**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 as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for one of four residents (Resident #1) reviewed for accidents hazards. The facility failed to ensure Resident #1, who received anticoagulant therapy, received adequate supervision when she experienced blunt trauma on 05/14/25 when she hit her head and, approximately 10 hours later, on 05/15/25, was transferred to the hospital due to vomiting and subsequently passed away. An Immediate Jeopardy (IJ) situation was identified on 05/22/25. While the IJ was removed on 05/26/25, 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. This failure could place residents at risk of injury, hospitalization and death. The findings include: Record review of Resident #1's face sheet, dated 05/21/25, reflected a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE] and 05/12/25. Resident #1 had diagnoses which included hemiplegia and hemiparesis (hemiplegia and hemiparesis both refer to weakness or paralysis on one side of the body), morbid (severe) obesity due to excess calories (refers to having a Body Mass Index [BMI] of 40 or higher, or a BMI of 35 or higher with at least one obesity-related health condition), and cellulitis of left lower limb (a bacterial skin infection that can cause redness, swelling, warmth, and pain in the affected area). Record review of Resident #1's admission MDS assessment, dated 03/24/25, reflected a BIMS of 11, which indicated moderate cognitive impairment. Section N (Medications) reflected she was taking an anticoagulant (blood thinner). Record review of Resident #1's admission care plan reflected: Resident #1, care plan focus, dated 02/07/22, had potential for bleeding related to anticoagulant therapy. Resident #1, care plan focus, dated 03/15/25, was at risk for injury, falls related to excessive clutter in room. Resident #1, care plan focus, revision dated 05/08/25, required extensive-total assist with intervention, dated 05/08/25, provide assist as needed check q 2 hrs. & prn. Resident #1, care plan focus, revision dated 05/03/22, Resident #1 had ADL self-care performance deficit related to pain and hemiplegia and hemiparesis following cerebral infarction (a type of stroke that occurs when blood flow to the brain is interrupted leading to a lack of oxygen and nutrients to brain tissues) affecting left non-dominant side with intervention revised on 05/08/24 Transfer: The resident requires extensive to total assistance by 2 staff to move between surfaces as necessary. ***mechanical lift*** and Resident #1 is also able to do a self-transfer if she isn't feeling weak Resident #1 care plan focus revision, dated 04/08/25, reflected Resident #1 has a history of verbally aggressive behavior. Observation on 05/23/25 at 1:48 PM of facility video footage of Resident #1's hallway on 05/14/25 beginning at 2:00 PM revealed at 2:49 PM on 05/14/25, CNA A entered Resident #1's room alone with a mechanical lift. No other staff member was observed entering or leaving Resident #1's room with CNA A and the mechanical lift. At 2:56 PM, CNA A left Resident #1's room and put the mechanical lift next to the wall outside of Resident #1's room. Record review of Police Incident Report, dated 05/17/25, reflected a police officer received a call from the hospital about a questionable death and a judge ordered an autopsy on a female who was believed to be a victim of abuse or neglect which caused her death. The report reflected Resident #1 was sent to the hospital due to nausea and vomiting that started around 3:00 AM. Hospital staff reported Resident #1 was coherent and alert and told them she hit her head on the cabinet the day prior 'during repositioning in bed on a sling.' Resident #1 reported to the hospital that she, 'was laid back and struck her head on the cabinet very hard.' Record review of the preliminary autopsy report, dated 05/17/25, reflected preliminary cause of death: blunt force trauma to the head, subdural hematoma of right cerebral hemisphere (a condition where blood collects between the skull and the surface of the right side of the brain. This occurs due to a head injury or other causes) and evidence of uncal herniation (a type of brain herniation where a portion of the temporal lobe [the uncus] is forced downwards and through the tentorial incisura due to increased intracranial pressure. It's a serious condition that can cause significant neurological damage and is often a life-threatening emergency.) Record review of hospital records, dated 05/15/25, reflected Emesis [vomiting] per EMS nausea/vomiting since 3:00 AM given Reglan (treats symptoms of gastroesophageal reflux disease [a condition where stomach acid and sometimes stomach contents flow back into the esophagus, the tube connecting your mouth to your stomach]), Zofran (prevents nausea and vomiting) at nursing home. 'PT states she hit head at NH (no LOC); H/O CVA, LT- sided weakness, [hospital] transport. Pt. reports that she hit her head on a cabinet yesterday Record review of hospital records Medical Decision Making, dated 05/15/25, reflected CT (computed tomography) did reveal a chronic appearing hygroma with acute intracranial hemorrhage (a situation where a patient presents with a long-standing subdural hygroma (a collection of cerebrospinal fluid) that is suddenly complicated by a fresh hemorrhage in the subdural space (a layer of cells called [NAME] border cells). Patient observations: PT alert and oriented X4 [someone who is alert and oriented to person, place, time, and event], cooperative, frequent request for nausea/pain meds [medication] upon arrival. Record review of hospital records, dated 05/15/25, reflected Injury Type: blunt trauma PT states she, 'hit her head on a wooden cabinet 05/14/25 while being lifted into a WC at NH' Record review of hospital records, dated 05/15/25, Brief History - she reports that yesterday during repositioning in bed on sling, she was asked to lay back and struck her head on a cabinet very hard. She had a cephalohematoma (an accumulation of blood under the scalp) but otherwise no issues related to this. She was found to have had an acute chronic subdural hematoma in the setting of recent acute mild traumatic brain injury secondary to her recent head trauma (the patient had a recent head trauma that caused initial bleeding, and then later, the blood clot organized into a chronic subdural hematoma) while at the care facility. Record review of hospital course/summary records, dated 05/17/25, reflected Resident #1 was a [AGE] year-old female with a past medical history of diabetes mellitus type II (blood sugar regulation disorder) and cerebrovascular accident (a medical condition where blood flow to the brain is suddenly disrupted leading to brain cell death and potential neurological damage) left sided and lower extension deficits (often associated with specific muscle imbalances or conditions), who was at her care facility when she developed nausea and vomiting. She said she reportedly struck her head on a cabinet. She was on chronic anticoagulation Lovenox (a medication that helps prevent blood clots from forming and is a type of anticoagulant) 100 mg twice a day for diabetes mellitus type II and cerebrovascular accident who was at her care facility when she developed persistent nausea and vomiting. The patient was unable to use or move her left upper and left lower extremity. She was found to have an acute on chronic subdural hematoma in the setting of recent acute mild traumatic brain injury secondary to her recent head trauma (refers to a situation where there is a new [acute] bleeding within an existing [chronic] subdural hematoma) while at the care facility. She is non-ambulatory due to prior cerebrovascular accident. The patient required intubation (a flexible tube is inserted into a person's airway to help them breath) in the emergency department for depressed Glasgow Coma Scale (a neurological scale used to assess the level of consciousness in people with head injuries) and was evaluated by the neurosurgery team who decided that her prognosis was exceedingly poor. She had a fixed and dilated right pupil (can be a serious sign, potentially indicating a neurological issue like stroke, brain injury or intracranial [within the skull] bleeding) as well as decerebrate posturing (a neurological sign indication severe brain damage, characterized by abnormal extensor responses (a reflex in which the big toe extends upward and the other toes fan outward when the sole of the foot is stroked) specifically in the upper and lower limbs. The patient did not make any neurologic recovery. Palliative care was consulted, and the patient was transitioned to comfort care on 05/17/25. She passed away at 12:48 AM on 05/17/25. Record review of LVN C's Nurses Note, dated 05/14/25 at 10:38 PM, reflected CNA'S reported to this nurse while they were transferring the resident from bed to shower chair the resident started to sliding down and they eased the resident down to the floor. I asked resident what happened the resident stated while they were transferring her, she was sliding down and they eased her to the floor. I assessed the resident head to toe and all body parts no injury noted resident denies pain. Vital signs - blood pressure 106/61, pulse 75, temperature 97.3, respiratory rate 18, oxygen saturation 97% room. Record review of LVN D's Nurses Notes reflected dated created 05/15/25 at 6:00 AM reflected, Resident noted to have nausea/vomiting. PRN zofran and reglan administered. C/O headache as well. PRN APAP administered. Resident noted to be diaphoretic (sweating heavily). VS: 97.0 [temperature] 132/57 [blood pressure] 72 [pulse]18 95% on room air [oxygen saturation] Increased weakness noted as well. Resident cleaned up and vomited two more times. Call returned by [MD], made aware of change in condition. New order received to transfer to ER for evaluation and tx. Call placed to daughter made aware of transfer to [hospital]. On call notified of transfer. Record review of resident #1's orders reflected aspirin oral capsule 81 mg (aspirin) give 81 mg by mouth one time a day related to hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side start date 01/31/2024 no discontinued dated. Record review of Resident #1's Neurological Check Assessment forms beginning 05/14/25 at 5:36 PM through 05/14/25 at 8:30 PM by LVN C and 05/14/25 at 10:30 PM through 05/15/25 at 5:15 AM by LVN D reflected: 05/14/25 at 5:36 PM, temperature within normal range, pulse within normal range, respiration readings within normal range, blood pressure within normal range, full consciousness (awake, aware, oriented), movement all four extremities, hand grip equal and strong, speech clear, pupil reactions brisk - both eyes, pupil size bilateral equal. 05/14/25 at 5:50 PM, temperature within normal range, pulse within normal range, respiration readings within normal range, blood pressure within normal range, full consciousness (awake, aware, oriented), movement all four extremities, hand grip equal and strong, speech clear, pupil reactions brisk - both eyes, pupil size bilateral equal. 05/14/25 at 6:07 PM, normal temperature within normal range, pulse within normal range, respiration readings within normal range, blood pressure within normal range, full consciousness (awake, aware, oriented), movement all four extremities, hand grip equal and strong, speech clear, pupil reactions brisk - both eyes, pupil size bilateral equal. 05/14/25 at 6:25 PM, normal temperature within normal range, pulse within normal range, respiration readings within normal range, blood pressure within normal range, full consciousness (awake, aware, oriented), movement all four extremities, hand grip equal and strong, speech clear, pupil reactions brisk - both eyes, pupil size bilateral equal. 05/14/25 at 7:00 PM, normal temperature within normal range, pulse within normal range, respiration readings within normal range, blood pressure within normal range, full consciousness (awake, aware, oriented), movement all four extremities, hand grip equal and strong, speech clear, pupil reactions brisk - both eyes, pupil size bilateral equal. 05/14/25 at 7:30 PM, normal temperature within normal range, pulse within normal range, respiration readings within normal range, blood pressure within normal range, full consciousness (awake, aware, oriented), movement all four extremities, hand grip equal and strong, speech clear, pupil reactions brisk - both eyes, pupil size bilateral equal. 05/14/25 at 8:30 PM, normal temperature within normal range, pulse within normal range, respiration readings within normal range, blood pressure within normal range, full consciousness (awake, aware, oriented), movement all four extremities, hand grip equal and strong, speech clear, pupil reactions brisk - both eyes, pupil size bilateral equal. 05/14/25 at 10:30 PM, normal temperature within normal range, pulse within normal range, respiration readings within normal range, blood pressure within normal range, full consciousness (awake, aware, oriented), movement all four extremities, hand grip equal and strong, speech clear, pupil reactions brisk - both eyes, pupil size bilateral equal. 05/14/25 at 11:15 PM, normal temperature within normal range, pulse within normal range, respiration readings within normal range, blood pressure within normal range, full consciousness (awake, aware, oriented), movement all four extremities, hand grip equal and strong, speech clear, pupil reactions brisk - both eyes, pupil size bilateral equal. 05/15/25 at 12:30 AM, normal temperature within normal range, pulse within normal range, respiration readings within normal range, blood pressure within normal range, full consciousness (awake, aware, oriented), movement all four extremities, hand grip equal and strong, speech clear, pupil reactions brisk - both eyes, pupil size bilateral equal. 05/15/25 at 1:30 AM, normal temperature within normal range, pulse within normal range, respiration readings within normal range, blood pressure within normal range, full consciousness (awake, aware, oriented), movement all four extremities, hand grip equal and strong, speech clear, pupil reactions brisk - both eyes, pupil size bilateral equal. 05/15/25 at 4:15 AM, normal temperature within normal range, pulse within normal range, respiration readings within normal range, blood pressure within normal range, full consciousness (awake, aware, oriented), movement all four extremities, hand grip equal and strong, speech clear, pupil reactions brisk - both eyes, pupil size bilateral equal. 05/15/25 at 5:15 AM, normal temperature within normal range, pulse within normal range, respiration readings within normal range, blood pressure within normal range, full consciousness (awake, aware, oriented), movement all four extremities, hand grip equal and strong, speech clear, pupil reactions brisk - both eyes, pupil size bilateral equal. Record review of CNA A's Employee Warning Report dated 05/16/25 reflected supervisor's/employer's statement, staff member suspended pending investigation of incident involving resident that occurred 05/14/25. During investigation, staff member was observed violating facility safety/nursing policies. Staff member has given multiple different accounts of incident, making it difficult to verify what actually occurred discussed with CNA A by phone and employee declined to sign document. Interview on 5/21/25 at 2:30 PM with CNA A revealed CNA A and CNA B were transferring Resident #1 together using a gait belt from Resident #1's bed into a shower chair and Resident #1 began to wiggle and she and CNA B eased Resident #1 to the floor. After Resident #1 was on the floor, CNA B got the mechanical lift and both CNA A and CNA B transferred Resident #1 into the shower chair using the mechanical lift. CNA A said when the nurse came into assess Resident #1, Resident #1 was in bed. She said Resident #1 did not hit her head and if Resident #1 hit her head, she would have told the nurse. Interview on 05/21/25 at 5:35 PM with CNA B reflected she worked the 2:00 PM - 10:00 PM shift on 05/14/25 and she and CNA A went into Resident #1's room to assist Resident #1 with her shower. CNA B said she thought it was about 3:30 PM on 05/14/25. CNA B said Resident #1 was wearing a gait belt and when she and CNA A were transferring Resident #1 from her bed to her shower chair Resident #1 became weak and they gently sat Resident #1 down on the floor of her room. CNA B said Resident #1 did not fall and she did not hit her head. She said after Resident #1 sat on the floor, they used a mechanical lift to transfer Resident #1 from the floor to her shower chair and they wheeled Resident #1 into the shower using the shower chair. CNA B said after Resident #1 was in her bed after her shower, LVN C came to assess Resident #1 . Interview on 05/21/25 at 1:16 PM with LVN C revealed CNA A and CNA B reported to her they were transferring Resident #1 from her bed to the shower chair and Resident #1 began to slide down and the CNAs eased Resident #1 down to the floor of Resident #1's room. The CNAs informed LVN C of the incident after Resident #1 was in her bed. LVN C said she did not know how the CNAs got Resident #1 from the floor to the bed. LVN C thought the CNAs used a mechanical lift, but she did not witness them using a mechanical lift to transfer Resident #1 from the floor to her bed. She said after the CNAs informed her Resident #1 slide to the floor, she assessed Resident #1. LVN C said Resident #1 was not a mechanical lift transfer prior to this incident but Resident #1 had been declining and just returned from the hospital. CNA C said she assessed her from head to toe and did not find any trauma to Resident #1's head. She said Resident #1 denied pain and was talking without difficulty. LVN C said the CNAs should have called her to assess Resident #1 before they moved Resident #1 because she was the charge nurse and residents were not to be moved when they were on the floor. Interview on 05/23/25 at 1:24 PM with LVN D revealed LVN D worked the 10:00 PM - 6:00 AM shift beginning 05/14/25 and conducted neurological checks on Resident #1 that evening. LVN D said on 05/15/25 Resident #1 had vomited, and she cleaned her up and gave her PRN nausea medication. LVN D stated Resident #1 had a fall during the 2:00 PM - 10:00 PM shift from a chair and this occurred before LVN D's shift started. LVN D said she was not told Resident #1 hit her head. LVN D said Resident #1 was not herself, not at baseline and she was sweating. Interview on 05/22/25 with a FP G at 9:05 am who was employed with the autopsy company that conducted Resident #1's autopsy, revealed Resident #1's injures were consistent with a fall and the injuries could have occurred even from a minor fall. He said her subdural hemorrhage was caused by trauma and it would have been exceedingly rare for her to have had those injuries if she had not had a fall. He said if she received treatment sooner, potentially, she might have survived or at least had a better chance of survival. He said because Resident #1 was on anticoagulants, a fall would work in tandem for causing catastrophic bleeding. He said the autopsy photos were consistent with a fall and there was a pretty significant contusion (an injury to soft tissue that causes bleeding without breaking the skin) of the frontal scalp and the back of the scalp. He said her trauma exhibited in the autopsy was from a fall and not a natural death. Interview on 06/11/25 at 9:15 am with a FP G at 9:15 am who was employed with the autopsy company that conducted Resident #1's autopsy and was the FP who conducted Resident #1's autopsy revealed that Resident #1's had an acute bleed that was a day or two old but could not say that it was not an older bleed. She stated there was a subdural contusion (a lift threatening condition where blood collects between the brain and its outer covering) underneath the scalp at the hairline and it did look like she hit her head. Interview on 05/21/25 at 12:36 PM with the DON reflected CNA A and CNA B reported to her that during a transfer with Resident #1, from her bed to a shower chair they broke a fall meaning the CNAs repositioned a person to prevent a fall from happening. The DON said most days Resident #1 did well with staff assisting her with transfers, but she was weak. The DON said she told the CNAs when in doubt, use a mechanical lift and sometimes Resident #1 needed a mechanical lift. The DON said after the CNAs, broke the fall Resident #1 was upset and cursing. She said that when the staff, broke her fall she decided to treat it like a fall and LVN C assessed Resident #1 and the DON wanted close attention paid to Resident #1 because Resident #1 could be difficult. The DON said they used the buddy system to care for Resident #1 because Resident #1 was challenging. The DON stated Resident #1 had a history of calling 911 to come to the facility to take her to the hospital. She said she wanted the nurses to conduct neurological checks on Resident #1 because she wanted to treat the situation where the CNAs broke her fall as if it were a fall and because of Resident #1's history of calling 911 and telling them she needed treatment. The DON stated she wanted the staff to go above and beyond, and they conducted the neurological checks to be on the safe side. Interview on 05/26/25 at 11:23 AM with the Administrator revealed, after observing on 05/23/25 the facility video footage of Resident #1's hallway on 05/14/25 at 2:49 PM, CNA A entered Resident #1's room alone with a mechanical lift. The Administrator said if CNA A was transferring Resident #1 using a mechanical lift, there should have been two people transferring Resident #1 to prevent any accidents and for the safety of Resident #1 . Interview on 05/22/25 at 5:30 PM with MD E revealed she received a call from the facility on 05/15/25 about Resident #1's nausea and vomiting. She said she did not remember the call very well and did not document the call in her records which she usually did. MD E said if Resident #1 was given PRN medication for the vomiting and she was still vomiting, she needed to go to the ER. She said she did not remember if they discussed Resident #1 falling or any discussion that Resident #1 hit her head. Record review of the facility's, undated, policy Safe Lifting and Movement of Residents, , reflected: In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. Resident safety, dignity comfort and medical condition will be incorporated into goals and decisions regarding the safe lifting and movement of residents. Nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents' needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan. Such assessment shall include residents' preferences for assistance, residents' mobility, resident size, weight bearing ability, cognitive status, whether the resident is usually cooperative with staff and the residents' goals for rehabilitation, including restoring and maintaining functional abilities. Record review of the facility's, undated, policy Neurological Assessment, reflected: The purpose of this procedure is to provide guidelines for a neurological assessment 1. upon physician order 2. when following an unwitnessed fall 3. subsequent to a fall with a suspected head injury 4. when indicated by resident condition When assessing neurological status, always include frequent vital signs. Particular attention should be paid to widening pulse pressure (often a sign of increased arterial stiffness or a decreased ability of the heart to pump effectively) a difference between systolic pressure (the higher number in the blood pressure reading and diastolic pressure (the pressure in your arteries when your heart is at rest between beats, allowing the heart to refill with blood). This may be indicative of increasing intracranial pressure. Record review of the facility's, undated, policy Falls-Clinical Protocol reflected all should be categorized as 1. those that occur while trying to rise from a sitting or lying to an upright position for an individual who has a fall, the staff and practitioner will begin to try to identify possible causes within 24 hours of the fall. 2. those that occur while upright and attempting to ambulate and 3. other circumstances such as sliding out of a chair or rolling from a low bed to the floor Falls should also be identified as witnessed or unwitnessed events. This was determined to be an Immediate Jeopardy (IJ) on 05/22/25 at 5:27 PM. The ADM was notified. 5:. The ADM was provided with the IJ template on 05/22/25 at 5:27 PM . The following Plan of Removal submitted by the facility was accepted on 05/24/25 at 4:02 PM: Plan of Removal Immediate Jeopardy On 05/22/2025 an abbreviated survey was initiated. On 05/22/25, 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 Resident #1 received adequate supervision when she experienced trauma to the head, and approximately 10 hours later was transferred to the hospital due to vomiting and subsequently passed away. Action: The DON was in-serviced by Corporate Consultant on safe transfers, mechanical lift safety guide, falls clinical protocol, incident and accident reporting via a conference call on 5/22/25, 6:22 PM. The DON will educate the ADON/ADM/designee and all direct care staff, PRN, new staff and agency staff upon hire: safe transfers, mechanical lift use, falls-clinical protocol, and incident and accident reporting before the beginning of next scheduled shift. All current staff, PRN, agency and new hires will receive this training prior to working their next shift. The retention of the training will be monitored by performing a pre/post test. Start Date: 05/22/2025 Completion Date: 05/23/2025 Responsible: DON/ADON/Therapy/designee Action: All current and new residents that require the use of the mechanical lift/2 person assist will have the care plan KARDEX reviewed to ensure they are up to date. Seventeen residents have been identified that currently use the lift or 2 person assist. Start Date: 05/22/2025 Completion Date: 05/23/2025 Responsible: MDS/designee Action: The DON/ADON/Therapy to help conduct lift competencies on all current, PRN, and new nursing staff and will be maintained in the employee file. The retention of the training will be monitored by performing a pre/posttest and will be maintained in the employee file. This will be conducted prior to working the next shift. All agency staff will complete a competency prior to working a shift. The DON/designee will monitor conduct three random observations of transfer with lifts and/or 2-person assists a week for the next 4 weeks then three random observations of transfer w/lifts and/or 2-person assists monthly thereafter. All findings will be reported to the QAPI team. Start Date: 05/22/2025 Completion Date: 05/23/2025 Responsible: Therapy/designee The charge nurse/DON/ADON will assess each resident that has been identified to use a mechanical lift to determine if any other residents have had any injury related to use of a lift. This will be completed on 5/23/25. Seventeen residents have been identified that use a mechanical lift. A facility-wide survey was completed 05/23/25, all residents deny that they have suffered any accidents or hazards. The DON was in-serviced by RN Corporate Consultant on 05/22/25 on safety and supervision. This in-service was then provided to the nursing staff, CMA's and CNA's on 05/23/25. All in-services will be provided to the two agency companies and will be required before working their next shift and future shifts. This will be ongoing. The agencies will provide signed confirmation on their electronic platform. The DON/ADON/ADM will be responsible for ensuring the education is completed prior to working a shift. A QAPI plan is being initiated with this POR , the DON and Administrator will carry out the plan and monitoring. The Corporate consultants will monitor the plan monthly with each site visit for the next 6 months . Monitoring of the POR included the following: Interview on 05/24/25 at 4:45 PM with the CC revealed she in-serviced the DON on the facility policy regarding safety and supervision, safe transfers, mechanical lift safety guidelines, falls clinical protocol, incident and accident reporting via a conference call on 5/22/25 at 6:22 PM. The CC discussed with the DON the safety and supervision of residents in general and during transfers and the falls protocol and using the mechanical lift for safe transfers and safety during 2-person non-mechanical lift transfers. The CC in-serviced the DON on educating her staff that even if they suspected there was an injury to the head, or any injury, nurses needed to notify the MD and send the resident to the hospital at that time. She in-serviced the DON on educating CNAs to report in a timely manner to the nurses anything out of the ordinary that occurred during transfers or during CNA involvement with resident care and safety. Interview on 05/24/25 with the DON at 4:00 pm revealed she was in-serviced by the CC and together they reviewed the facility policy procedures on safety and supervision, safe transfers, mechanical lift guidelines, falls clinical protocol, incident and accident reporting via a conference call on 5/22/25 at 6:22 PM. They discussed ensuring the safety of residents who used a mechanical lift and residents who were a two person assist. The DON said during the in-service they discussed the requirement for nurses to call the MD and get an order for the resident to go to the hospital if there was even a suspicion of the resident hitting their head or had any safety issues. CNAs were to report to their charge nurse any type of fall, incident, or accident even if they thought it was minimal. It needed to be reported to the charge nurse because it was the responsibility of the charge nurse to follow up with the resident and escalate as needed. It was the responsibility of the charge nurse to report any suspected head injury to the MD. It was the responsibility of the Abuse and Neglect coordinator to report any concerns of abuse and neglect and the responsibility of the DON to assist with investigations as directed and follow up with any reported suspicion of head injury. It was the responsibility of the charge nurse to make sure CNAs were reporting to the nurses any and all concerns about resident care and safety and problems or concerns with resident transfers and the nurse's responsibility to follow up with those concerns to the MD and to notify on call staff. Interview on 05/25/25 at 9:26 AM with the DOR reflected

**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 for 1 of 1 resident (Resident #1) reviewed for supervision. The facility failed to ensure Resident #1 did not elope from the facility on [DATE]. Resident #1 was missing from the facility from approximately 5:00 am to 8:00am am until he was located by police. An IJ was identified on [DATE] at 4:10 PM. While the IJ was removed on [DATE] at 7:45AM, the facility remained out of compliance at a level of no actual harm at a scope of isolated with a 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. This deficient practice placed residents at risk for falls, injuries, dehydration, hospitalization, and death. Findings included: Record review of Resident #1's admission recorded dated [DATE] reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses that included: dementia (brain diseases that cause declining thinking, memory, and reasoning skills), psychosis (mental state where a person's perception of reality is different from other such as hallucinations and delusions), depression (feeling sad, unhappy, or miserable), major depressive disorder (mood disorder that can cause a persistent feeling of sadness and loss of interest), muscle weakness(when your muscle feel tired, weak, or unable to exert their usual force), abnormality of gait and mobility (any deviation from a normal walking pattern, including changes in the rhythm, coordination, and stability of movement), lack of coordination(not being able to move your body smoothly and precisely), and symbolic dysfunction (disorder that affects a person's ability to perceive or perform certain activities). Record review of Resident #1's Annual MDS assessment, dated [DATE], revealed the resident had a BIMS score of 03 indicating the resident had severe cognitive impairment. Resident #1 required supervision or touching assistance in the following areas: personal hygiene, putting on/taking off footwear, lower body dressing, upper body dressing, shower/bathe self, toileting hygiene, and oral hygiene. Record review of an Elopement Risk Assessment dated [DATE], reflected Resident #1 was a risk for elopement. Record review of local weather with outside temperatures for the local area on [DATE] from 5:00am 8:00am temperatures ranged from 28 degrees to 30 degrees F. Record review of progress note, dated [DATE], reflected nurse was made aware of elopement at approx. 0800 that resident was not in room or unit. This nurse made staff aware of situation and head count and search initiated of building and surrounding area of outside perimeter. Resident was seen approximately 0500 near day room and was unable to sit down on couch and returned to room at this time. Call placed to DON, made aware of situation. Call placed to emergency contact, made aware and will keep updated. Record review of progress note, dated [DATE], reflected DON responded to report by charge nurse of suspected elopement. CODE Pink response measure deployed, unable to locate resident facility premises. Administrator and Corporate Team alerted of incident; local PD dispatched for further assistance. Resident located near facility by local PD. Nursing Admin arrived at scene, where Resident #1 refused to be transported back to facility. After several minutes of convincing by the officer on scene, Resident #1 was transported to facility by police car. Upon arrival to the facility, Resident #1 became increasingly irate and agitated, adamantly refusing to return to facility. Resident #1 stated, Don't come near me, I'm not going in there, and if you force me I'll f**k you up and everyone else back there. Police Dept able to eventually de-escalate the situation. Resident #1 demanded that we give him his belongings and release him now! I explained to Resident #1 that we would have to get an order from his physician in order to release him and have a meeting with our Team and his friend to come up with a plan for him to leave safely. Resident #1 began to yell and curse and said, I'm not waiting on a Dr, I'm leaving now, I'm a grown man and it's my choice, I'm not in prison! PD stated, Resident #1 is his own Responsible Party and appears to be alert and cognitive and the facility cannot hold him here against his will. I explained to PD that resident had history of alcohol-induced dementia, and I did not feel comfortable releasing him into the community with no secure discharge plan. Local PD began asking a series of questions to attempt to review his cognitive status. They stated Resident #1 knew his name, the year, his whereabouts, where he was from, and named several people on his contact list. I explained to local PD that LTC settings have clinical assessments used to determine a resident's cognitive status, and PD attempted to assist me with completing this assessment to no avail. Resident #1 grew agitated towards the end of the assessment, began to make threats of physical violence, and did not allow completion. At this time, I requested that the officers encourage Resident #1 to go to the local hospital for further evaluation to rule out infection, abnormal labs, etc. After several moments, Resident #1 was transferred to local hospital via police car. IDT team, ombudsman, medical director, corporate team notified. Record review of progress note, dated [DATE] at 10:31am, reflected the DON spoke w/staff from local hospital re: transfer of Resident #1 to in-patient psychiatric hospital. Stated that another psychiatric evaluation had been completed and per the new psychiatric evaluation, resident did not meet criteria for in-patient psych stay. Local hospital staff stated, Resident #1 continued to refuse to return to the nursing facility and continued to make threats of physical harm if made to return to facility. DON requested that local hospital staff forward clinical updates/evaluation notes and results to e-fax for review as soon as possible, so that resident updates could be discussed with Administrator, Clinical Consultant, IDT Team and appropriate interventions and measures are able to be put in place. Emphasized to local hospital staff that we are willing to accept resident back, however we want to ensure the safety of the residents and staff upon his return. Encouraged local hospital to connect Resident #1 with a counselor or social worker that may be able to help him cope with the emotions that he was experiencing, and acceptance of his need to be in a long-term care setting. DON requested that local hospital stay in close contact with the nursing facility so that we may collaborate on a safe transfer for the resident. Anticipated to connect [DATE] after the nursing facility IDT meeting and local hospital doctor rounds/team meeting to discuss further. Record review of Resident #1's care plan, dated [DATE], revealed Resident #1 was care planned for risk of side effects/complications from antidepressant use related to depression, deep vein thrombosis, difficulty making decisions dementia associated with alcoholism with behavioral disturbance, placed in secure unit d/t history of elopement, physically aggressive behavior, h/o of wandering, and impaired comprehension. Record review of a police report date [DATE], revealed the local pd was notified Resident #1 was missing at 8:33am on [DATE]. The record review also revealed Resident #1 was located at 10:16am on [DATE]. An interview with the MD on [DATE] at 1:11pm, revealed the MD was told that Resident #1 departed through a window, the doors had an alarm but not the windows. The MD stated Resident #1's elopement could have caused Resident #1 harm from hypothermia(a condition that occurs when body temperature drops below 95 degrees Fahrenheit or 35 degrees Celsius.) or possible death. The MD stated Resident #1's elopement was unacceptable. An interview with the DON on [DATE] at 11:27am, revealed the DON stated she was informed by the charge nurse that Resident #1 was noticed missing around 7:30am on [DATE]. The DON stated a CNA noticed that Resident #1 wasn't in his normal seat for breakfast. DON stated the staff then checked all of the rooms, smoking area, rest room and therapy room but Resident #1 could not be found. The DON stated staff searched all over the facility inside and outside. The DON stated she advised staff to go to Resident #1 room and it was noticed that his window was ajar. The DON stated that's when the local PD was notified Resident #1 was missing. The DON stated Resident #1 was found 4-5 away blocks from the facility by the local PD and returned. The DON stated once Resident #1 was in the parking lot of the facility having behaviors, so the local PD took him to a local hospital for an evaluation. The DON stated that Resident #1 did not qualify for inpatient stay and was return to the facility later the same day. The DON stated that some negative outcomes of Resident #1's elopement could have been the resident could have been injured or died. The DON stated that expectations for residents' supervision to be carried out appropriately, all residents were safe, and their needs are being met. An observation and interview with Resident #1 on [DATE] at 12:25pm, revealed that Resident #1 stated that he was feeling good and did not have any thought of leaving the facility. Resident #1 did not state how he left the facility. Resident #1 was in his room lying in bed at the time of the interview. An interview with CNA A on [DATE] at 2:42pm, revealed that CNA A stated she worked on [DATE] when Resident #1 eloped. CNA A stated she usually laid eyes on all residents when the shift started but not on that day because she was running late so she just went to working. CNA A stated that around breakfast time she noticed she had seen Resident #1 in the common area, so she went to Resident #1's room and opened the door but he wasn't there. CNA A stated she checked the common area and his room twice but couldn't locate Resident #1. CNA A stated she then notified the nurse that Resident #1 was missing. CNA A stated her, and the nurse went to Resident #1's room that was when the nurse noticed Resident #1's window was open. CNA A stated that Resident #1 could have been hurt or died due to his elopement. Review of the facility's Safety and Supervision of Resident policy, dated [DATE], 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. Policy Interpretation and Implementation Facility Oriented Approach to Safety 1. Our facility-oriented approach to safety addresses risks for groups of residents. Resident Risks and Environmental Hazards 1. Due to their complexity and scope, certain resident risk factors and environmental hazards are addressed in dedicated policies and procedures. These risk factors and environmental hazards include the following: e. unsafe wandering . This was determined to be an Immediate Jeopardy on [DATE] at 4:10 pm. The DON was notified. The DON was provided with the IJ template on [DATE] at 4:10 pm. The Plan of Removal was accepted on [DATE] at 7:45 am and included the following: All listed items will be completed by [DATE] with continued follow-up: 1. Elopement, wandering residents, emergency Response: Missing Resident, Abuse and Neglect, Window Alarms Recognition, Response and Maintenance policy and procedure review was facilitated by DON with all facility staff. [DATE]. 2. The DON or designee will audit new admissions for elopement risk and ensure appropriate interventions are in place. 3. The facility will implement census checks every 4 hours until further review, facility wide. Charge Nurses and/or Designee will be responsible for completion. 4. Window alarms were placed on each window in the secure unit by the Maintenance/Life Safety Team. Completed [DATE]. Placement and checking function will be performed by Charge Nurse/designee each shift. 5. Every resident will have an updated wandering risk scale completed by Charge Nurse/designee by [DATE]. 6. New hires will receive education on wandering, elopement, and resident safety by the DON, Director of Social Services, or designee(s). 7. Any resident that attempts to leave or wishing to leave will be reported to the DON/designee and new interventions will be put in place at that time. 8. Twice a week, for 3 months or until the pattern of compliance is maintained, the DON/designee will check the monitoring logs to ensure compliance, any non-compliance will be reported to the facility administrator. 