 1/12/2024, to validate all implemented interventions are in place and any newly identified residents at risk are addressed accordingly with appropriate interventions. Any identified concerns will be corrected with applicable education completed as identified, Director of Nursing/Designee will then continue to monitor daily in clinical meeting ongoing. Monitoring will continue daily in kitchen with temperature log completed on each new batch. Administrator/designee will audit logs daily Monday through Friday to validate hot liquids are temped prior to serving and will review in QAPI for compliance. Any trends or concerns were/will be addressed with the Quality Assurance Performance Committee and continue until a lessor frequency deemed appropriate through QAPI review. Plan of Removal completion date is 01/12/2024. Monitoring for Plan of Removal was completed on 01/12/2024 as follows: The Director of Nursing/Designee provided education to all facility staff on policy for hot liquids and list of specific residents that require additional interventions for hot liquid safety. This education included the requirement to implement appropriate interventions to prevent burns for residents consuming hot liquids. In an interview on 01/12/2024 at 9:05 am with Regional RN, stated Resident #1 was assessed and not exhibiting and signs or symptoms of physical or psychological distress related to recent deficient practice in regard to the coffee burn. Measure have been put in in place to prevent further coffee burns including a cup with a lid, the kitchen staff will ensure coffee remains 155 or less prior to serving coffee to the resident. Resident #1 was in a great mood. He stated, I'm getting better every day. Wounds are improving. Noted inner left thigh was healed, and 2 of the wounds to the right inner thigh are pink, and dry, without any scabs. The wound to the top of the right thigh was approximately 1cm x 1cm, skin pink, blister has popped and without any signs of infection. Resident #1 stated, it does itch a bit. Resident #1 denies any pain. Family and physician were notified of the deficient practice. The physician agrees with current wound care orders and interventions. Regional RN also stated that the facility identified Resident #1, Resident #2, and Resident #3 will use a Kennedy cup (non-spill cup). Resident #4, Resident #5, Resident #6, and Resident #7 will need physical assistance at the table during meals. Resident #8 Resident #9 Resident #10, and Resident #11 will need to be sitting at a table when receiving hot liquids. During interviews on 01/12/24 from 9:50 am - 10:45 am with six dietary staff members (1 dietary supervisor, 3 dietary aides and 2 dietary cooks), who were able to articulate information from the hot liquid in-service. Observation on 01/12/2024 at 9:30am, Kennedy cups for Resident #1, Resident #2, and Resident #3. Each cup had the resident's name on it. Record review on 01/12/2024 at 9:45am, reflected a new hot liquid temperature sheet with columns for documentation for date, time, batch, temp, staff name, and correction/retemp. Record review of the facility's Procedure for monitoring temperature of Coffee 1. All batches of coffee to have temperature taken prior to being allowed for resident consumption. 2. Log each temperature, date/time, batch number, your initials, and time temperature taken. 3. If temperature too high - above 135 degrees, correction taken and what temperature was on recheck. An IJ was identified on 01/11/2024. The IJ template was provided to the facility on [DATE] at 4:10 PM. While the IJ was removed on 01/12/2024, the facility remained out of compliance at a severity level of actual harm and a scope of isolated harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal.