**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure residents received adequate supervision and assistive devices to prevent accidents for two of five residents (Resident #1 and Resident #2) reviewed for supervision. 1.) The facility failed to ensure Resident #1 was adequately supervised in order to prevent her from eloping from the facility. Resident #1, who was known to have confusion and wandering behaviors, first exited from an exterior door of the facility on 04/01/25. The facility failed to provide adequate supervision, and Resident #1 eloped from the facility on 09/06/25. 2.) The facility failed to ensure the Wander Guard system (an electronic system that could trigger alarms and lock monitored doors to prevent a resident from leaving unattended) utilized for Resident #2 was in proper working order. An Immediate Jeopardy (IJ) was identified on 09/10/25 at 1:50PM. The IJ template was provided to the facility on [DATE] at 2:08PM. While the IJ was removed on 09/11/25, the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm and a scope of pattern due to the facility still monitoring the effectiveness of their Plan of Removal. This failure placed residents at risk for not being adequately supervised and the potential for serious injury and/or death.Findings included: 1.) Record review of Resident #1's Face Sheet, dated 09/10/25, reflected she was an [AGE] year-old female, who was admitted to the facility on [DATE], with diagnoses including vascular dementia (a general term describing problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to your brain) and repeated falls (a personal history of falls). Resident #1 was discharged from the facility on 09/07/25. Record review of Resident #1's MDS Assessment, dated 07/09/25, reflected she had a BIMS score of 04, indicating she had severe cognitive impairment. She was not documented as utilizing a wandering/elopement alarm at the time of the assessment. Resident #1 was identified as being able to walk 150 feet independently. The MDS Assessment reflected she had not displayed any recent wandering behaviors. Record review of Resident #1's Care Plan, dated 07/09/25, reflected an identified focus area of being at-risk for wandering (initiation date 12/31/24, revision date 01/14/25). Goals included for Resident #1's safety to be maintained and for Resident #1 not to leave the facility unattended. Identified interventions included assessing Resident #1 for her risk of falls, distracting Resident #1 from wandering by offering pleasant diversions (structured activities, food, conversation, television, books), identifying a pattern for wandering, staying with Resident #1 and notifying the Charge Nurse if she was exit seeking, monitoring Resident #1 for fatigue and weight loss, and providing structured activities (toileting, walking inside and outside, reorientation strategies including signs, pictures, and memory boxes). Record review of Resident #1's Progress Notes, dated 04/01/25, reflected, .Resident disoriented but easily redirected opened door which activated the alarm. Staff immediately followed resident and walked with resident and assisted her back inside the facility. Resident stated she was searching for her car. Resident assisted back to her room. Record review of Resident #1's Elopement Risk Assessment, dated 04/01/25 (following the wandering/elopement incident), reflected she scored a 12.0, indicating she was at an increased risk for elopement. Record review of Resident #1's Elopement Risk Assessment, dated 07/02/25, reflected she scored a 20.0, indicating she was at an increased risk for elopement. Record review of an Event Report for Resident #1, dated 09/06/25, reflected, .Resident was found outside the facility after exiting through the 200 hall door. Resident was located in the front parking lot between two vehicles, on the ground. When asked, resident stated she was trying to get in her car. Assessment revealed no injuries. Resident was assisted to a standing position and ambulated back into the facility without difficulty. Record review of Resident #1's Progress Notes, dated 09/06/25 at 7:44PM, reflected, .The front and back door alarms were sounding, and staff initiated a search for residents. Resident was found outside the facility after exiting through the 200 hall door. Resident was located in the front parking lot between two vehicles, on the ground. When asked, resident stated she was trying to get in her car. Assessment revealed no injuries. Resident was assisted to a standing position and ambulated back into the facility without difficulty. Resident was redirected, and safety precautions were reinforced. Will continue to assess the resident closely for changes in condition, ensure door alarms remain functional, and notify the physician and family of the incident. Record review of Resident #1's Elopement Risk Assessment, dated 09/06/25 (following the wandering/elopement incident), reflected she scored a 26.0, indicating she was at an increased risk for elopement. Observation of the path from the exterior door on the 200 Hall to the front of the building in which Resident #1 was located (the path in which it was determined by the facility that Resident #1 walked, after she eloped from the building on 09/06/25) on 09/11/25 at 8:40AM revealed the path was approximately 150 feet in length. During an interview with the ADON on 09/10/25 at 11:22AM, she stated Resident #1 had a history of confusion, and it was not uncommon for her to sundown (a phenomenon where people with dementia or other cognitive impairments experience increased confusion, agitation, and other behavioral changes in the late afternoon and evening hours). The ADON stated Resident #1 had previously gone toward exterior doors before and had even opened an exterior door in the past, but she was always easily redirected. The ADON stated when Resident #1 previously opened an exterior door (04/01/25), a staff member had line-of-sight supervision of her and was able to redirect her back inside. The ADON stated on 09/06/25 at approximately 7:00PM, the front door alarm and the alarm from the exterior door on the 200 Hall were both sounding at the same time. She stated facility staff immediately responded to the alarms. The ADON stated she went outside via the exterior door on the 200 Hall and LVN A went outside via the front door; staff remaining inside were conducting a head count of residents. The ADON stated she did not immediately see anyone when she went outside, so she started to walk around the exterior of the building. When she arrived at the front of the building, she noted LVN A waving her hands and calling her (the ADON) over toward her. The ADON stated when she arrived to where LVN A was standing, she saw Resident #1 sitting between two cars, on the concrete ground. Resident #1 denied being injured and stated she was looking for her car. She was easily redirected and taken back inside of the facility. A head-to-toe assessment revealed no noted injuries. The Administrator was notified of the incident, and Resident #1 was placed on 1:1 supervision/monitoring until alternate placement could be located at a secured facility the following day. The ADON stated in total, it was about 2-3 minutes from the time the alarms went off until the time Resident #1 was located outside. Through the facility's investigation, it was determined that the front door alarm was sounding because the door had not adequately latched when a visitor had exited the building (a company came out and repaired the latch following the incident). Resident #1 exited through the exterior door of the 200 Hall, which was the reason for that alarm sounding. Following the incident, facility staff were in-serviced on abuse/neglect and elopement prevention/response. The ADON stated the risk of a resident eloping from the facility included the potential for injury. During an interview with LVN A on 09/10/25 at 11:36AM, she stated on 09/06/25 at approximately 7:00PM, the front door alarm started sounding. When staff attempted to immediately disarm the alarm, it was noted that the alarm from the exterior door on the 200 Hall was also sounding. LVN A stated the sound from the front door alarm was overpowering the sound of the alarm from the exterior door on the 200 Hall. Upon realizing that the exterior door on the 200 Hall was also sounding, LVN A said she immediately questioned to available staff, Where is [Resident #1]? LVN A stated this was her first thought because she knew Resident #1 had a history of sundowning, packing up her belongings, and attempting to exit from the exterior door on the 200 Hall. LVN A stated she went to Resident #1's room and noticed the top drawer of her dresser was out (as though she was potentially packing up her belongings), and she was not in the restroom. LVN A stated she immediately went outside and started searching for Resident #1. She found Resident #1 in the front of the building, sitting between two parked cars. Resident #1 was confused; she stated she had found her car and was trying to get in it. LVN A stated she waved facility staff over toward her and Resident #1 was assisted back inside the building. She was clearly confused but had no signs of injury. She was placed on 1:1 supervision/monitoring until alternate placement could be located the following day. LVN A stated facility staff were in-serviced on abuse/neglect and elopement prevention/response. She also stated the facility had the alarm system repaired, so the front door alarm no longer overpowered the other exterior door alarms. LVN A stated the risk of a resident eloping from the facility included the potential for injury. During an interview with the Administrator in Training on 09/10/25 at 11:44AM, she stated Resident #1 had a history of wandering and sundowning; she had also previously exited from an exterior door (04/01/25). The Administrator in Training stated the facility's policy was to find alternate, secured placement for residents who began showing signs of exit-seeking behavior. She stated she was not sure why Resident #1 was allowed to stay at the facility following the incident in April of 2025; she believed it must have been because she was always easily redirected. The Administrator in Training stated she responded to the most recent incident involving Resident #1's elopement (09/06/25), as the Administrator was on leave at that time. The Administrator in Training stated she came to the facility following the incident, after she had been notified by the ADON that Resident #1 eloped. The Administrator in Training stated it was her understanding that Resident #1 eloped from the exterior door on the 200 Hall. She was found within just a few minutes by facility staff and was easily redirected and brought back inside the building. She denied the presence of pain and did not sustain any injuries. Her family and physician were notified of the incident. Resident #1 was placed on 1:1 supervision/monitoring until alternate placement could be located the following day. The Administrator in Training stated Resident #1 did not have a Wander Guard bracelet (an electronic device that could trigger alarms and lock monitored doors to prevent a resident from leaving unattended) at the time of the incident. The Administrator in Training stated there was one resident at the facility (Resident #2) who utilized a Wander Guard bracelet, but aside from that, the facility stopped ordering them. Following the incident, the Administrator in Training stated facility staff were in-serviced on abuse/neglect and elopement prevention/response. She also stated the facility had the alarm system repaired, so the front door alarm no longer overpowered the other exterior door alarms. During an interview with the Administrator on 09/10/25 at 12:05PM, she stated she was on leave when the incident involving Resident #1's elopement occurred (09/06/25). She stated the Administrator in Training responded to the incident. The Administrator stated Resident #1 initially admitted to the facility in December of 2024; she was very ambulatory, so she was placed on 1:1 supervision/monitoring to ensure she would adjust appropriately to the facility. She did not display any exit-seeking behaviors, so 1:1 supervision/monitoring was discontinued. She continued to reside at the facility without incident until 04/01/25, when she opened the exterior door on the 200 Hall. A staff member saw her open the door, walked with her and redirected her back inside. A staff member was with her at all times during that incident. The Administrator stated the incident was discussed amongst facility staff and they did not think Resident #1 was actually trying to elope from the building, so she was allowed to stay at the facility. She stated if a resident was truly trying to elope from the building, then that resident would be moved to a sister facility with a secured unit. The Administrator stated the facility was trying to get away from the use of Wander Guard bracelets, which was why Resident #1 did not have one at the time of the incident on 09/06/25. The Administrator stated the risk of a resident eloping from the facility included the potential for harm and/or death. 2.) Record review of Resident #2's Face Sheet, dated 09/10/25, reflected she was a [AGE] year-old female, who was admitted to the facility on [DATE], with diagnoses including dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), vascular dementia (a general term describing problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to your brain), and anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). Record review of Resident #2's MDS Assessment, dated 06/13/25, reflected she had a BIMS score of 03, indicating she had severe cognitive impairment. She was not documented as utilizing a wandering/elopement alarm at the time of the assessment. Resident #2 was identified as being able to walk 10 feet with partial/moderate assistance from staff. The MDS Assessment reflected she had not displayed any recent wandering behaviors. Record review of Resident #2's Care Plan, dated 07/01/25, reflected an identified focus area of being at-risk for injuries/elopement due to wandering behaviors and wandering with poor safety awareness. This focus area also identified Resident #2 as wearing a Wander Guard bracelet (initiation date 11/21/22, revision date 01/21/25). Goals included for Resident #2 to have no elopements/injuries due to wandering behaviors. Identified interventions included assessing Resident #2 for her risk of falls, distracting Resident #2 from wandering by offering pleasant diversions (structured activities, food, conversation, television), identifying a pattern for wandering, staying with Resident #2 and notifying the Charge Nurse if she was exit seeking, monitoring the placement of the Wander Guard bracelet each shift, and providing structured activities (toileting, walking inside and outside, reorientation strategies including signs, pictures, and memory boxes). Record review of Resident #2's Physician's Orders, dated 09/10/25, reflected, .Monitor Wander Guard to right lower leg for placement, function, and skin integrity every shift. The start date for this order was 10/18/24 and there was no set end date. Record review of Resident #2's September 2025 Medication Administration Record/Treatment Administration Record, dated 09/10/25, reflected facility staff documented confirming the placement, function, and skin integrity for Resident #2's Wander Guard bracelet every shift. Record review of Resident #2's Elopement Risk Assessment, dated 07/21/25, reflected she scored a 12.0, indicating she was at an increased risk for elopement. Record review of Resident #2's Elopement Risk Assessment, dated 09/06/25, reflected she scored an 11.0, indicating she was at an increased risk for elopement. Observation of Resident #2 on 09/10/25 at 11:55AM revealed she was wearing a Wander Guard bracelet on her ankle. Observation revealed the front door of the facility (the door which was equipped with a Wander Guard alarm system; all other exterior doors were fire alarm doors with controlled egress locks) did not automatically lock, as it should have, when Resident #2 was within one foot of the door. This occurred on two out of three attempts of verification of the functionality of the Wander Guard alarm system. The Administrator and the Administrator in Training both verified this observation. During an interview with the Administrator of 09/10/25 at 12:05PM, she stated she would ensure the Wander Guard alarm system was fixed today. She stated Resident #2 had been placed on 1:1 supervision/monitoring until it could be fixed. The Administrator stated she herself had verified the Wander Guard alarm system was working multiple times within the past few days, as a result of the investigation following Resident #1's elopement. Record review of the facility's Elopement Prevention Policy, dated 01/2023, reflected, .Every effort will be made to prevent elopement episodes while maintaining the least restrictive environment for residents who are at risk for elopement. and .All facility exits that residents have access to will have a device in place to alert staff of possible elopement attempts. Examples of these devices included Wander Guard systems (locking or alarming), keypad exit magnetic locks, keyed alarms, secured units, and/or a combination of these interventions. Record review of the facility's Elopement Response Policy, dated 01/2023, reflected, .Nursing personnel must report and investigate all reports of missing residents. When an elopement has occurred or is suspected, our elopement response plan will be implemented immediately. and .A resident is determined to be missing when he/she leaves the facility without the staff's knowledge. An Immediate Jeopardy (IJ) was identified on 09/10/25 at 1:50PM. The IJ template was provided to the facility on [DATE] at 2:08PM and signed by the Administrator. A Plan of Removal was requested at that time. The facility's Plan of Removal was accepted on 09/11/25 at 5:51AM and reflected the following: .Interventions: Resident #1 no longer resides in the facility as of 9-10-25. Resident #2 was placed on 1:1 supervision by DON/designee on 9-10-25 until the wander guard system on the door is fixed by Fire Protection. Line of sight monitoring for the front door initiated by Admin/designee on 9-10-25 until the wander guard system on the door is fixed by Fire Protection. An audit was completed on all residents in the facility to determine if they are at risk for elopement by Regional Compliance Nurse on 9.10.25. Resident #2 was the only resident identified as an elopement risk as of 9-10-25. IDT will review elopement risk scores on admission and quarterly. A Secure Care Consult while [sic] be requested by the DON/Designee to assist with ensuring appropriate placement and interventions if a resident is at risk. Administrator contacted Fire Protection vendor to inspect the doors and alarms on 9-8-25. Fire Protection vendor ensured the annunciator panel at the nurse's station was functioning and alarming properly. This was completed on 9-9-25. Administrator contacted Fire Protection vendor to inspect the front door to ensure proper functioning of the Wander Guard system. The front door will now be locked 24 hrs per day and 7 days per week and the latch was fixed. Completed on 9-10-25. The medical director was notified by the Administrator of the immediate jeopardy on 9-10-25. An Ad Hoc QAPI meeting to include the medical director was conducted on 9-10-25 to review the immediate jeopardy citation and subsequent plan of removal. In-services: The Administrator, DON, and ADON were in-serviced 1:1 by the Regional Compliance Nurse and completed as of 9-10-25 on the following: Abuse/Neglect Policy Proper functioning of the Wander Guard systemElopement Prevention and Response In-services: All staff will be in-serviced on 9.10.25 by the Admin/designee regarding the following and all staff not in-serviced by 9.10.25 will not be allowed to work their assigned position until completion of these in-services. All new hires, PRN, and agency staff will be in-services prior to the start of their assignment: This will be ongoing. Admin and ADON were in-serviced by Compliance Nurse. Abuse and NeglectProper functioning of the Wander Guard system Elopement Prevention and Response. The facility's implementation of the Plan of Removal was verified through the following: Record review of the facility's Resident Roster, dated 09/11/25, reflected Resident #1 was not listed as a current resident. Observations of Resident #2 on 09/10/25 at 2:17PM and on 09/11/25 at 8:27AM revealed she was being provided with 1:1 supervision/monitoring by facility staff. Observation of the facility's front door on 09/11/25 at 9:23AM revealed the door was securely locked. Upon opening the door and allowing it to close, the latch secured properly and the door automatically locked. Resident #2, who was wearing her ordered Wander Guard bracelet on her ankle, was brought within one foot of the door, and the door remained locked. Observation of the annunciation panel (a panel that provides both visible and audible indications to alert caregivers about the status of alarmed doors) for the door alarm system on 09/11/25 at 9:28AM revealed when multiple alarms were sounding, the front door alarm did not overpower other alarms. All alarms sounding were able to be heard. Record review of Resident #1's Face Sheet, dated 09/10/25, reflected Resident #1 was discharged from the facility on 09/07/25. Record review of a 1:1 Supervision/Monitoring Log for Resident #2, dated 09/10/25, reflected Resident #2 had been provided with 1:1 supervision/monitoring by facility staff on 09/10/25 starting at 12:00PM through 09/11/25. Record review of a Line of Sight Door Monitoring Log, dated 09/10/25, reflected there was line of sight monitoring of the front door at the facility by facility staff on 09/10/25 starting at 12:00PM through 09/11/25. Record review of an Elopement Risk Assessment History audit, dated 09/10/25, reflected Resident #2 was the only resident present at the facility who was identified as being at-risk for elopement. Record review of in-service logs, dated 09/10/25, reflected facility staff members had been in-serviced on areas including abuse/neglect, elopement/wandering prevention and response, and proper functioning of the Wander Guard system. During interviews with multiple staff members who represented all departments and all assigned shifts (MDS Coordinator, Social Worker, Business Office Manager, Dietary Manager, Maintenance Director, Housekeeping Supervisor, LVN A, LVN B, LVN C, LVN D, LVN E, LVN F, RN G, CNA H, CNA I, CNA J, CNA K, CNA L, and MA M) on 09/11/25 between 5:38AM 9:15AM, they each reported being in-serviced on topics including abuse/neglect, elopement/wandering prevention and response, and proper functioning of the Wander Guard system. These staff members were able to verbalize the facility's policies and procedures related to the aforementioned areas, as well as how they would respond to resident changes of condition, residents who were wandering, missing residents, etc. These staff members appeared knowledgeable on the facility's policies and procedures. They each verbalized being aware that the facility had one resident with a Wander Guard system in place (Resident #2). These staff members reported that there had been no previous attempts of elopement by Resident #2, but the Wander Guard was in place as a prevention method due to her increased risk of elopement. These interviews were conducted without incident or concern regarding the trainings provided. During interviews with the Administrator, the Administrator in Training, and the ADON on 09/11/25 between 7:45AM and 9:05AM, they reported being in-serviced on topics including abuse/neglect, elopement/wandering prevention and response, and proper functioning of the Wander Guard system. These staff members appeared knowledgeable on the facility's policies and procedures. It was reported that the facility's Interdisciplinary Team (IDT) would review elopement risk scores on admission and quarterly; if a resident was identified as being at-risk for elopement, a Secure Care Consult would be requested to assist in ensuring appropriate placement and interventions. It was also reported that a QAA/QAPI meeting was held on 09/10/25 to review the Immediate Jeopardy citation and discuss the plan of removal. The Administrator stated she would be responsible for overseeing the plan and would notify the Regional Compliance Nurse of any negative findings. The Administrator was notified the IJ was removed on 09/11/25 at 9:35AM, however the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm and a scope of pattern due to the facility still monitoring the effectiveness of their Plan of Removal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for one of six residents (Resident #1) reviewed for abuse. The facility failed to ensure Resident #1 had the right to be free from abuse when Resident #2 physically assaulted her on 04/29/25 in Resident #3's room. The noncompliance was identified as PNC. The IJ began on 04/29/25 and ended on 05/05/25. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for abuse. Findings included: Record review of Resident #1's admission record, dated 06/26/25, reflected a [AGE] year-old female who admitted to the facility on [DATE]. Record review of Resident #1's Annual MDS Assessment, dated 03/17/25, reflected she had a BIMS of 03, indicating severe cognitive impairment. Her active diagnoses included non-traumatic brain dysfunction (refers to brain damage caused by factors other than external trauma), non-alzheimer's dementia (loss of memory and other intellectual functions severe enough to cause problems in one's abilities to perform their usual personal, social, or occupational activities), anxiety disorder (a mental health condition characterized by excessive fear or anxiety that interferes with daily activities), and depression (a mood disorder that causes persistent feelings of sadness and loss of interest). Record review of Resident #1's care plan reflected the following: Focus: [Resident #1] has a potential psychosocial well-being problem r/t potential altercation with another resident .Interventions: Monitor/document residents feelings relative to (i.e [sic] isolation, unhappiness, anger). Date Initiated: 04/29/25 .Skin assessment, Pain assessment, Trauma Informed Care, MD and RP notified .The resident needs assistance/encouragement/support to identify precipitating factors, and stressors . Record review of Resident #1's Trauma Informed PRN Assessment, dated 04/29/25, reflected there was no indication the resident had recalled the situation. Record review of Resident #1's Weekly Skin Assessment, dated 04/29/25, reflected she had a bruise and laceration, but it did not specify any additional details. Record review of Resident #1's Weekly Skin Assessment, dated 05/06/25, reflected she had a bruise described as: Right forearm: bruising to the dorsal aspect measuring 5.5 cm x 4.5 cm; Adjacent Bruising lateral to the first, measuring 2.5 cm x 3.5 cm; Bruising to right lateral forearm, measuring 3 cm x 2.5 cm; Right hand: Bruising near the base of the thumb, lateral aspect,.08 cm [sic] x .2 cm; Bruising to dorsum of hand 3.5 cm x 2.5 cm; Left arm: Bruising near the elbow, 3.5 cm x 2.5 cm; Left hand: Bruise measuring 0.7 cm x 0.1 cm; Right lower extremity: Bruising to the right shin, 3.5 cm x 2.5 cm, Bruising to right knee, measuring 6 cm x 3 cm and a laceration described as: Laceration to the right shin, measuring 1 cm x 0.8 cm x .1 cm. Record review of Resident #1's x-ray report, dated 04/29/25, reflected there was no evidence of a fracture or dislocation. Record review of Resident #1's Progress Notes reflected the following: - On 04/29/25 at 4:00 PM, the WCN wrote: Weekly Skin Assessment .Bruise present: Yes. Location, measurements of bruising: Right forearm: bruising to the dorsal aspect measuring 5.5 cm x 4.5 cm; Adjacent Bruising lateral to the first, measuring 2.5 cm x 3.5 cm; Bruising to right lateral forearm, measuring 3 cm x 2.5 cm; Right hand: Bruising near the base of the thumb, lateral aspect,.08 cm [sic] x .2 cm; Bruising to dorsum of hand 3.5 cm x 2.5 cm; Left arm: Bruising near the elbow, 3.5 cm x 2.5 cm; Left hand: Bruise measuring 0.7 cm x 0.1 cm; Right lower extremity: Bruising to the right shin, 3.5 cm x 2.5 cm, Bruising to right knee, measuring 6 cm x 3 cm and Laceration is 0.6 cm x 0.6 cm .Laceration present: Yes. Location, measurements of laceration: Right hand: dorsum of hand, a pinpoint opening noted within the contusion. Left arm, Left temple: Laceration present, measuring 3 cm x 2 cm. Left hand, Right lower extremity: Laceration to the right shin, measuring 1 cm x 0.6 cm. Laceration to right knee, measuring 0.6 cm x 0.6 cm . - On 04/29/25 at 7:58 PM, the WCN wrote: Skin assessment completed. Multiple contusions and lacerations noted: .Contusion and laceration to the right shin, measuring 3.5 cm x 2.5 cm, with an open area within the contusion measuring 1 cm x 0.6 cm. Contusion and Laceration [sic] to right knee, measuring 6 cm x 3 cm and Laceration [sic] is 0.6 cm x 0.6 cm .Patient tolerated assessment without complaints. Wounds to be monitored per protocol. - On 04/29/25 at 7:59 PM, the WCN wrote: Injury Follow-Up .Swelling Present, Painful, Pain appear to be present: Yes Location [sic] of resident pain: right knee and shin Pain [sic] is described as: unable to specify due to dementia Pain [sic] relieving interventions: Tylenol as ordered .Interventions: .The assailant was removed from the building immediately . - On 04/29/25 at 9:31 PM, RN A wrote: Resident was in another resident's room when staff entered the room and observed other resident holding a footrest to a wheelchair in his hand. Upon seeing staff, he immediately dropped the footrest to the floor. [Resident #1] was noted to have a small amount of blood to her left forehead, lacerations to right knee and shin, three raised red areas to right forearm and two raised red areas to left forearm. Resident was immediately removed from room and assessed by nurse. The other resident was removed from room and placed on 1 on 1 monitoring until transported to local hospital. MD and family notified. - On 04/29/25 at 9:44 AM, RN A wrote: .Resident has multiple lacerations with small amount of blood coming out on her legs , [sic] knees, left side of the head, some bumps in her hands . - On 04/30/25 at 12:54 AM, LVN B wrote: xray [sic] results received sent to [Physician C ] and poa notified no fracture [sic] or dislocation noted. -On 05/02/25 at 6:10 PM, the SW wrote: Resident is doing well. No distress over incident with another resident earlier this week. No recollection of incident at all. Observation and attempted interview on 06/26/25 at 9:21 AM with Resident #1 revealed she was in her room eating breakfast. Resident #1 did not have any signs of injuries to her that could be seen. Resident #1 said no one had ever tried to hurt or hit her. Resident #1 said she felt safe in the facility. Record review of Resident #2's face sheet, dated 06/26/25, reflected an [AGE] year-old male who originally admitted to the facility on [DATE], readmitted on [DATE], and discharged on 05/05/25. Record review of Resident #2's MDS Assessment, dated 05/05/25, reflected a BIMS score was not calculated. His MDS indicated he had physical behavioral symptoms directed towards others and other behavioral symptoms not directed toward others. His active diagnoses included unspecified dementia (loss of cognitive functioning, including memory, language, and problem-solving abilities, that is severe enough to interfere with daily life) and recurrent depressive disorder (a mental health condition characterized by repeated episodes of deep sadness, hopelessness, and loss of interest in daily activities). Record review of Resident #2's care plan reflected the following: Focus: [Resident #2] has potential to demonstrate physical behaviors due to Dementia, Date Initiated: 04/29/25 .Interventions: 1:1 monitoring, Skin assessment, Psych follow up, Med review w/ med [sic] adjustment, MD and NP notified .If the resident has physical behaviors toward another resident, immediately intervene to protect the residents involved and call for assistance. If intervening would be unsafe, call out for staff assistance immediately .Notify the charge nurse of any physically abusive behaviors .When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later. Record review of Resident #2's Progress Notes reflected the following: - On 04/09/25 at 5:43 AM, LVN D wrote: Resident is very combative; he refuses to go to bed and wanders in other residents 'rooms. [sic] this nurse has redirected him multiple times but resident refuses to listen and try to fight. - On 04/10/25 at 11:44 AM, LVN E wrote: res [sic] in dining room stealing residents belongings. staff [sic] tried to get belongings back and res became very agitated with staff and hit one staff member and bit the nurse on the forearm. staff [sic] trying to explain that he cant [sic] be taking stuff from other residents. will [sic] cont to monitor resident. - On 04/19/25 at 3:31 PM, the WCN wrote: Behavioral Incident: At approximately [9:00 AM], [Resident #2] exited his room without wearing pants or undergarments, exposing his genitalia in a public area. When nursing staff approached to redirect him to his room for redressing, he became combative and attempted to fight staff. Staff ensured safety precautions were followed during redirection. At approximately [2:30 PM], [Resident #2] began to remove his pants and exposed his genitals while walking toward the dining room. Staff promptly intervened, redirected him to his room, and assisted with redressing. Currently, [Resident #2] is ambulating in the 300 Hall. He is no longer exhibiting irate behavior but continues towander [sic]. Staff will continue to monitor closely for safety and further behavioral concerns. - On 04/24/25 at 9:32 PM, LVN E wrote: combative [sic] with staff and refused to shower or let aide help him toilet . - On 04/25/25 at 3:36 PM, the SW wrote: Call placed to [Resident #2's RP] to inform him that we needed to seek alternate placement for resident due to combative behaviors with staff and wandering in to other res rooms. [Resident #2's RP] verbalized understanding and agreement . - On 04/29/25 at 5:24 PM, LVN E wrote: [Resident #2] was observed by staff member in another resident's room sitting in his wheelchair holding a foot rest [sic] to a wheelchair in the air. When this writer walked in the room, [Resident #2] dropped the foot rest [sic] on floor [sic]. The other resident was observed with blood noted to left side of forehead and right shin and two raised red areas to right forearm. The other resident was immediately removed from the room and was assessed by nurse. [Resident #2] was placed on 1 on 1 monitoring. Family, police and EMS were called and resident was transported to hospital [sic] via police accompanied by [Resident #2's family]. - On 04/29/25 at 7:07 PM, LVN E wrote: [Resident #2] was transferred to a hospital on [DATE] at 3:00 PM related to police came and escorted resident to [Hospital Name] to evaluation and treatment [sic]. - On 04/30/25 at 12:15 AM, LVN F wrote: res back to facility via EMS Transportation [sic], received new orders from the hospital to start amoxicillin 500mg [sic] tablet, to be given orally twice daily x10 days and azithromycin 250 mg tablet to be taken as directed for pneumonia. res [sic] assessed, he is awake and alert and able to answer questions in a coherent manner. he [sic] doesn't appear in distress, helped put to bed, no skin issues head to toe assessment done. family [sic], administrator and md notified or res return. - On 04/30/25 at 3:00 AM, LVN F wrote: .attempts to calm him down to no effect as he fights and is combative trying to hit staff who are helpinghim [sic] with wheelchair foot pedals . - On 05/05/25 at 2:10 PM, LVN G wrote: Pt left facility at 210pm [sic]. discharged to [NF Name, Address, and Phone Number]. Left with all belongings including medication and clothing. Sent via transport with family by side. Interview on 06/26/25 at 1:19 PM with LVN I who said she recalled Resident #2 having behaviors because he had bit her one time. LVN I said she also saw Resident #2 hit a staff member as well. LVN I said Resident #2 had a behavior or stealing items from other residents and staff tried to prevent him from doing that but he would swing and kick at staff when they tried to redirect him. LVN I said she did not know about the altercation that happened between Residents #1 and #2. LVN I said she had been in-serviced and knew what to do regarding abuse, resident-to-resident altercations, and de-escalation techniques. Interview on 06/26/25 at 1:41 PM with CNA J who said she recalled Resident #2 being very aggressive because he would fight the staff. CNA J said Resident #2 would get made at staff when they tried to redirect him. CNA J she knew of the incident that occurred between Residents #1 and #2 but she never saw Resident #1's injuries. CNA J said she only knew that because of Resident #1's injuries the day after it happened, she had to keep her in bed. CNA J said she had been in-serviced and knew what to do regarding abuse, resident-to-resident altercations, and de-escalation techniques. Interview on 06/26/25 at 1:55 PM with MA K who said he recalled Resident #2 lived here briefly but had already left. MA K said Resident #2 had behaviors where he displayed anger and got mad and would throw things and was very agitated. MA K said he did not know what happened between Residents #1 and #2. MA K said he had been in-serviced and knew what to do regarding abuse, resident-to-resident altercations, and de-escalation techniques. Interview on 06/26/25 at 1:57 PM with CNA L who said she could not recall Resident #2 and did not know about what happened between Residents #1 and #2. CNA L said she had been in-serviced and knew what to do regarding abuse, resident-to-resident altercations, and de-escalation techniques. Interview on 06/26/25 at 2:09 PM with LVN G who said she had cared for Resident #2 one time, and he hit her once on her hand when she was trying to redirect him. LVN G said Resident #2 had a habit of going to other residents' rooms and taking their items. LVN G said she had to redirect Resident #2 often. LVN G said she did not know about what happened between Residents #1 and #2. LVN G said she had been in-serviced and knew what to do regarding abuse, resident-to-resident altercations, and de-escalation techniques. Interview on 06/26/25 at 2:38 PM with CNA M who said she had cared for Resident #2, and he refused all care and would never let anyone touch him. CNA M said Resident #2 would also curse staff out in Spanish and would put furniture in front of his door on the inside so staff could not enter his room. CNA M said she saw Resident #1 after the incident with Resident #2 and said she was beaten with some sort of stick. CNA M said Resident #1 was bleeding badly, her head was swollen, her knee was bleeding, and her arms had bruises on them. CNA M said Resident #1 did not recall what happened to her. CNA M said from what she understood, a different CNA saw the incident happen between Residents #1 and #2 so the nurse on duty was alerted and the administrator was informed. CNA M said she had been in-serviced and knew what to do regarding abuse, resident-to-resident altercations, and de-escalation techniques. Record review of witness statement completed by CNA H, dated 04/29/25, reflected the following: On April 29th I was walking the hall after arriving for my shift I [sic] noticed that [Resident #3] room [sic] door was closed was shut [sic] that is why I proceeded to open it that is [sic] when I seen [sic] that [Resident #2] was in [Resident #3's] rom and was holding the wheelchair foot rest [sic] in his hand in the air while aggressively talking to [Resident #1] while she was just sitting there that is [sic] when I entered the room and asked [Resident #1] if she was okay and if [Resident #2] hit her she said [sic] that he hit her on her hand, knee, leg and the side of her face head [sic] so I proceeded to remove [Resident #1] from the room on to the front of the door away from [Resident #2] and called the nurse over and explain [sic] what I witness [sic] and showed her that [Resident #1] was bleeding. Interview on 06/26/25 at 2:49 PM on the phone with CNA H revealed she no longer worked at the facility and could not say what actually happened between Residents #1 and #2. CNA H said that she was walking down the hall and noticed Resident #3's door was closed but she was a fall risk, so she went to open the door and noticed Resident #1 in the room with Resident #2. CNA H said she walked into the room and noticed Resident #2 had a footrest from a wheelchair in his hand and he was waving it towards Resident #1. CNA H said she immediately separated the residents and took Resident #1 out of the room, asked her if she was okay, and Resident #1 told her no, he hit me. CNA H said once she got to the hallway with Resident #1, she faced towards the resident and noticed she was bleeding, had contusions to her head, knee, and foot. CNA H said she took Resident #1 to the nurse's station and told the nurse on duty what had happened. CNA H said she then tried to get Resident #2 out of Resident #3's room but he had a behavior of being aggressive towards staff. CNA H said she tried to reorient and redirect Resident #2 and started to remove him from the situation and talk to him afterwards. CNA H said she had been in-serviced and knew what to do regarding abuse, resident-to-resident altercations, and de-escalation techniques. Interview on 06/26/25 at 2:53 PM with CNA N who said she did not know about the situation that happened between Residents #1 and #2. CNA N said she had been in-serviced and knew what to do regarding abuse, resident-to-resident altercations, and de-escalation techniques. Record review of a witness statement completed by LVN E, dated 04/29/25, reflected the following: Writer was called in room [sic] by staff. [Resident #2] was in another resident's room. When writer walked in he was holding a foot rest [sic] in L hand [sic] and dropped it. Another female resident was noted with injuries when asked what occurred 'stated, he hit her' [sic]. He was asked to leave the room and refused, stayed one-on-one with resident until he exited room. Interview on 06/26/25 at 3:03 PM with LVN E who said she was told by the aide who came to get her that Resident #1 was found near Resident #3's bed bleeding. LVN E said the aide told her that Resident #2 was also in the room and had something in his hand and he dropped it. LVN E said when she assessed Resident #1, she was bleeding from her head and leg, so she provided first aide. LVN E said Resident #2 had behaviors of lashing out towards staff verbally, did not want to take his medications, and had a habit of going to other rooms and taking their items. LVN E said staff tried to redirect Resident #2 and keep him as busy as possible, but it was hard to focus on just one resident at all times. LVN E said she had been in-serviced and knew what to do regarding abuse, resident-to-resident altercations, and de-escalation techniques. Interview on 06/26/25 at 3:14 PM with RN O who said she only heard that Resident #2 hit Resident #1 with a wheelchair footrest. RN O said Resident #2 would show behaviors of being physically aggressive and did not allow staff to care for him. RN O said she had been in-serviced and knew what to do regarding abuse, resident-to-resident altercations, and de-escalation techniques. Interview on 06/27/25 at 11:01 AM with the SW who said Resident #2 could be short tempered and was easily agitated or aggravated. The SW said Resident #2 had a behavior of assaulting staff before this incident happened with Resident #1 but had not gone after residents that she was aware of. The SW said after the residents were separated immediately following the incident, she was told to start seeking alternate placement for Resident #2. The SW said the facility was already in the process of transferring him to another facility due to his behaviors with staff because it made it hard to care for him. The SW said the facility requested Resident #2's family to also come and sit with him to help manage his behaviors as he was also placed on one-to-one until he discharged to a different facility. The SW said Resident #2 was also moved down the hall where he kept wandering towards because he was convinced that was where his room was. The SW said she talked to Resident #1 who was a poor historian and could not recall what had happened to her. Interview on 06/27/25 at 11:48 AM with the WCN who said she completed a skin assessment on Resident #1 after the incident between her and Resident #2. The WCN said from what she remembered, Resident #1 had a gash to her temple on her right side, another gash to her lower right leg, both of which took time to get those two to stop bleeding. The WCN said Resident #1 also had contusions, 3 on her arm where she assumed the resident was trying to guard herself from the hits by Resident #2. The WCN said Resident #1 also had a few injuries to her hand as well. The WCN said she applied first aid to Resident #1 and the wound care doctor came to round on her two or three times before her injuries were healed. The WCN said Resident #1 could not remember what happened to her since she had severe dementia. The WCN said Resident #3 was in her room where all of this happened between Residents #1 and #2. The WCN said Resident #3 told her that Resident #2 had a footrest from a wheelchair that he used to hit Resident #1 with that caused the gashes to her body. The WCN said when Resident #2 first admitted to the facility he had behaviors, which the facility thought was related to his blood sugar levels being very brittle. The WCN said later on, they learned his behaviors were not related to his blood sugar levels. The WCN said Resident #2 seemed to be targeting women for some reason so he was placed on one-to-one and every 15 minute checks. The WCN said Resident #2 often went down the 500 hallway even though his room was not on that hall, so staff had to redirect him back to his own room. The WCN said Resident #2 was a very strong guy and the facility could not figure out what his triggers were. The WCN said Resident #2 never harmed other residents that she knew of but was physically aggressive with staff. The WCN said she had been in-serviced and knew what to do regarding abuse, resident-to-resident altercations, and de-escalation techniques. Interview on 06/27/25 at 11:58 AM with the ADON revealed she was told that Resident #2 was in a room on the 500 hallway which was not his hall but he was fixated on that hall for some reason. The ADON said Resident #1 was in Resident #3's room visiting when Resident #2 entered. The ADON said a CNA was walking down the hallway and saw Resident #3's door closed which was unusual so she opened it and saw Resident #2 with a footrest in his hand and Resident #1 did not look like herself. The ADON said she saw the skin tears to Resident #1 and put two and two together. The ADON said the CNA separated the two residents and brought Resident #1 to the nurse's station so she could be assessed. The ADON said the facility also ordered x-rays, notified the doctor, and got psych involved as well. The ADON said the facility began to look for alternate placement for Resident #2, but in the meantime, he was placed on one-on-one and every 15-minute checks until he discharged . The ADON said Resident #1's injuries included skin tears to her knuckles, a laceration to her forehead on the left side by her ear, injuries to her arms with a couple of skin tears, and a laceration to her right shin. The ADON said Resident #1 was not able to say what had happened to her. The ADON said it happened in Resident #3's room but when asked, she only stated she had stayed out of it. The ADON said that Resident #3 seemed to be confused, thinking that what was happening was a domestic dispute between a couple. The ADON said Resident #2 had behaviors that included thinking other resident items were his. The ADON said once he thought an item was his he would begin to go after it, even if it was in another resident's room. The ADON said staff tried to redirect him but it happened often. The ADON said she and other staff had been in-serviced and knew what to do regarding abuse, resident-to-resident altercations, and de-escalation techniques. Interview on 06/27/25 at 12:16 PM with the Administrator revealed the facility did not currently have a DON at the facility. The Administrator said it was reported to her that a CNA walked in and Residents #1 and #2 were in Resident #3's room. The Administrator said Resident #3 was in her bed and Resident #2 was holding a footrest up in the air yelling. The Administrator said Resident #1 was taken out of the room and had scratches or a laceration on the side of her temporal, redness on her arms and scratches, and some injury on her knee. The Administrator said Resident #2 was immediately placed on one-to-one and the facility began searching for somewhere else to send him. The Administrator said Resident #1 was not able to say what had happened to her, and neither could Resident #3. The Administrator said Resident #2 had verbal behaviors because he would curse staff out often, but he never hit another resident that she knew of. The Administrator said staff would see Resident #2 escalating in the dining room so staff would move him away and he would calm down. The Administrator said Resident #2 would also fight staff while receiving care. The Administrator said after the incident occurred, all staff were in-serviced regarding de-escalation techniques, abuse, and resident-to-resident altercations. The Administrator said anytime someone was assaulted, that would be considered abuse. The Administrator said in the situation involving Residents #1 and #2, Resident #2 had physically abused Resident #1. The Administrator said all staff had been trained to identify abuse and intervene beforehand. The Administrator said all residents had the right to be free from abuse and all staff were responsible for providing that right for them. The Administrator said anything could happen if a resident was not free from abuse, including injury or emotional trauma. The Administrator said all staff should be making rounds, assessing residents, and checking for any sign or symptom of abuse. Record review of the facility's Provider Investigation Report reflected the following: Provider Response: [Resident #1] was immediately removed from room and assesses [sic] and treated by nurse. [Resident #2] was placed on 1 on 1 monitoring. Administrator obtained witness statements from staff and residents. MD, family, and EMS/Police notified. Social Worker completed trauma informed assessment on all residents involved with no negative findings. Facility completed x-rays on [Resident #1] with no negative findings. [Resident #2] was sent to hospital for evaluation on 4/29/25. Resident returned to facility on 4/29/25 with new diagnosis of Pneumonia and new orders for antibiotics. Psych MD reviewed medications and added new order for Risperidone. Also, obtained order from Medical Director for Tylenol BID and order to obtain CBC, BMP and UA on [Resident #2]. Social Worker began seeking placement for [Resident #2] at alternate facilities. Staff inserviced [sic] on Abuse & Neglect/Resident to Resident Altercations-Deescalation [sic]. [Resident #1] sustained minor injuries that did not require hospital treatment .Investigation Summary: Both residents involved in incident have diagnosis of dementia. [Resident #2] denied hitting [Resident #1]. [Resident #1] and [Resident #3] stated that [Resident #2] hit [Resident #1]. However, upon reinterview on 4/30/25 with [Resident #1] and [Resident #3], neither resident could recall the incident .Facility Investigation Findings: Confirmed .Provider Action Taken Post-Investigation: .[Resident #2] was discharged to another facility with memory [sic] care unit on 5/5/25. Record review of a witness statement completed by the ADON, dated 04/29/25, reflected the following: This nurse interviewed 3 residents in regard to the resident-to-resident altercation with [Resident #2] and [Resident #1]. Please read below for all statements. [Resident #1]- 'no one has done anything to me'. When asked is she hurt she rubbed her knees and thigh on the right side .[Resident #3]- 'that man had that thing in his hand swinging it hitting that woman. No. he [sic] didn't hit me. I stayed away from him.' [Resident #3]- translator present 'I didn't do anything she was in my room.' I want her out' [sic] Resident remains on 1 on 1 supervision. Record review of five safe surveys completed with residents revealed they felt safe in the facility. Record review of an in-service record, dated 04/29/25, and titled Abuse & Neglect/Res to Res Altercations revealed 60 staff signatures indicating they had been in-serviced. Record review of the facility's Abuse/Negelct policy, revised 09/09/24, reflected the following: The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart .Resident should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals .1. Abuse: Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish .Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It included verbal abuse, sexual abuse, physical abuse, and mental abuse .Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. The noncompliance was identified as PNC. The IJ began on 04/29/25 and ended on 05/05/25. The facility had corrected the noncompliance before the survey began.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents were free from neglect for one of two residents (Resident #1) reviewed for suicidal ideation. The facility failed to put measures in place when Resident #1 admitted to the facility with the diagnosis of suicidal ideation. On 08/15/24, Resident #1 reported to facility that she drank hand sanitizer from a small pocket-sized bottle and wanted to kill herself. An IJ was identified on 08/15/24. The IJ template was provided to the facility on [DATE] at 3:48 PM. While the IJ was removed on 08/16/24, 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. The failure placed residents at risk for neglect. Findings included: Review of Resident #1's face sheet printed on 08/17/24 reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included schizoaffective disorder, major depressive disorder, post-traumatic stress disorder, adjustment disorder with anxiety, conversion disorder with sensory symptom (condition where a mental health issue causes physical symptoms), moderate intellectual disabilities, autistic disorder, and suicidal ideation. Review of Resident #1's New Referral documentation dated 07/30/24, sent from the prior nursing facility where Resident #1 resided at, reflected one of the resident's diagnoses was suicidal ideation. Further review of Resident #1's referral documentation reflected there was a progress note dated 07/23/24 which reflected: Resident is having suicidal attempts, suicidal thoughts. Sent to [Hospital] for further treatment. Notified the Legal Guardian. Review of Resident #1's baseline care plan initiated on 08/06/24 reflected Resident #1 had attention seeking behaviors as evidenced by not allowing staff to maintain professional boundaries. Resident would go into multiple staff offices with no regard with what is going on in the office such as meetings with other residents or families and attempt to talk to staff regarding resident's personal life and history for hours at a time. When staff reinforce professional boundaries resident thinks staff do not like her or are being mean to her and make allegations. Interventions included to monitor behavior episodes and attempts to determine underlying cause. Document behavior and potential causes. Further review of the baseline care plan revealed there was no diagnosis of suicide ideation. Review of a statement from the facility's Provider Investigation Report, dated 08/15/24, documented by the Administrator in Training reflected the following: At approximately 8:30 AM on 08/15/24, I was standing at the nurse's station when [Resident #1] wheeled up to me with a liquid staining on the front of the shirt. She showed me a small personal hand sanitizer bottle and said that she drank it. The bottle was approximately ¼ full. She said that she drank it to kill herself then expressed a series of similar suicidal ideations. I immediately provided 1:1 attention to her while the nursing staff contacted emergency services. The staff offered her water and milk, but the resident refused despite prompting from multiple staff, including myself. I remained with the resident until emergency services arrived approximately 15 minutes later. Although I observed the resident expressing sadness and making weeping sounds, I did not witness any tears throughout the time period that I interacted with her. Review of Resident #1's progress notes dated 08/15/24 documented by LVN A reflected the following: Resident at nurses desk states she swallowed a bottle of hand sanitizer, Resident states she wanted to kill herself. Resident places on one on one. DON present. Resident very upset. She is alert and oriented. New order to send resident to hospital. Resident sent to [Hospital]. Her conservator notified Interview on 08/15/24 at 9:34 AM with LVN A revealed Resident #1 had gone to the hospital the evening before, 08/14/24, due to feeling ill and she got report from the previous charge nurse that Resident #1 had wrote on her hospital discharge paperwork, scribbled out some of her diagnoses and wrote other in. LVN A said it appeared Resident #1 became upset when she was asked why she had written on her discharge paperwork. A while later after LVN A had finished getting report from the previous charge nurse, LVN A was at the nurse's station and Resident #1 approached her, holding a small bottle of hand sanitizer and said, I hope everyone is happy. I just drank this. LVN A said the bottle of hand sanitizer still had about a ¼ left inside. The DON was also at the nurse's station at the time, and they called 911 and the resident's guardian. Resident #1 was visibly upset, and she was offered milk which she refused, and she was monitored until she was transferred to the hospital. LVN A further stated Resident #1 sought out attention from the staff, would report one ailment after another and if they took too long to respond, Resident #1 would begin to say people did not like her and she was going to be kicked out of the facility. LVN A further stated Resident #1 had not expressed any suicidal ideations prior to the incident on 08/15/24. Interview on 08/16/24 at 11:15 AM with the Administrator in Training revealed he was at the nurses' station the day of the incident, 08/15/24 and heard Resident #1 call for him and wheeled towards him very quickly. The front of Resident #1's shirt looked like she had vomited or spit something out of her mouth, and the resident held up a small, pocket size bottle of hand sanitizer. The resident stated she had drunk the sanitizer and wanted to die. The bottle of sanitizer appeared to have about a quarter left inside. LVN A and the DON were also at the nurses' station when the incident occurred, and they stayed with the resident 1:1 until 911 was contacted. While they waited for EMS to arrive, Resident #1 continued to say she wanted to die even if she went to hell because no one loved her, and she did not belong in heaven. Resident #1 was transferred to the hospital for further evaluation. The Administrator in Training said he had a lot of contact with Resident #1 prior to the incident and said the resident did not respect boundaries and made her way into staff offices, even if they were with other residents or families. When the resident would be reminded of the boundaries, she would become upset stating no one loved her even when they would try to reassure her. The Administrator in Training further stated Resident #1's moods were very unpredictable and described them as lows and highs but the resident had never expressed suicidal ideations. Interview on 08/16/24 at 10:08 AM with the Social Worker revealed Resident #1 had attention seeking behaviors and did not have a lot of boundaries towards others. She said the resident was upbeat for the most part and had never expressed suicidal ideations during her stay. The day of the incident, 08/15/24, Resident #1 had already handed the sanitizer to the nursing staff and she was being monitored until the resident was transferred to hospital. The Social Worker stated she was not aware the resident has a diagnosis of suicidal ideations and had she seen that on the face sheet, that would have been a red flag to look into the matter further to put appropriate measure in place. The Social Worker said Resident #1 had a guardian that had been appointed to her in April 2024, who told her after the incident, that Resident #1 had previously tried to drink mouthwash and swallowed a keychain in an attempt to harm herself. Interview on 08/16/24 at 10:54 AM with Resident #1's guardian revealed she had taken over as legal guardian for Resident #1 in April 2024, because her family could no longer do it. She said shortly after either late April or early May, Resident #1 had expressed suicidal ideations and had drank mouthwash and swallowed a keychain. The resident was transferred to the hospital where they had to do an endoscopy to remove the keychain. While Resident #1 was at the previous facility, she continuously called 911 wanting to be taken to the emergency room for various reasons. The resident was given a 30-day discharge notice from the previous facility and when she was transferred to the current facility, she forgot to tell the facility about the mouthwash and keychain incident because there were so many things going on with Resident #1's behaviors. Interview on 08/16/24 at 11:26 AM with the DON revealed after Resident #1 was admitted she began to make accusations against staff stating they did not like her. The resident was attention seeking and would enter staff offices even if they were busy with other staff or residents wanting to talk about her childhood life. The day of the incident, 08/15/24, Resident #1 was at the nurse's station, upset, stating no one liked her because she had been questioned about writing on her hospital discharge paperwork from the day prior. Resident #1 had scribbled out some of her diagnoses and handwritten others and when she was questioned about it, she became upset, cried and rolled away from the nurse's station. The DON said Resident #1 returned back to the nurse's station holding a pocket size hand sanitizer and said she had drank it because she wanted to die. The resident made the statement that she had googled if she drank enough of the hand sanitizer it would kill her that she has in her personal belongings. They immediately called 911 as the resident continued to say she wanted to die. Initially Resident #1 refused to go to the hospital but eventually was transferred out. The DON further stated new admission paperwork was reviewed by the Administrator, the ADON and herself and she did not see the diagnosis of suicidal ideations or read the note where Resident #1 had suicide attempts. The DON said if she would have seen that, she probably would have recommended Resident #1 to a psychiatric facility instead of admitting her to their facility. Interview on 08/16/24 at 11:40 AM with the ADON revealed Resident #1 was very talkative and was attention seeking. As the days went by, the attention seeking escalated and the resident would go around asking for hugs and kisses, asking people if they liked her. The day of the incident, 08/15/24, when she got to work, Resident #1 was at the nurse's station and there were a couple of staff around the resident and she had already drank the hand sanitizer. Resident #1 continued to state no one liked her. The ADON said she had read Resident #1's referral before she was admitted , and the documentation had not painted the real picture of who the resident really was. The ADON further stated she did not see the suicidal ideation diagnosis, or the progress note of an attempt. She said if she would have seen that she would have notified the department heads because the facility was possibly not the place for the resident. Interview on 08/16/24 at 12:11 PM with the MDS Nurse revealed he had created Resident #1's face sheet for the facility and copied the resident's diagnoses from the previous facility's face sheet including the diagnosis of suicidal ideation. The MDS Nurse said he did not tell anyone about the suicidal ideation because he assumed they were all aware. Interview on 08/16/24 at 8:15 AM with the Administrator revealed Resident #1 was transferred from another nursing facility. They were not aware until after the resident's incident, 08/15/24, that the resident had been given a 30-day discharge notice. After the resident arrived, she started to want a lot of one-on-one attention from the staff. On Wednesday, 08/14/24, Resident #1 began to complain of stomach issues and after she had been given medication, the resident then escalated her stomach symptoms to saying she had chest pains. Resident #1 was assessed, and her vitals were within normal range but she was sent to the hospital and returned shortly with no new orders. The Administrator said Resident #1 was making statements the morning of 08/15/24 saying everyone hated her and she was going to get kicked out of the facility. Resident #1 later went to the nurse's station and told staff she had drank hand sanitizer from a pocket size bottle she was holding stating she wanted to kill herself. There appeared to be some on her shirt, so they were not aware how much she had consumed so they called 911 and she was transferred out for evaluation. The Administrator further stated she had seen the suicidal ideation on the face sheet before Resident #1 has been admitted but she did not know how long ago it had taken place and when she had reviewed the referral she had not read anything recent that implied the resident had attempted suicide. No one was asked about her past and they were just going off of what was in the recent notes. Review of the facility's Abuse/Neglect policy, revised 03/29/18, reflected the following: The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in the this subpart The facility will provide and ensure the promotion and protection of resident rights. It is each individual's responsibility to recognize, report, and promptly investigate actual alleged abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property and situations that may constitute abuse or neglect to any resident in the facility. An Immediate Jeopardy/Immediate Threat was identified on 08/16/24. The Administrator and the Regional RN were notified of the Immediate Jeopardy on 08/16/24 at 3:33 PM. The IJ template was provided to the facility on [DATE] at 3:48 PM. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The facility's Plan of Removal for the Immediate Jeopardy was accepted on 08/17/24 at 9:50 AM and reflected the following: F600 Abuse and Neglect The facility failed to ensure a resident had the right to be free of neglect when a resident with a documented diagnosis of suicidal ideation reported that she wanted to kill herself and ingested a small amount of hand sanitizer. Interventions: 1. As of 8/16/24, Resident #1 remains in the hospital for evaluation. 2. All resident rooms were inspected by the Administrator, DON, and ADON for hazardous items that are not allowed in resident rooms as of 8/16/24. All pocket hand sanitizers have been removed from resident rooms and common areas. 3. A complete audit of active resident diagnoses in the facility was completed by the Regional Compliance Nurse on 8/16/24. 1 additional resident with a diagnosis of suicidal ideations was verified by the Regional Compliance Nurse to have a care plan with interventions as of 8/16/24. This resident is not actively suicidal. All suicidal diagnoses and care plans have been reviewed as of 8/16/24. 4. The Regional Compliance Nurse will complete a 1:1 in-service the Administrator, DON, and ADON on reviewing the diagnosis list upon admission to ensure the diagnosis and appropriate interventions are included on the baseline care plan. Completed 8/16/24. 5. The DON/MDS Coordinator/ designee will review all new admission records, diagnoses, and care areas daily during the morning clinical meeting to ensure that all suicidal ideation diagnoses are listed on the baseline care plan with appropriate interventions. The IDT Team will review the baseline care plan in the meeting to ensure all necessary care and services listed on the care plan have been initiated. A copy of the baseline care plan will be provided and discussed with the resident and/or RP within 48hrs. This will begin on 8/16/24 and continue indefinitely. The DON/MDS Coordinator/designee will be responsible for this process. 6. The Medical Director notified of the immediate jeopardy by the Administrator on 8/16/24. 7. An QAPI meeting was conducted with the IDT team to include the Medical Director on 8/16/24 to discuss the immediate jeopardy citation and subsequent plan of correction. In-services: 1. The Regional Compliance Nurse will in-service the Administrator, DON, and ADON 1:1 on the following topics below. The Administrator, DON, and ADON will then in-service all staff on the following topics below. All staff not present for the in-services will not be allowed to work their next shift until the in-services are complete. All new hires will be in-serviced during orientation prior to working their shift. All agency staff will be in-serviced prior to assuming scheduled shift. a. All staff will be in-serviced by the Administrator, DON, and Regional Compliance Nurse on Abuse and Neglect on 8/16/24. b. All staff will be in-serviced by the Administrator, DON, and Regional Compliance Nurse on hazardous items that are not allowed in resident rooms including alcohol-based hand sanitizer on 8/16/24. c. All Charge Nurses will be in-serviced on baseline care plans- ensuring a diagnosis of suicidal ideations is included on the baseline care plan with appropriate interventions upon admission. In-servicing will be completed by the Regional Compliance Nurse and DON on 8/16/24. Monitoring of facility's Plan of Removal included the following: Observation on 08/17/24 from 10:35 AM to 11:20 AM of the resident rooms where residents resided on hall 100, 300, and 500 and common areas revealed there were no hazardous items observed in the room or within resident reach to include hand sanitizer. Record Review of Resident #2, who was identified as having a diagnosis of suicidal ideation revealed the resident has been assessed and there were measures in place to monitor the resident. Interviews on 08/17/24 from 11:17 AM to 2:19 PM from staff from various shifts were Administrator, Administrator in Training, DON, ADON, Social Worker, MDS Nurse, BOM, Marketer, Medical Records, Maintenance Director, Dietary Aide, Laundry Aide LVN's A, B, C and D, RNs I, J, K, CNAs E, F, G, H, MAs N, O, Housekeeping L, M. All staff were able to identify the following: - The different types of abuse. - What do if they see a resident showing signs of distress or hear a resident verbalizing harm to themselves or stating they want to die. - What hazardous items not allowed in resident rooms and what to do if they find them. LVN's A, B, C, D and RNs I, J, K were able to explain what to do if a resident was admitted with a diagnosis of suicidal ideation. The Administrator, DON, and ADON were provided in-service to review all resident diagnoses before they are admitted and to put the proper interventions in place for each resident. An IJ was identified on 08/15/24. The IJ template was provided to the facility on [DATE] at 3:48 PM. While the IJ was removed on 08/16/24, 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 observation, interview and record review, the facility failed to develop and implement written policies and procedures that prohibit and prevent the neglect of residents for one of two residents (Resident #1) reviewed for neglect. The facility failed to implement the facility's written policies and procedures to prohibit and prevent neglect of Resident #1. The facility failed to put measures in place when Resident #1 admitted to the facility with the diagnosis of suicidal ideation. On 08/15/24, Resident #1 reported to facility that she drank hand sanitizer from a small pocket-sized bottle and wanted to kill herself. After administrative review, an IJ was identified on 08/29/24. The IJ template was provided to the facility on [DATE] at 4:31 PM. While the IJ was removed on 08/16/24, 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. The failure placed residents at risk for neglect. Findings included: Review of the facility's Abuse/Neglect policy and procedure, dated 03/29/18, reflected: The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart .The facility will provide and sure the promotion and protection of resident rights. It is each individuals' responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, exploitation, and mistreatment of residents or misappropriation of resident property abuse and situations that may constitute abuse or neglect to any resident in the facility. Definitions .7. Neglect: is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. .B. Training The faciilty will train through orientation and on-going in-services on issues related to abuse/neglect prohibition practices regularly. .C. Prevention The facility will provide the residents, families, and staff an environment free from abuse and neglect. .D. Identification The facility will identify and investigate events that may constitute abuse/neglect. The facility will determine the direction of the investigation based on a thorough examination of events. Opportunities to prevent abuse/neglect will be managed accordingly. .G. Protection The facility will take necessary measures to protect residents and employees from harm during and following an abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property investigation Review of Resident #1's face sheet printed on 08/17/24 reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included schizoaffective disorder, major depressive disorder, post-traumatic stress disorder, adjustment disorder with anxiety, conversion disorder with sensory symptom (condition where a mental health issue causes physical symptoms), moderate intellectual disabilities, autistic disorder, and suicidal ideation. Review of Resident #1's New Referral documentation dated 07/30/24, sent from the prior nursing facility where Resident #1 resided at, reflected one of the resident's diagnoses was suicidal ideation. Further review of Resident #1's referral documentation reflected there was a progress note dated 07/23/24 which reflected: Resident is having suicidal attempts, suicidal thoughts. Sent to [Hospital] for further treatment. Notified the Legal Guardian. Review of Resident #1's baseline care plan initiated on 08/06/24 reflected Resident #1 had attention seeking behaviors as evidenced by not allowing staff to maintain professional boundaries. Resident would go into multiple staff offices with no regard with what is going on in the office such as meetings with other residents or families and attempt to talk to staff regarding resident's personal life and history for hours at a time. When staff reinforce professional boundaries resident thinks staff do not like her or are being mean to her and make allegations. Interventions included to monitor behavior episodes and attempts to determine underlying cause. Document behavior and potential causes. Further review of the baseline care plan revealed there was no diagnosis of suicide ideation. Review of a statement from the facility's