9. A Quality Assurance Performance Improvement (QAPI) Performance Improvement Project (PIP) was implemented to review and interpret all audit findings on [DATE]. Members of the IDT Team including DON, ADON, Director of Rehab, Maintenance Director, Admission/Marketing Team, Social Services Director, Activities Director, Business of Manager, and Central Supply Director. All findings will be discussed at the monthly QAA meeting for a minimum of three months or until the pattern of compliance is maintained. Plan of Removal completion date is [DATE]. Monitoring for Plan of Removal was completed on [DATE] as follows: Record review on [DATE] at 9:00am, reflected staff were inserviced on elopement, wandering residents, emergency Response: Missing Resident, Abuse and Neglect, Window Alarms Recognition, Response and Maintenance policy. 48 staff were inserviced on elopement, wandering residents, emergency Response: Missing Resident, Abuse and Neglect, Window Alarms Recognition, Response and Maintenance policy Record review on [DATE] at 10:35am, reflected all 89 residents had updated wandering assessments. Record review on [DATE] at 10:40am, reflected census check were being completed every four hours. Observation on [DATE] at 9:30am, reflected window alarms on all windows in the secure unit were working. There were 12 rooms on the secure unit. Each alarm was triggered and could be heard from a far distance. Staff responded to the window alarms appropriately. During interviews on [DATE] from 9:50 am - 11:45 am with six staff members (2 6am - 2pm LVNs, 2 6am-2pm CNAs, 2 2pm-10pm LVNs 2 2pm-10pm CNAs, 2 10pm-6am LVNs, and 2 10pm-6am CNAs), who were able to articulate information from the following in-services: Elopement, wandering residents, emergency Response: Missing Resident, Abuse and Neglect, Window Alarms Recognition, Response and Maintenance policy and procedure. All staff interviewed stated if any residents that attempt to leave or wishing to leave they would report it to the DON/designee immediately. During an interview with the DON on [DATE] at 11:50am, revealed the DON stated the facility had not any new admissions, no new hires, and no resident had attempted to leave or wished to leave since Resident #1's elopement. The DON stated that all patio furniture was removed from the smoking area due to Resident #1 elopement. The DON stated that with the information gather it was likely that Resident #1 used the patio furniture to get over the fence to elope. While the IJ was removed on [DATE] at 7:45AM, the facility remained at a level of no actual harm at a scope of isolated that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the residents that included measurable objectives and timeframe's to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment . For 1 (Resident # 52) of 16 reviewed. The facility failed to develop and implement a comprehensive care plan for Resident # 52 that included interventions to ensure safety from the residents aggressive physical and verbal behaviors. On 08/30/24 at 6:16 PM an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 08/31/24, the facility remained out of compliance at a scope of widespread and a severity level of potential for more than minimal harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure put the resident at risk from their highest practicable physical, mental, and psychosocial well-being. Findings included: Review of Resident # 52's face sheet dated 8/30/2024 revealed a [AGE] year-old male admitted on [DATE] with diagnosis that include Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, ( partial paralysis due to a blockage in the brain impeding blood flow), Unspecified mood ( Affective) disorder ( any in a group of conditions of mental and behavioral disorder where the main underlying characteristic is a disturbance in the person's mood) Major depressive disorder, recurrent, severe with psychotic symptoms (sadness and hopelessness with symptoms of seeing, hearing, smelling or believing things that are not real) and Intermittent Explosive Disorder ( a condition that causes repeated, sudden outburst of impulsive, violent behavior or angry verbal outburst). Review of Resident #52's Quarterly MDS dated [DATE], revealed a BIMS score of 08 (indicates a Moderate cognitive impairment) Section E0200 Behavioral symptoms revealed no physical behavioral symptoms directed to others, no verbal behavioral symptoms directed toward others, and no other behavioral symptoms not directed toward others. Review of Residents # 52 care plan 04/02/2023 and updated 2/20/2024 revealed Resident #52's h/o using profanity/verbally aggressive with staff and resident's r/t intermittent explosive disorder. 04/07/2023 Cursed out nurse,04/19/2023 Cursed out resident,04/20/2020 cursed staff and residents,05/03/2023 Cursed out nurse,05/20/2023 Cursed out nurse and CNA, 06/01/2023 Cursed out nurse,06/08/2023 cursed nurse,06/09/2023 cursed nurse,06/11/2023 Cursed CNA,06/12/2023 Cursing staff,06/15/2023 Cursed out nurse,06/20/2023 Cursed out nurse,06/23/2023 cursing in dining room,07/24/2023 cures out resident,07/25/2023 cursed resident out,08/02/2023 cursing staff,08/13/2023 cursed out nurse,08/23/2023 Resident in common area, calling female resident a fucking whore,08/24/2023 Residents behavior, unacceptable, cursing and yelling at nurse and,08/29/203 cursing staff and residents,1/31/2024 verbal aggression initiated,2/19/2024 verbal aggression initiated Review of Resident's #52 Process notes dated 8/30/2024 at 11.49 am written by the SW revealed Spoke with the resident regarding incident that happened over the weekend. When SW asked him about it, he responded, you don't' Know?' Resident then stated that he was attacked by the other resident who hit him. He stated he needed to contact his family to let them know that he had been attacked. SW informed him that he has the right to call his family and asked if he needed assistance, he responded no, he can do it. The incident is still under investigation. Several residents were witnesses and state that Resident # 52 was the instigator. Review of Incident and accident report which is not a part of the medical record dated 8/25/2024 09:02 am completed by LVN J, At approximately 0 am, once breakfast was completed, this nurse was assessing another resident her breathing treatment when a resident came wheeling down the hall stating, they are fighting. I did not immediately understand what was going on, then I realized everyone was moving towards the dining hall and I followed. Once I arrived in the dining hall resident where being separated. I spoke and found a housekeeper who had witnessed most of the incident, Resident # 52 was verbally, harassing Resident #42, Resident # 42 told him something around the lines of leave me alone I'm not bothering you or anyone, Resident #52 preceded to go around the wall towards Resident #42 and continued to verbally harass him then threw something towards Resident #42's direction. Resident #42 then picked up a chair to hit Resident # 52 and staff members removed the chair from Resident # 42's hands, then Resident #42 attempted to hit Resident #52. Due to a lot of bodies and movement it is unsure if Resident #42 actually hit Resident #52. During the Resident council meeting on 8/28/224 at 10 am revealed many of the residents stated there was a resident in the facility that is verbally and aggressive behavior (Resident # 52), resident report the facility is aware of the behaviors and do not appear to be doing anything about it. Several residents stated that there were afraid of (resident #52 because of his aggressive behaviors) , one resident stated he now carries a cane with him when he leaves his room so that he can protect himself from (Resident #52). In an interview on 8/29/2024 at 11:45 am with the SW, she stated that she was trying very hard to get Resident # 52 to a different facility. SW stated she is aware of the concerns of the other resident with the behaviors of Resident # 52, She stated that her interventions with Resident # 52 are to discuss the behavior with him and try to redirect it., she admitted that most times this is not successful. She stated Resident # 52 is not currently on any kind of behavior modification plan and the psychiatric NP sees him, and the local authority follows. him with services. She stated there is a policy for dealing with aggressive residents but the she does not use the interventions with Resident # 52 and he is not responsive to it, her goal for Resident # 52 is to keep him and the other residents safe until placement can be found. In an interview on 8/29/2024 at 11:30 with the ADN, he stated that he looked into the resident-to-resident altercation and felt that there was no intent for the bystander resident to be harmed so he did not report it. The ADN stated he was notified on Saturday of the event and did his investigation on Monday. He stated he was aware of the 24 hours requirement to report abuse which resident to resident altercation is considered. He acknowledged that and was not sure what he needed to report. He stated the injury to Resident # 62 by Resident # 52 was an accident and not intentional, he stated from the staff report over the phone to him on Saturday he determined that the injury was unintentional and did not do an investigation till Monday. The ADN stated Resident #52 was a difficult case, and that he never should have been admitted to the facility. He stated the more they document Resident #52's behaviors the more difficult placement will be. He stated he was afraid to put him on a one to one because that could set him off and may result in him getting physical. The ADN stated he is not really is not sure what to do, until they get him accepted at another facility. He stated his expectation that the staff keep them and the other resident's safe from Resident # 52's behaviors. The ADN stated Resident #52 's behavior did place the residents and staff at risk for abuse. He stated Resident #52 was difficult to deal with and they had been seeking placement for Resident # 52 in a more appropriate facility but had not found a placement yet that would accept him with his behaviors. The ADN stated there were no special interventions in place at this time for his behaviors. Review of Policy Care Plans, comprehensive Person-centered revised December 2016 on 8/30/2024 at 1:30 PM revealed The comprehensive, person-centered care plan will be. Describe the services that are to be furnished to attain or maintain the resident highest practicable physical, mental and psychosocial well-being. This was determined to be an Immediate Jeopardy (I) on [Date] at [Time]. The [identifier of people notified] were notified. The [identifier of the person given the I template ] was provide with the IJ template on [Date] at [Time]. The following Plan of Removal submitted by the facility was accepted on 08/31/24 at 12:35 PM and reflected the following: The alleged deficient practice was the facility failed to develop and implement a comprehensive care plan that included interventions to ensure safety from the residents aggressive, physical, and verbal behaviors. 