Provider Investigation Report, dated 08/15/24, documented by the Administrator in Training reflected the following: At approximately 8:30 AM on 08/15/24, I was standing at the nurse's station when [Resident #1] wheeled up to me with a liquid staining on the front of the shirt. She showed me a small personal hand sanitizer bottle and said that she drank it. The bottle was approximately ¼ full. She said that she drank it to kill herself then expressed a series of similar suicidal ideations. I immediately provided 1:1 attention to her while the nursing staff contacted emergency services. The staff offered her water and milk, but the resident refused despite prompting from multiple staff, including myself. I remained with the resident until emergency services arrived approximately 15 minutes later. Although I observed the resident expressing sadness and making weeping sounds, I did not witness any tears throughout the time period that I interacted with her. Review of Resident #1's progress notes dated 08/15/24 documented by LVN A reflected the following: Resident at nurses desk states she swallowed a bottle of hand sanitizer, Resident states she wanted to kill herself. Resident places on one on one. DON present. Resident very upset. She is alert and oriented. New order to send resident to hospital. Resident sent to [Hospital]. Her conservator notified Interview on 08/15/24 at 9:34 AM with LVN A revealed Resident #1 had gone to the hospital the evening before, 08/14/24, due to feeling ill and she got report from the previous charge nurse that Resident #1 had wrote on her hospital discharge paperwork, scribbled out some of her diagnoses and wrote other in. LVN A said it appeared Resident #1 became upset when she was asked why she had written on her discharge paperwork. A while later after LVN A had finished getting report from the previous charge nurse, LVN A was at the nurse's station and Resident #1 approached her, holding a small bottle of hand sanitizer and said, I hope everyone is happy. I just drank this. LVN A said the bottle of hand sanitizer still had about a ¼ left inside. The DON was also at the nurse's station at the time, and they called 911 and the resident's guardian. Resident #1 was visibly upset, and she was offered milk which she refused, and she was monitored until she was transferred to the hospital. LVN A further stated Resident #1 sought out attention from the staff, would report one ailment after another and if they took too long to respond, Resident #1 would begin to say people did not like her and she was going to be kicked out of the facility. LVN A further stated Resident #1 had not expressed any suicidal ideations prior to the incident on 08/15/24. Interview on 08/16/24 at 11:15 AM with the Administrator in Training revealed he was at the nurses' station the day of the incident, 08/15/24 and heard Resident #1 call for him and wheeled towards him very quickly. The front of Resident #1's shirt looked like she had vomited or spit something out of her mouth, and the resident held up a small, pocket size bottle of hand sanitizer. The resident stated she had drunk the sanitizer and wanted to die. The bottle of sanitizer appeared to have about a quarter left inside. LVN A and the DON were also at the nurses' station when the incident occurred, and they stayed with the resident 1:1 until 911 was contacted. While they waited for EMS to arrive, Resident #1 continued to say she wanted to die even if she went to hell because no one loved her, and she did not belong in heaven. Resident #1 was transferred to the hospital for further evaluation. The Administrator in Training said he had a lot of contact with Resident #1 prior to the incident and said the resident did not respect boundaries and made her way into staff offices, even if they were with other residents or families. When the resident would be reminded of the boundaries, she would become upset stating no one loved her even when they would try to reassure her. The Administrator in Training further stated Resident #1's moods were very unpredictable and described them as lows and highs but the resident had never expressed suicidal ideations. Interview on 08/16/24 at 10:08 AM with the Social Worker revealed Resident #1 had attention seeking behaviors and did not have a lot of boundaries towards others. She said the resident was upbeat for the most part and had never expressed suicidal ideations during her stay. The day of the incident, 08/15/24, Resident #1 had already handed the sanitizer to the nursing staff and she was being monitored until the resident was transferred to hospital. The Social Worker stated she was not aware the resident has a diagnosis of suicidal ideations and had she seen that on the face sheet, that would have been a red flag to look into the matter further to put appropriate measure in place. The Social Worker said Resident #1 had a guardian that had been appointed to her in April 2024, who told her after the incident, that Resident #1 had previously tried to drink mouthwash and swallowed a keychain in an attempt to harm herself. Interview on 08/16/24 at 10:54 AM with Resident #1's guardian revealed she had taken over as legal guardian for Resident #1 in April 2024, because her family could no longer do it. She said shortly after either late April or early May, Resident #1 had expressed suicidal ideations and had drank mouthwash and swallowed a keychain. The resident was transferred to the hospital where they had to do an endoscopy to remove the keychain. While Resident #1 was at the previous facility, she continuously called 911 wanting to be taken to the emergency room for various reasons. The resident was given a 30-day discharge notice from the previous facility and when she was transferred to the current facility, she forgot to tell the facility about the mouthwash and keychain incident because there were so many things going on with Resident #1's behaviors. Interview on 08/16/24 at 11:26 AM with the DON revealed after Resident #1 was admitted she began to make accusations against staff stating they did not like her. The resident was attention seeking and would enter staff offices even if they were busy with other staff or residents wanting to talk about her childhood life. The day of the incident, 08/15/24, Resident #1 was at the nurse's station, upset, stating no one liked her because she had been questioned about writing on her hospital discharge paperwork from the day prior. Resident #1 had scribbled out some of her diagnoses and handwritten others and when she was questioned about it, she became upset, cried and rolled away from the nurse's station. The DON said Resident #1 returned back to the nurse's station holding a pocket size hand sanitizer and said she had drank it because she wanted to die. The resident made the statement that she had googled if she drank enough of the hand sanitizer it would kill her that she has in her personal belongings. They immediately called 911 as the resident continued to say she wanted to die. Initially Resident #1 refused to go to the hospital but eventually was transferred out. The DON further stated new admission paperwork was reviewed by the Administrator, the ADON and herself and she did not see the diagnosis of suicidal ideations or read the note where Resident #1 had suicide attempts. The DON said if she would have seen that, she probably would have recommended Resident #1 to a psychiatric facility instead of admitting her to their facility. Interview on 08/16/24 at 11:40 AM with the ADON revealed Resident #1 was very talkative and was attention seeking. As the days went by, the attention seeking escalated and the resident would go around asking for hugs and kisses, asking people if they liked her. The day of the incident, 08/15/24, when she got to work, Resident #1 was at the nurse's station and there were a couple of staff around the resident and she had already drank the hand sanitizer. Resident #1 continued to state no one liked her. The ADON said she had read Resident #1's referral before she was admitted , and the documentation had not painted the real picture of who the resident really was. The ADON further stated she did not see the suicidal ideation diagnosis, or the progress note of an attempt. She said if she would have seen that she would have notified the department heads because the facility was possibly not the place for the resident. Interview on 08/16/24 at 12:11 PM with the MDS Nurse revealed he had created Resident #1's face sheet for the facility and copied the resident's diagnoses from the previous facility's face sheet including the diagnosis of suicidal ideation. The MDS Nurse said he did not tell anyone about the suicidal ideation because he assumed they were all aware. Interview on 08/16/24 at 8:15 AM with the Administrator revealed Resident #1 was transferred from another nursing facility. They were not aware until after the resident's incident, 08/15/24, that the resident had been given a 30-day discharge notice. After the resident arrived, she started to want a lot of one-on-one attention from the staff. On Wednesday, 08/14/24, Resident #1 began to complain of stomach issues and after she had been given medication, the resident then escalated her stomach symptoms to saying she had chest pains. Resident #1 was assessed, and her vitals were within normal range but she was sent to the hospital and returned shortly with no new orders. The Administrator said Resident #1 was making statements the morning of 08/15/24 saying everyone hated her and she was going to get kicked out of the facility. Resident #1 later went to the nurse's station and told staff she had drank hand sanitizer from a pocket size bottle she was holding stating she wanted to kill herself. There appeared to be some on her shirt, so they were not aware how much she had consumed so they called 911 and she was transferred out for evaluation. The Administrator further stated she had seen the suicidal ideation on the face sheet before Resident #1 has been admitted but she did not know how long ago it had taken place and when she had reviewed the referral she had not read anything recent that implied the resident had attempted suicide. No one was asked about her past and they were just going off of what was in the recent notes. After administrative review, an Immediate Jeopardy was identified on 08/29/24. The Administrator was notified of the Immediate Jeopardy on 08/29/24 4:31 PM. The IJ template was provided to the facility on [DATE] at 4:31 PM. The facility's Plan of Removal for the Immediate Jeopardy was accepted on 08/17/24 at 9:50 AM and reflected the following: F600 Abuse and Neglect The facility failed to ensure a resident had the right to be free of neglect when a resident with a documented diagnosis of suicidal ideation reported that she wanted to kill herself and ingested a small amount of hand sanitizer. Interventions: 1. As of 8/16/24, Resident #1 remains in the hospital for evaluation. 2. All resident rooms were inspected by the Administrator, DON, and ADON for hazardous items that are not allowed in resident rooms as of 8/16/24. All pocket hand sanitizers have been removed from resident rooms and common areas. 3. A complete audit of active resident diagnoses in the facility was completed by the Regional Compliance Nurse on 8/16/24. 1 additional resident with a diagnosis of suicidal ideations was verified by the Regional Compliance Nurse to have a care plan with interventions as of 8/16/24. This resident is not actively suicidal. All suicidal diagnoses and care plans have been reviewed as of 8/16/24. 4. The Regional Compliance Nurse will complete a 1:1 in-service the Administrator, DON, and ADON on reviewing the diagnosis list upon admission to ensure the diagnosis and appropriate interventions are included on the baseline care plan. Completed 8/16/24. 5. The DON/MDS Coordinator/ designee will review all new admission records, diagnoses, and care areas daily during the morning clinical meeting to ensure that all suicidal ideation diagnoses are listed on the baseline care plan with appropriate interventions. The IDT Team will review the baseline care plan in the meeting to ensure all necessary care and services listed on the care plan have been initiated. A copy of the baseline care plan will be provided and discussed with the resident and/or RP within 48hrs. This will begin on 8/16/24 and continue indefinitely. The DON/MDS Coordinator/designee will be responsible for this process. 6. The Medical Director notified of the immediate jeopardy by the Administrator on 8/16/24. 7. An QAPI meeting was conducted with the IDT team to include the Medical Director on 8/16/24 to discuss the immediate jeopardy citation and subsequent plan of correction. In-services: 1. The Regional Compliance Nurse will in-service the Administrator, DON, and ADON 1:1 on the following topics below. The Administrator, DON, and ADON will then in-service all staff on the following topics below. All staff not present for the in-services will not be allowed to work their next shift until the in-services are complete. All new hires will be in-serviced during orientation prior to working their shift. All agency staff will be in-serviced prior to assuming scheduled shift. a. All staff will be in-serviced by the Administrator, DON, and Regional Compliance Nurse on Abuse and Neglect on 8/16/24. b. All staff will be in-serviced by the Administrator, DON, and Regional Compliance Nurse on hazardous items that are not allowed in resident rooms including alcohol-based hand sanitizer on 8/16/24. c. All Charge Nurses will be in-serviced on baseline care plans- ensuring a diagnosis of suicidal ideations is included on the baseline care plan with appropriate interventions upon admission. In-servicing will be completed by the Regional Compliance Nurse and DON on 8/16/24. Monitoring of facility's Plan of Removal included the following: Observation on 08/17/24 from 10:35 AM to 11:20 AM of the resident rooms where residents resided on hall 100, 300, and 500 and common areas revealed there were no hazardous items observed in the room or within resident reach to include hand sanitizer. Record Review of Resident #2, who was identified as having a diagnosis of suicidal ideation revealed the resident has been assessed and there were measures in place to monitor the resident. Interviews on 08/17/24 from 11:17 AM to 2:19 PM from staff from various shifts were Administrator, Administrator in Training, DON, ADON, Social Worker, MDS Nurse, BOM, Marketer, Medical Records, Maintenance Director, Dietary Aide, Laundry Aide LVN's A, B, C and D, RNs I, J, K, CNAs E, F, G, H, MAs N, O, Housekeeping L, M. All staff were able to identify the following: - The different types of abuse. - What do if they see a resident showing signs of distress or hear a resident verbalizing harm to themselves or stating they want to die. - What hazardous items not allowed in resident rooms and what to do if they find them. LVN's A, B, C, D and RNs I, J, K were able to explain what to do if a resident was admitted with a diagnosis of suicidal ideation. The Administrator, DON, and ADON were provided in-service to review all resident diagnoses before they are admitted and to put the proper interventions in place for each resident. After administrative review, an IJ was identified on 08/29/24. The IJ template was provided to the facility on [DATE] at 4:31 PM. While the IJ was removed on 08/16/24, 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 interview and record review, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality of care for one of five residents (Resident #1) reviewed for baseline care plans. The facility failed to establish a base line care plan to address Resident #1's diagnosis of suicidal ideation when she admitted to the facility. On 08/15/24, Resident #1 reported to facility that she drank hand sanitizer from a small pocket-sized bottle and wanted to kill herself. An IJ was identified on 08/15/24. The IJ template was provided to the facility on [DATE] at 3:48 PM. While the IJ was removed on 08/16/24, 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. This failure place residents at risk of not having their needs met, serious physical harm, injury, and/or death. Findings included: Review of Resident #1's face sheet printed on 08/17/24 reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included schizoaffective disorder, major depressive disorder, post-traumatic stress disorder, adjustment disorder with anxiety, conversion disorder with sensory symptom (condition where a mental health issue causes physical symptoms), moderate intellectual disabilities, autistic disorder, and suicidal ideation. Review of Resident #1's New Referral documentation dated 07/30/24, sent from the prior nursing facility where Resident #1 resided at, reflected one of the resident's diagnoses was suicidal ideation. Further review of Resident #1's referral documentation reflected there was a progress note, dated 07/23/24 reflected: Resident is having suicidal attempts, suicidal thoughts. Sent to [Hospital] for further treatment. Notified the Legal Guardian. Review of Resident #1's baseline care plan initiated on 08/06/24 reflected Resident #1 had attention seeking behaviors as evidenced by not allowing staff to maintain professional boundaries. Resident would go into multiple staff offices with no regard with what is going on in the office such as meetings with other residents or families and attempt to talk to staff regarding resident's personal life and history for hours at a time. When staff reinforce professional boundaries resident thinks staff do not like her or are being mean to her and make allegations. Interventions included to monitor behavior episodes and attempts to determine underlying cause. Document behavior and potential causes. Further review of the baseline care plan revealed there was no diagnosis of suicide ideation. Review of a statement from the facility's Provider Investigation Report for Resident #1, dated 08/15/24, documented by the Administrator in Training reflected the following: At approximately 8:30 AM on 08/15/24, I was standing at the nurse's station when [Resident #1] wheeled up to me with a liquid staining on the front of the shirt. She showed me a small personal hand sanitizer bottle and said that she drank it. The bottle was approximately ¼ full. She said that she drank it to kill herself then expressed a series of similar suicidal ideations. I immediately provided 1:1 attention to her while the nursing staff contacted emergency services. The staff offered her water and milk, but the resident refused despite prompting from multiple staff, including myself. I remained with the resident until emergency services arrived approximately 15 minutes later. Although I observed the resident expressing sadness and making weeping sounds, I did not witness any tears throughout the time period that I interacted with her. Review of Resident #1's progress notes dated 08/15/24 documented by LVN A reflected the following: Resident at nurses desk states she swallowed a bottle of hand sanitizer, Resident states she wanted to kill herself. Resident places on one on one. DON present. Resident very upset. She is alert and oriented. New order to send resident to hospital. Resident sent to [Hospital]. Her conservator notified Interview on 08/15/24 at 9:34 AM with LVN A revealed Resident #1 had gone to the hospital the evening before, 08/14/24, due to feeling ill and she got report from the previous charge nurse that Resident #1 had wrote on her hospital discharge paperwork, scribbled out some of her diagnoses and wrote other in. LVN A said it appeared Resident #1 became upset when she was asked why she had written on her discharge paperwork. A while later after LVN A had finished getting report from the previous charge nurse, LVN A was at the nurse's station and Resident #1 approached her, holding a small bottle of hand sanitizer and said I hope everyone is happy I just drank this. LVN A said the bottle of hand sanitizer still had about a ¼ left inside. The DON was also at the nurse's station at the time, and they called 911 and the resident's guardian. Resident #1 was visibly upset, and she was offered milk which she refused, and she was monitored until she was transferred to the hospital. LVN A further stated Resident #1 sought out attention from the staff, would report one ailment after another and if they took too long to respond, Resident #1 would begin to say people did not like her and she was going to be kicked out of the facility. LVN A further stated Resident #1 had not expressed any suicidal ideations prior to the incident on 08/15/24. Interview on 08/16/24 at 11:15 AM with the Administrator in Training revealed he was at the nurse's station the day of the incident, 08/15/24, and heard Resident #1 call for him and wheeled towards him very quickly. The front of Resident #1's shirt looked like she had vomited or spit something out of her mouth, she held up a small, pocket size bottle of hand sanitizer and stated she had drank it and wanted to die. The bottle of sanitizer appeared to have about a quarter left inside. LVN A and the DON were also at the nurse's station when the incident occurred and they stayed with the resident 1:1 until 911 was contacted. While they waited for EMS to arrive, Resident #1 continued to say she wanted to die even if she went to hell because no one loved her, and she did not belong in heaven. Resident #1 was transferred to the hospital for further evaluation. The Administrator in Training said he had a lot of contact with Resident #1 prior to the incident and said the resident did not respect boundaries and made her way into staff offices, even if they were with other residents or families. When the resident would be reminded of the boundaries, she would become upset stating no one loved her even when they would try to reassure her. The Administrator in Training further stated Resident #1's moods were very unpredictable and described them as lows and highs but the resident had never expressed suicidal ideations. Interview on 08/16/24 at 10:08 AM with the Social Worker revealed Resident #1 had attention seeking behaviors and did not have a lot of boundaries towards others. She said the resident was upbeat for the most part and had never expressed suicidal ideations during her stay. The day of the incident, 08/15/24, Resident #1 had already handed the sanitizer to the nursing staff and she was being monitored until the resident was transferred to hospital. The Social Worker stated she was not aware the resident has a diagnosis of suicidal ideations and had she seen that on the face sheet, that would have been a red flag to look into the matter further to put appropriate measure in place. The Social Worker said Resident #1 had a guardian that had been appointed to her in April 2024, who told her after the incident, that Resident #1 had previously tried to drink mouthwash and swallowed a keychain in an attempt to harm herself. Interview on 08/16/24 at 10:54 AM with Resident #1's guardian revealed she had taken over as legal guardian for Resident #1 in April 2024, because her family could no longer do it. She said shortly after either late April or early May, Resident #1 had expressed suicidal ideations and had drank mouthwash and swallowed a keychain. The resident was transferred to the hospital where they had to do an endoscopy to remove the keychain. While Resident #1 was at the previous facility, she continuously called 911 wanting to be taken to the emergency room for various reasons. The resident was given a 30-day discharge notice from the previous facility and when she was transferred to the current facility, she forgot to tell the facility about the mouthwash and keychain incident because there were so many things going on with Resident #1's behaviors. Interview on 08/16/24 at 11:26 AM with the DON revealed after Resident #1 was admitted she began to make accusations against staff stating they did not like her. The resident was attention seeking and would enter staff offices even if they were busy with other staff or residents wanting to talk about her childhood life. The day of the incident, 08/15/24, Resident #1 was at the nurse's station, upset, stating no one liked her because she had been questioned about writing on her hospital discharge paperwork from the day prior. Resident #1 had scribbled out some of her diagnoses and handwritten others and when she was questioned about it, she became upset, cried and rolled away from the nurse's station. The DON said Resident #1 returned back to the nurse's station holding a pocket size hand sanitizer and said she had drank it because she wanted to die. The resident made the statement that she had googled if she drank enough of the hand sanitizer it would kill her that she has in her personal belongings. They immediately called 911 as the resident continued to say she wanted to die. Initially Resident #1 refused to go to the hospital but eventually was transferred out. The DON further stated new admission paperwork was reviewed by the Administrator, the ADON and herself and she did not see the diagnosis of suicidal ideations or read the note where Resident #1 had suicide attempts. The DON said if she would have seen that, she probably would have recommended Resident #1 to a psychiatric facility instead of admitting her to their facility. Interview on 08/16/24 at 11:40 AM with the ADON revealed Resident #1 was very talkative and was attention seeking. As the days went by, the attention seeking escalated and the resident would go around asking for hugs and kisses, asking people if they liked her. The day of the incident, 08/15/24, when she got to work, Resident #1 was at the nurse's station and there were a couple of staff around the resident and she had already drank the hand sanitizer. Resident #1 continued to state no one liked her. The ADON said she had read Resident #1's referral before she was admitted , and the documentation had not painted the real picture of who the resident really was. The ADON further stated she did not see the suicidal ideation diagnosis, or the progress note of an attempt. She said if she would have seen that she would have notified the department heads because the facility was possibly not the place for the resident. Interview on 08/16/24 at 12:11 PM with the MDS Nurse revealed he had created Resident #1's face sheet and copied the resident's diagnoses from the previous facility's face sheet including the diagnosis of suicidal ideation. The MDS Nurse said he did not tell anyone about the suicidal ideation because he assumed they were all aware. The MDS nurse further stated RNs were responsible for creating the baseline care plans. Interview on 08/16/24 at 12:27 PM with RN K revealed she had initiated Resident #1's care plan based on her initial assessment. RN K said she never saw the suicidal ideation diagnosis on the resident's face sheet. RN K further stated if she would have seen that diagnosis, she would have made nursing management aware so they could have put precautions in place. Interview on 08/16/24 at 8:15 AM with the Administrator revealed Resident #1 was transferred from another nursing facility. They were not aware until after the resident's incident, 08/15/24, that the resident had been given a 30-day discharge notice. After the resident arrived, she started to want a lot of one-on-one attention from the staff. On Wednesday, 08/14/24, Resident #1 began to complain of stomach issues and after she had been given medication, the resident then escalated her stomach symptoms to saying she had chest pains. Resident #1 was assessed, and her vitals were within normal range but she was sent to the hospital and returned shortly with no new orders. The Administrator said Resident #1 was making statements the morning of 08/15/24 saying everyone hated her and she was going to get kicked out of the facility. Resident #1 later went to the nurse's station and told staff she had drank hand sanitizer from a pocket size bottle she was holding stating she wanted to kill herself. There appeared to be some on her shirt, so they were not aware how much she had consumed so they called 911 and she was transferred out for evaluation. The Administrator further stated she had seen the suicidal ideation on the face sheet before Resident #1 has been admitted but she did not know how long ago it had taken place and when she had reviewed the referral she had not read anything recent that implied the resident had attempted suicide. No one was asked about her past and they were just going off of what was in the recent notes. Review of the facility's undated policy titled Base Line Care Plans reflected the following: Completion and implementation of the baseline care plan within 48 hours of a resident's admission is intended to promote continuity of care and communication among nursing home staff, increase resident safety, and safeguard against adverse events that are most likely to occur right after admission This facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care An Immediate Jeopardy was identified on 08/16/24. The Administrator and the Regional RN were notified of the Immediate Jeopardy on 08/16/24 at 3:33 PM. The IJ template was provided to the facility on [DATE] at 3:48 PM. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The facility's Plan of Removal for the Immediate Jeopardy was accepted on 08/17/24 at 9:50 AM and reflected the following: F655 Baseline Care Plan The facility failed to develop a baseline care plan for a resident, who admitted with a documented diagnosis of suicidal ideation. Interventions: 8. As of 8/16/24, Resident #1 remains in the hospital for evaluation. 9. A complete audit of active resident diagnoses in the facility was completed by the Regional Compliance Nurse on 8/16/24. 1 additional resident with a diagnosis of suicidal ideations was verified by the Regional Compliance Nurse to have a care plan with interventions as of 8/16/24. All suicidal diagnoses and care plans have been reviewed as of 8/16/24. 10. The Regional Compliance Nurse will complete a 1:1 in-service the Administrator, DON, and ADON on reviewing the diagnosis list upon admission to ensure the diagnosis and appropriate interventions are included on the baseline care plan. Completed 8/16/24. 