1. Identification of Residents Affected or Likely to be Affected: The facility took the following actions to address the citation and prevent any additional residents from suffering an adverse outcome. (Completion Date: 8/30/24) This Resident was discharged on 8/30/2024 with no plan to return to the facility. The facility issued an emergency discharge to ensure the safety of other residents. 2. Actions to Prevent Occurrence/Recurrence: The facility took the following actions to prevent an adverse outcome from reoccurring. (Completion Date: 8/31/24) Every incident should result in a revision of the care plan to prevent recurrence of any altercation. All residents were reviewed by the SS and marketing director with no one exhibiting aggressive behaviors at this time of 8/31/24 @ 11:30 am. The IDT team will be in-serviced on the care plan revision policy and process by the corporate nurse/DON by 8/31/24. The DON or designee will audit each care plan after each incident to ensure interventions were in place to protect the well-being of other residents as appropriate. In-serviced by corporate nurses at 8:00 PM on 8/30/24. A Quality Assurance Performance Improvement (QAPI) Performance Improvement Project (PIP ) was implemented to review and interpret all audit findings. All findings will be discussed at the monthly QAA meeting for a minimum of three months or until the pattern of compliance is maintained. QAPI will be completed by corporate nurse by 8/30/24. New staff will be educated and trained on facility abuse policies upon hire during general orientation. Agency staff will be educated and trained on facility abuse policies prior to starting shift. Abuse Prevention and Response policies made available for review at all times. Date Facility Asserts Likelihood for Serious Harm No Longer Exists: 8/31/24. Monitoring of facility's Plan of Removal included the following: 3. Confirmation that Resident # 52's was discharged on 8/30/2024 to behavioral hospital. 4. Audit of Policies to show they were reviewed by the corporate nurse and the administrative team were educated on 8/30/2024. 5. In-services to Staff on Abuse and Neglect were started on 8/30/24 and per audit completed at 2:30 PM on 8/31/2024 all staff scheduled from 8/30/2024 thru 8/31/2024 have completed the training. All administrative staff completed the training, plan is for remaining staff and PRNs to complete training prior to working the next shift. A text was sent out to all employees with expectations. 6. In-services to Nursing staff and IDT team on Care plans and documentation were started on 8/30/2024 and per audit on 8/31/2024, all nursing staff on duty and all IDT team members have completed training, Plan is for remaining staff and PRNs to complete training prior to working the next shift. A text was sent out to all employees with expectations. 7. Per interview with administrator, 1:1's will be determined by himself and the DON and in services will be done at that time to address the resident's needs. 8. Interviews with 9/18 staff members on duty 8/31/2024 revealed they have all had training and all were able to verbalize the training and the process for reporting and managing resident to resident aggression. An IJ was identified on 08/30/24 at 6:16 PM . The IJ template was provided to the facility on [DATE] at 6:16 PM. While the IJ was removed on 08/3124, the facility remained out of compliance at a scope of Isolated and a severity level of potential for more than minimal harm because all staff had not been trained on the plan of removal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to ensure the resident had the right to be free from Abuse as defined in this subpart to protect 2 (Resident #42 and Resident #62) of 82 residents from Resident's # 52 aggressive behavior. 1. The facility failed to protect the residents from an aggressive resident with behaviors (Resident # 52). Resident #62 sustained an injury to her foot that required her to be taken to the hospital for evaluation. 2. The facility failed to put interventions in place to ensure the safety of Resident # 52 and other residents at the facility. On 08/30/24 at 6:16 PM an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 08/31/24, the facility remained out of compliance at a scope of widespread and a severity level of potential for more than minimal harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure placed the residents at risk for abuse. Findings included: Review of Resident # 42's Quarterly MDS dated [DATE] revealed a [AGE] year-old male admitted to the facility 03/25/2022 with diagnoses that included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), stroke (a condition in which poor blood flow to the brain causes cell death) and anxiety disorder (significant and uncontrollable feeling of anxiety and fear such that a person's social, occupational, and personal functions are significantly impaired). Resident #42 had a BIMS score of 11 which suggested moderate cognitive impairment. Review of Resident # 62's Quarterly MDS dated [DATE] revealed a [AGE] year-old female admitted to the facility 01-30-2024 with diagnoses that included cerebralvascular accident (a condition in which poor blood flow to the brain causes cell death), anxiety disorder (significant and uncontrollable feeling of anxiety and fear such that a person's social, occupational, and personal functions are significantly impaired). Resident #52's BIMS score was 15 which suggested no cognitive impairment. Review of Resident # 52's face sheet dated 8/30/2024 revealed a [AGE] year-old male admitted on [DATE] with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (partial paralysis due to a blockage in the brain impeding blood flow), unspecified mood (affective) disorder (any in a group of conditions of mental and behavioral disorder where the main underlying characteristic is a disturbance in the person's mood), major depressive disorder, recurrent, severe with psychotic symptoms (sadness and hopelessness with symptoms of seeing, hearing, smelling, or believing things that are not real), and intermittent explosive disorder (a condition that causes repeated, sudden outburst of impulsive, violent behavior, or angry verbal outburst). Review of Resident #52's Quarterly MDS dated [DATE], revealed a BIMS score of 08 which indicated a moderate cognitive impairment. Section E0200 Behavioral symptoms revealed no physical behavioral symptoms directed to others, no verbal behavioral symptoms directed toward others, and no other behavioral symptoms not directed toward others. Review of Resident # 52's care plan, dated 04/02/2023 and updated 2/20/2024, revealed Resident # 52's h/o using profanity and verbally aggressive with staff and resident's r/t intermittent explosive disorder. On 04/07/2023 cursed out nurse, 04/19/2023 cursed out resident, 04/20/2020 cursed staff and residents, 05/03/2023 cursed out nurse, 05/20/2023 cursed out nurse and CNA, 06/01/2023 cursed out nurse, 06/08/2023 cursed nurse, 06/09/2023 cursed nurse, 06/11/2023 cursed CNA, 06/12/2023 cursing staff, 06/15/2023 cursed out nurse, 06/20/2023 cursed out nurse, 06/23/2023 cursing in dining room, 07/24/2023 cursed out resident, 07/25/2023 cursed resident out, 08/02/2023 cursing staff, 08/13/2023 cursed out nurse, 08/23/2023 resident in common area, calling female resident a fucking whore, 08/24/2023 residents behavior, unacceptable, cursing, and yelling at nurse, and 08/29/2023 cursing staff and residents: 1/31/2024 verbal aggression initiated, 2/19/2024 verbal aggression initiated. Review of Resident #52's Progress notes dated 8/30/2024 at 11:49 am written by the SW revealed Spoke with the resident regarding incident that happened over the weekend. When SW asked him about it, he responded, 'you don't know?' Resident then stated that he was attacked by the other resident who hit him. He stated he needed to contact his family to let them know that he had been attacked. SW informed him that he has the right to call his family and asked if he needed assistance, he responded no, he can do it. The incident is still under investigation. Several residents were witnesses and state that Resident # 52 was the instigator. Review of Incident and accident report which was not a part of the medical record dated 8/25/2024 at 09:02 am completed by LVN J, At approximately 9 am , once breakfast was completed, this nurse was assessing another resident her breathing treatment when a resident came wheeling down the hall stating, they are fighting. I did not immediately understand what was going on, then I realized everyone was moving towards the dining hall and I followed. Once I arrived in the dining hall the residents were being separated. I spoke and found a housekeeper who had witnessed most of the incident, Resident # 52 was verbally, harassing Resident #42, Resident # 42 told him something around the lines of leave me alone I'm not bothering you or anyone. Resident #52 preceded to go around the wall towards Resident #42 and continued to verbally harass him then threw something towards Resident #42's direction. Resident #42 then picked up a chair to hit Resident # 52 and staff members removed the chair from Resident # 42's hands, then Resident #42 attempted to hit Resident #52. Due to a lot of bodies and movement it is unsure if Resident #42 actually hit Resident #52. In an interview on 8/27/2024 at 10:00 am with Resident # 52 he stated he did not wish to answer questions at that time. In an interview on 8/27/2024 at 10:30 am with Resident #42, he stated that Resident #52 always picked on him and this last weekend he pushed to far and he felt he had to do something . He did not share details of the other incidents but stated that the administrator and other staff were aware of the situation. In an interview on 8/27/2024 at 11 am with Resident #62, she reported that when Resident #52 threw a bowl this weekend, it hit her foot. There was a bruise, swelling, and pain. She was sent to the Emergency R room that afternoon for evaluation. The doctor will follow up with her today about the foot as she was still in pain . The resident stated this happened on Saturday and several staff member were present, she stated that this is an ongoing issue but did not elaborate for the other incidents. During the Resident council meeting on 8/28/224 at 10 am revealed many of the residents stated there was a resident in the facility that is verbally and aggressive behavior (Resident # 52), resident report the facility is aware of the behaviors and do not appear to be doing anything about it. Several residents stated that there were afraid of (resident #52 because of his aggressive behaviors) , one resident stated he now carries a cane with him when he leaves his room so that he can protect himself from (Resident #52). In an interview on 8/29/2024 at 11 am with the DON, she stated that she was aware of the incident and did not know if it was reported to the state, as the administrator was the one that was responsible for that. She was not sure if it would qualify as reportable or not. She stated all they could do was redirect Resident # 52 when he got upset to help keep the other residents safe in the dining room. The DON stated an incident report was completed and the incident was not part of the medical record. She stated they were actively seeking placement for the resident and were having placement issues with Resident # 52 because of the behaviors . In an interview on 8/29/2024 at 11:30 with the ADM, he stated that he looked into the resident-to-resident altercation and felt that there was no intent for the bystander resident to be harmed so he did not report it. The ADM stated he was notified on Saturday of the event and did his investigation on Monday. He stated he was aware of the 24 hours requirement to report abuse which resident to resident altercation is considered. He acknowledged that and was not sure what he needed to report. He stated the injury to Resident # 62 by Resident # 52 was an accident and not intentional, he stated from the staff report over the phone to him on Saturday he determined that the injury was unintentional and did not do an investigation till Monday. The ADM stated Resident #52 was a difficult case, and that he never should have been admitted to the facility. He stated the more they document Resident #52's behaviors the more difficult placement will be. He stated he was afraid to put him on a one to one because that could set him off and may result in him getting physical. The ADM stated he is not really is not sure what to do, until they get him accepted at another facility. He stated his expectation that the staff keep them and the other resident's safe from Resident # 52's behaviors. The ADM stated Resident #52 's behavior did place the residents and staff at risk for abuse. He stated Resident #52 was difficult to deal with and they had been seeking placement for Resident # 52 in a more appropriate facility but had not found a placement yet that would accept him with his behaviors. The ADM stated there were no special interventions in place at this time for his behaviors. In an interview on 8/29/2024 at 11:45 am with the SW, she stated that she was trying very hard to get Resident # 52 to a different facility. SW stated she is aware of the concerns of the other resident with the behaviors of Resident # 52, She stated that her interventions with Resident # 52 are to discuss the behavior with him and try to redirect it., she admitted that most times this is not successful. She stated Resident # 52 is not currently on any kind of behavior modification plan and the psychiatric NP sees him, and the local authority follows. him with services. She stated there is a policy for dealing with aggressive residents but the she does not use the interventions with Resident # 52 and he is not responsive to it, Her goal for Resident # 52 is to keep him and the other residents safe until placement can be found. Review of Tulip 8/29/2024 at noon revealed no reported incident from the 8/26/2024 or 8/27/2024. Review of the facility policy Abuse Prevention Program revised December of 2016 stated As part of the abuse prevention, the administration will 1. Protect our resident from abuse by anyone including but not necessarily limited to facility, staff, other residents. Review of the facility policy Resident to Resident Altercations/aggressive behavior Revised September 2022 Facility staff should monitor resident for aggressive behavior, instance of behavior should be reported immediately .If you are unable to prevent an aggressive behavior or altercation, your priority is to ensure the safety of yourself and anyone around. This was determined to be an Immediate Jeopardy (IJ) on [8/30/2024 at 5:25 PM The ADM] were notified. The ADM] was provide with the IJ template on [8/30/2024 at 5:25 PM]. The following Plan of Removal submitted by the facility was accepted on 08/31/24 at 12:35 PM and reflected the following: The alleged deficient practice was the facility failed to protect the residents from an aggressive resident with behaviors and failed to put interventions in place to ensure the safety of the resident and other residents. 1. Identification of Residents Affected or Likely to be Affected: The following actions were taken to prevent Resident # 52 from perpetrating additional abusive behaviors. (Completion Date: 8/30/2024) The Medical director was notified of the current IJ at the facility. Resident # 52 was admitted to hospital on [DATE]. admitted via emergency detention order on 8/30/24. 2. Actions to Prevent Occurrence/Recurrence: The facility took the following actions to prevent an adverse outcome from reoccurring. Abuse policies were reviewed/updated on 8/30/24. The Administrator/designee re-educated all staff on facility abuse policies. This will be completed by 8/31/24. The administrator/DON were provided re-education from the corporate nurse and COO on 8/30/24 7:30 PM. All residents were reviewed by the SW and marketing director with no aggressive behaviors found at this time. 8/31/24 11:30 am. The administrator/designee provided re-education to all staff on abuse prevention and reporting. The DON and designee educated Nurse Aides and Licensed Nurses on documenting behaviors. Behavior documentation will be monitored by the Social Services Director or designee and care plans will be updated as indicated. Staff will be educated on new interventions either verbally or in written form by the Care Plan Coordinator or designee. In the event of any future resident to resident abuse, the perpetrating resident will immediately be placed on 1:1 supervision until primary care, nursing, and psychiatric evaluations can be complete. Outcomes of these evaluations will result in continued 1:1 supervision or the initiation of discharge planning to a facility with a focus on behavior management. New staff will be educated and trained on facility abuse policies upon hire during general orientation. Agency staff will be educated and trained on facility abuse policies prior to starting shift. Abuse Prevention and Response policies made available for review at all times. Date Facility Asserts Likelihood for Serious Harm No Longer Exists: 8/31/24. Monitoring of facility's Plan of Removal included the following: 1. Audit of Policies : Abuse and Neglect, Reporting, care plans and documentation to show they were reviewed by the corporate nurse and the administrative team were educated on 8/30/2024. 2. In-services to Staff on Abuse and Neglect were started on 8/30/24 and per audit completed at 2:30 PM on 8/31/2024 all staff scheduled from 8/30/2024 thru 8/31/2024 have completed the training. All administrative staff completed the training, plan was for remaining staff and PRNs to complete training prior to working the next shift. A text was sent out to all employees with expectations. 3. In-services to Nursing staff and IDT team on Care plans and documentation were started on 8/30/2024 and per audit on 8/31/2024, all nursing staff on duty and all IDT team members have completed training. The plan was for the remaining staff and PRNs to complete training prior to working the next shift. A text was sent out to all employees with expectations. 4. Per interview with administrator, 1:1's will be determined by himself, and the DON and in-services will be done at that time to address the residents needs. 5. Interviews with 9/18 staff members on duty 8/30 /2024 and on 8/31/2024 in the day and evening shift revealed they have all had training and all were able to verbalize the training and the process for reporting and managing resident to resident aggression . The ADM was informed the Immediate Jeopardy (IJ) was removed on 8/31/2024 at 5:45 PM ). The facility remained out of compliance at a scope of widespread and a severity level of potential for more than minimal harm 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 interviews and record review, the facility failed to implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of resident's, establish policies and procedures to investigate any such allegations for 3 out of 16 residents reviewed for abuse. The facility failed to follow and implement its policy regarding Resident # 52's verbal and physical abuse of other residents to ensure the safety of all residents . An IJ was identified on 08/30/24. The IJ template was provided to the facility on [DATE] at 6:16 PM. While the IJ was removed on 08/31/24, the facility remained out of compliance at a scope of widespread and a severity level of potential for more than minimal harm because all staff had not been trained on the plan of removal. This failure could put all residents at risk from abuse. Finding include: Review of Resident # 52's face sheet dated 8/30/2024 revealed a [AGE] year-old male admitted on [DATE] with diagnosis that include Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, ( partial paralysis due to a blockage in the brain impeding blood flow), Unspecified mood ( Affective) disorder ( any in a group of conditions of mental and behavioral disorder where the main underlying characteristic is a disturbance in the person's mood) Major depressive disorder, recurrent, severe with psychotic symptoms (sadness and hopelessness with symptoms of seeing, hearing, smelling or believing things that are not real) and Intermittent Explosive Disorder ( a condition that causes repeated, sudden outburst of impulsive, violent behavior or angry verbal outburst). Review of Resident #52's Quarterly MDS dated [DATE], revealed a BIMS score of 08 (indicates a Moderate cognitive impairment) Section E0200 Behavioral symptoms revealed no physical behavioral symptoms directed to others, no verbal behavioral symptoms directed toward others, and no other behavioral symptoms not directed toward others. Review of Residents # 52 care plan 04/02/2023 and updated 2/20/2024 revealed Resident #52's h/o using profanity/verbally. aggressive with staff and resident's r/t intermittent explosive disorder. 04/07/2023 Cursed out nurse,04/19/2023 Cursed out resident,04/20/2020 cursed staff and residents,05/03/2023 Cursed out nurse,05/20/2023 Cursed out nurse and CNA, 06/01/2023 Cursed out nurse,06/08/2023 cursed nurse,06/09/2023 cursed nurse,06/11/2023 Cursed CAN,06/12/2023 Cursing staff,06/15/2023 Cursed out nurse,06/20/2023 Cursed out nurse,06/23/2023 cursing in dining room,07/24/2023 cures out resident,07/25/2023 cursed resident out,08/02/2023 cursing staff,08/13/2023 cursed out nurse,08/23/2023 Resident in common area, calling female resident a fucking whore,08/24/2023 Residents behavior, unacceptable, cursing and yelling at nurse and,08/29/203 cursing staff and residents,1/31/2024 verbal aggression initiated,2/19/2024 verbal aggression initiated Review of Resident's #52 Process notes dated 8/30/2024 at 11.49 am written by the SW revealed Spoke with the resident regarding incident that happened over the weekend. When SW asked him about it, he responded, you don't' Know?' Resident then stated that he was attacked by the other resident who hit him. He stated he needed to contact his family to let them know that he had been attacked. SW informed him that he has the right to call his family and asked if he needed assistance, he responded no, he can do it. The incident is still under investigation. Several residents were witnesses and state that Resident # 52 was the instigator. Review of Incident and accident report which is not a part of the medical record dated 8/25/2024 09:02 am completed by LVN J, At approximately 0 am, once breakfast was completed, this nurse was assessing another resident her breathing treatment when a resident came wheeling down the hall stating, they are fighting. I did not immediately understand what was going on, then I realized everyone was moving towards the dining hall and I followed. Once I arrived in the dining hall resident where being separated. I spoke and found a housekeeper who had witnessed most of the incident, Resident # 52 was verbally, harassing Resident #42, Resident # 42 told him something around the lines of leave me alone I'm not bothering you or anyone, Resident #52 preceded to go around the wall towards Resident #42 and continued to verbally harass him then threw something towards Resident #42's direction. Resident #42 then picked up a chair to hit Resident # 52 and staff members removed the chair from Resident # 42's hands, then Resident #42 attempted to hit Resident #52. Due to a lot of bodies and movement it is unsure if Resident #42 actually hit Resident #52. Review of Resident # 42 Quarterly MDS dated [DATE] revealed a [AGE] year-old male admitted to the facility 03/25/2022 with diagnosis that include Alzheimer's disease ( A progressive disease that destroys memory and other important mental functions), Stroke ( a condition in which poor blood flow to the brain causes cell death) and Anxiety disorder (significant and uncontrollable feeling of anxiety and fear such that a person's social, occupational and personal functions are significantly impaired). BIMS score of 11 (8-12 suggests moderate cognitive impairment) Review of Resident # 62 Quarterly MDS dated [DATE] revealed a [AGE] year-old female admitted to the facility 01-30-2024 with diagnosis that include Cardiovascular Accident ( a condition in which poor blood flow to the brain causes cell death) Anxiety disorder (significant and uncontrollable feeling of anxiety and fear such that a person's social, occupational and personal functions are significantly impaired).BIMS score of 15 ( 13-15 suggest no cognitive impairment) Interview 8/27/2024 at 10:00 am with Resident # 52 he does not wish to answer questions at this time. Interview 8/27/2024 at 10:30 am with Resident #42, he stated that Resident #52 always picks on him and this last weekend he pushed too far, and he felt he had to do something. Interview 8/27/2024 at 11 am with Resident #62 reported that when Resident #52 threw a bowl this weekend, it hit her foot and there was a bruise, swelling and pain, she was sent to the ER that afternoon for evaluation, the doctor will follow up with he today about the foot as she is still in pain. During the Resident council meeting on 8/28/224 at 10 am revealed many of the residents stated there was a resident in the facility that is verbally and aggressive behavior (Resident # 52), resident report the facility is aware of the behaviors and do not appear to be doing anything about it. Several residents stated that there were afraid of (resident #52 because of his aggressive behaviors) , one resident stated he now carries a cane with him when he leaves his room so that he can protect himself from (Resident #52). Interview 8/29/2024 at 11 am with the DON, she stated that she was aware of the incident and does not know if it was reported to the state, as the administrator is the one that is responsible for that. she is not sure if it would qualify as reportable or not. she stated all we can do is redirect Resident # 52 when he gets upset, Staff are to monitor Resident # 52 when in common area's to assist in this to keep the others residents safe. They do have a policy for aggressive residents, Resident's #52 is resistance to any interventions. She stated her expectation is that all resident's incident should be reflected in the Resident's progress notes. Interview 8/29/2024 at 11:30 with ADN He stated that he looked into the resident-to-resident altercation and feel that there was no intent for the bystander resident to be harmed so he did not report it. ADN stated he was notified on Saturday by phone of the incident with Resident # 52 did his investigation on Monday He stated the facility policy it that resident to resident are to be reported within 24 hours, he stated that he determined the injury to Resident # 62 foot was not intention and did not meet the reporting requirement. Interview 8/29/2024 at 11:45 am with SW, she stated that she is trying very hard to get Resident #52 to a different facility. She stated that the Facility does have a policy for Resident-to-Resident altercations that include separating the residents involved, and they do that with Resident #52. She does not know how many incidents with Resident's #52's behavior there are but she thinks at the minimum he is verbally aggressive two to three times a week. Review of Tulip 8/29/2024 at noon revealed no reported incident from the 8/26/2024 or 8/27/2024. Review of facility policy 8/29/2024 at 12:30 PM Resident to Resident Altercations/aggressive behavior Revised September 2022 Facility staff should monitor resident for aggressive behavior, instance of behavior should be reported immediately .If you are unable to prevent an aggressive behavior or altercation, your priority is to ensure the safety of yourself and anyone around. The facility's Plan of Removal for the Immediate Jeopardy was accepted on 08/31/24 at 12:35 PM and reflected the following: The alleged deficient practice was the facility failed to follow and implement a policy regarding verbal and physical abuse of other residents and ensure the safety of other residents. 3. Identification of Residents Affected or Likely to be Affected: The facility took the following actions to address the citation and prevent any additional residents from suffering's an adverse outcome. (Completion Date: by. 8/30/24) The Administrator or designee immediately ensured the safety and well-being of all residents. Resident #52 was sent to psych hospital for inpatient stay by an emergency detention warrant obtained through the county judges office on 8/30/24. 4. Actions to Prevent Occurrence/Recurrence: The facility took the following actions to prevent an adverse outcome from reoccurring. (Completion Date: 8/30/24) Resident #52 was taken to psych hospital on 8/30/24, Oceans hospital. Abuse policies were reviewed 8/30/24 by both corporate nurses at 6:30 PM The Administrator and DON were re-in serviced by the corporate nurse and COO on 8/30/24 at 7:30 PM. All residents were reviewed by the SS and marketing director, and no one is exhibiting aggressive behaviors at this time on 8/31/24 at 11:30 am. Abuse investigation procedure and documentation process were reviewed 8/30/24 by both corporate nurses at 6:30pm. The administrator and designees educated all staff on facility abuse policies. Started on 8/30/24 and will be completed by 8/31/24. The administrator and designees educated all staff on abuse prevention and reporting, started on 8/30/24 and will be completed by 8/31/24. The Social Services Director began discussing facility abuse policies with residents and families at the initial care plan conference for all new residents that enter the facility. New staff will be educated and trained on facility abuse policies upon hire during general orientation. Agency staff will be educated and trained on facility abuse policies prior to starting shift. Abuse Prevention and Response policies made available for review at all times. Date Facility Asserts Likelihood for Serious Harm No Longer Exists: 8/31/24. The alleged deficient practice is the facility failed to protect the residents from an aggressive with behaviors and failed to put interventions in place to ensure the safety of the resident and other residents. Monitoring of facility's Plan of Removal included the following: 1. Confirmation that Resident was discharged on 8/30/2024 to Ocean' behavioral hospital. 2. Audit of Policies to show they were reviewed by the corporate nurse and the administrative team were educated on 8/30/2024. 3. In-services to Staff on Abuse Neglect were started on 8/30/24 and per audit completed at 2:30 PM on 8/31/2024 all staff scheduled from 8/30/2024 thru 8/31/2024 have completed the training. All administrative staff completed the training, plan is for remaining staff and PRNs to complete training prior to working the next shift. A text was sent out to all employees with expectations. 4. In-services to Nursing staff and IDT team on Care plans and documentation were started on 8/30/2024 and per audit on 8/31/2024, all nursing staff on duty and all IDT team members have completed training, Plan is for remaining staff and PRNs to complete training prior to working the next shift. A text was sent out to all employees with expectations. 5. Per interview with administrator, 1:1's will be determined by himself and the DON and in services will be done at that time to address the resident's needs. 6. Interviews with 9/18 staff members on duty 8/31/2024 revealed they have all had training and all were able to verbalize the training and the process for reporting and managing resident to resident aggression. An IJ was identified on 08/30/24. The IJ template was provided to the facility on [DATE] at 6:16 PM. While the IJ was removed on 08/3124, the facility remained out of compliance at a scope of widespread and a severity level of potential for more than minimal harm because all staff had not been trained on the plan of removal.