11. The DON/MDS Coordinator/ designee will review all new admission records, diagnoses, and care areas daily during the morning clinical meeting to ensure that all suicidal ideation diagnoses are listed on the baseline care plan with appropriate interventions. The IDT Team will review the baseline care plan in the meeting to ensure all necessary care and services listed on the care plan have been initiated. A copy of the baseline care plan will be provided and discussed with the resident and/or RP within 48hrs. This will begin on 8/16/24 and continue indefinitely. The DON/MDS Coordinator/designee will be responsible for this process. 12. The Medical Director notified of the immediate jeopardy by the Administrator on 8/16/24. 13. An ADHOC QAPI meeting was conducted with the IDT team to include the Medical Director on 8/16/24 to discuss the immediate jeopardy citation and subsequent plan of correction. In-services: 2. The Regional Compliance Nurse will in-service the Administrator, DON, and ADON 1:1 on the following topic below. The Administrator, DON, and ADON will then in-service all staff on the following topic below. All staff not present for the in-services will not be allowed to work their next shift until the in-services are complete. All new hires will be in-serviced during orientation prior to working their shift. All agency staff will be in-serviced prior to assuming scheduled shift. a. All Charge Nurses will be in-serviced on baseline care plans- ensuring a diagnosis of suicidal ideations is included on the baseline care plan with appropriate interventions upon admission. In-servicing will be completed by the Regional Compliance Nurse and DON on 8/16/24. Monitoring of facility's Plan of Removal included the following: Record Review of Resident #2, who was identified as having a diagnosis of suicidal ideation revealed the resident has been assessed and there were measures in place to monitor the resident. Interviews on 08/17/24 from 11:17 AM to 2:19 PM from staff from various shifts were Administrator, Administrator in Training, DON, ADON, Social Worker, MDS Nurse, BOM, Marketer, Medical Records, Maintenance Director, Dietary Aide, Laundry Aide LVN's A, B, C and D, RNs I, J, K, CNAs E, F, G, H, MAs N, O, Housekeeping L, M. All staff were able to identify the following: - What do if they see a resident showing signs of distress or hear a resident verbalizing harm to themselves or stating they want to die. LVN's A, B, C , D and RNs I, J, K were able to explain what to do if a resident is admitted with a diagnosis of suicidal ideation. The Administrator, DON, and ADON were provided in-service to review all resident diagnoses before they are admitted and to put the proper interventions in place for each resident. An IJ was identified on 08/15/24. The IJ template was provided to the facility on [DATE] at 3:48 PM. While the IJ was removed on 08/16/24, 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 observation, interview and record review, the facility failed to provide a safe environment free from abuse for one (Resident #23) of 17 residents reviewed for abuse. Facility staff failed to immediately intervene when Resident #23 and Family #1 were in a verbal altercation on 01/08/23, in the resident's room with the door closed and once staff intervened, Resident #23 was visibly upset and afraid. Days prior to the incident (01/08/23), Resident #23 reported to the BOM, LVN A and CNA B, that Family #1 had grabbed her face and shook it, and the incident was not reported to the Administrator. There were no interventions put in place after the incident to protect the resident and the family continued to visit. An Immediate Jeopardy was identified on 01/26/23. While the Immediate Jeopardy was removed on 01/27/23, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not Immediate Jeopardy, due to the facility's continuation of in-servicing and monitoring the Plan of Removal. The failure placed residents at risk for abuse and neglect. Findings included: Review of Resident #23's admission MDS dated [DATE] revealed the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included stroke, cancer, hypertension, dementia, and presence of cardiac pacemaker. The MDS further reflected Resident #23 had difficulty communicating some words or finishing thoughts and missed some part/intent of message but comprehended most conversations . Resident #23 required extensive assistance of one to two staff for ADLs and she used a wheelchair for mobility. Review of Resident #23's undated care plan revealed the resident's family was known to argue in the room, upsetting the resident. Approaches included family visits to occur in common areas where staff could monitor for abuse/neglect, remove resident from situations that were potentially upsetting and report any situations where abuse/neglect was suspected to the Administrator/Abuse Coordinator immediately. Interview on 01/25/22 at 3:49 PM with the APS Investigator revealed their agency had received an anonymous report on 01/13/23, regarding concerns of financial exploitation and abuse of Resident #23. The APS Investigator called the facility the same day they received the report and spoke with the BOM about the resident's finances and then asked her if she (BOM) knew about an incident involving Resident #23 being grabbed by her face and yelled at by her family The APS Investigator further stated the BOM was able to provide some of the same details that were in the anonymous report. The APS Investigator was not able to provide further details on the incident. Review of the APS report received on 01/13/23 revealed an anonymous caller reported an allegation of physical abuse the week prior (date not provided). The resident's (Resident #23) family grabbed her by the face and yelled at her and said, YOU WILL SIT DOWN AND LISTEN TO ME. The report reflected the resident was extremely upset and hysterically crying when she was trying to share the information. Interview on 01/25/23 at 4:12 PM with the BOM revealed she received a phone call (did not recall the date) from an APS Investigator initially inquiring about Resident #23's finances. The BOM stated the APS Investigator then asked if she was aware of an incident that took place where Resident #23 was yelled at and grabbed by the face. The BOM stated she told the APS Investigator she was not aware of the incident, nor had she heard or witnessed Resident #23 being abused by her family. The BOM further stated she was aware she needed to report allegations of abuse/neglect but she did not report the alleged abuse the APS Investigator mentioned to the Administrator/Abuse Coordinator or anyone because she did not believe it was true . Review of Resident #23's progress notes dated 01/08/23 documented by LVN A revealed the following: Prior when [Family #1] entered the facility resident was on phone with other [Family #2] and she [Family #1] stated, 'get off the phone, Hang Up'. Resident became agitated and they wheeled her to room. 8:20 PM Resident's [Family #1 and spouse visiting resident inside her room. Few minutes later we heard loud voices and resident yelling, and shaking as they was discussing issue about money. Conversation continues and this nurse called weekend supervisor to assist. Resident was asking [Family #1] and spouse to leave facility, which complied to resident. Nurse assessed resident in distress VS WNL 159/89 [blood pressure], 18 [heart rate] , 116 pulse. Asked to close door so they wouldn't enter the room, was put to bed for night. Call light within reach. Resident felt safe and secure. Interview on 01/25/23 at 11:34 AM with Resident #23 revealed she was unable to complete a full interview due to her diagnosis of aphasia (loss of ability to understand or express speech). She was able to express feelings and needs but could not speak in full sentences and her thoughts appeared scattered. Resident #23 was asked if she had ever been mistreated and she then grabbed her own face and demonstrated someone had grabbed her face and yelled at her to be quiet. The resident denied being afraid but said she was always fussing and was mean mean. Resident #23 was asked who she was referring to and she said half-sister, but she was not able to provide further details. Interview on 01/25/23 at 4:58 PM with LVN A revealed on 01/08/23, during the evening shift, Resident #23 was at the nurse's station talking to Family #2 on the phone. LVN A stated mid-conversation Family #1 entered the facility and very loudly told Resident #23 to hang the phone up and ordered the resident not to talk to her (Family #2). Resident #23 hung up the phone and Family #1 took the resident to the room and closed the door. After they were in the room, LVN A heard loud voices coming from the resident's room and she was able to hear Resident #23 say, It's my money, and I decide what to do. LVN A did not initially go into the room because she did not want to get in the middle of family drama. The yelling escalated and LVN A heard Family #1 tell the resident to Shut up! so LVN A went and reported the yelling to the Weekend Supervisor. LVN A said she and the Weekend Supervisor entered Resident #23's room and the resident was shaking and crying and stated she did not want Family #1 in there. They asked Family #1 to step out of the room so they could provide care and the resident was also assessed at that time and her blood pressure and pulse were elevated. Resident #23 was put to bed but the rest of the night the resident was worried and afraid and wanted to make sure Family #1 would not return. LVN A further stated she did not recall what day but days prior to the incident (01/08/23) Resident #23 made hand gestures showing LVN A her family had grabbed her face and shook it and the incident had occurred at the facility. LVN A was not able to fully understand what the resident was talking about due to the resident's communication deficit, so she told CNA B what Resident #23 had said . LVN A further stated she let the DON know about the verbal altercation, after it occurred, between the resident and the family only and not the physical incident because she was unsure if it had really occurred. LVN A also said the family continued to visit after the allegations of abuse were reported by Resident #23. Interview on 01/25/23 at 5:27 PM with CNA B revealed she was close to Resident #23's room when she heard yelling on 01/08/23. The door to the room was closed and LVN A was able to hear Family #1 yell at the resident to Shut up! Shut up! Just shut up!, but she was not able to make out what other things they were yelling about. CNA B said she did not feel comfortable entering the room when she heard the yelling because Family #1 was mean and crazy so she went to tell LVN A. LVN A then went and got the Weekend Supervisor so they could go in the room together. Once Family #1 had left the room, Resident #23 remained scared because she kept asking her (CNA B) not to leave her alone. The resident kept staring at the door and would jump at loud sounds and CNA B had to reassure the resident that Family #1 would not be entering her room that night. CNA B further stated, days prior to that incident (unable to recall which day), Resident #23 told her Family #1 had grabbed her face with her hand and shook it. She said she had not witnessed the incident so she then reported what Resident #23 had said to LVN A. CNA B also said she did not report the allegation to the Administrator because it was the weekend so she let LVN A know . CNA B also said the family continued to visit after the allegations of abuse were reported by Resident #23. Interview on 01/26/23 at 3:48 PM with the Weekend Supervisor revealed Resident #23 was at the nurse's station on the phone with Family #2 when Family #1 arrived on 01/08/23, during the evening shift. The Weekend Supervisor said Family #1 and Family #2 began to argue over the phone and she heard them mention there was an APS case and Resident #23 was asking Family #1 to stop arguing with Family #2. Later, LVN A told the Weekend Supervisor there was yelling coming from Resident #23's room, but LVN A did not feel comfortable going into the room alone. When LVN A and the Weekend Supervisor entered Resident #23's room, Family #1 was leaving. Family #1 was told they needed to visit another time. She further stated she did not recall seeing the resident upset and crying. The Weekend Supervisor further stated LVN A had documented the incident in Resident #23's progress notes and notified the DON. Interview on 01/25/23 at 5:18 PM with the DON revealed there appeared to be a lot of family dynamics between Resident #23 and her family. The DON was made aware by nursing staff that Resident #23 had been in a yelling match about money with her family (01/08/23). The DON was also told the resident appeared to be a little disheveled after the family left and the staff had to calm the resident down. The DON said no one mentioned the resident had been told to shut up by the family and he thought the commotion was between Family #1 and Family #2. He further stated he did not feel like the incident was considered abuse because Resident #23 appeared to be fine, did not complain, and thought the incident did not directly involve the resident. The DON said he was never made aware the resident's family had put their hands on the resident until today (01/25/23). The DON further stated he did not report the incident to the Administrator because he did not feel the incident was abusive as the resident did not complain and appeared to be fine. He said the family also continued to visit often. Interview on 01/25/23 at 6:14 PM with the Administrator revealed she was not aware of the family dynamics between Resident #23 and Family #1 and #2. The Administrator was not told of any abuse allegations until the surveyor was inquiring with the BOM, and she then read the progress notes for Resident #23 for the incident on 01/08/23. The Administrator said as the Abuse Prevention Coordinator, she would have expected to be contacted about the incidents and expected the BOM to have told her about the allegation the APS Investigator made. The Administrator also expected the staff to have intervened immediately when they heard the verbal altercation between Resident #23 and her family so they could have put measures in place to protect the resident from abuse. The Administrator revealed staff had recently been in-serviced on abuse and neglect not that long ago. Review of the facility's Abuse/Neglect policy revised March 2018 reflected the following: The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint no required to treat the resident's medical symptoms. Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants, or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. The facility will provide and ensure the promotion and protection of resident rights. It is each individual's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property abuse and situations that may constitute abuse or neglect to any resident in the facility An Immediate Jeopardy was identified on 01/26/23. The Administrator, Regional RN, and DON were notified of the Immediate Jeopardy on 01/26/23 at 01:05 PM and were provided with the Immediate Jeopardy Template. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The Facility's Plan of Removal for Immediate Jeopardy was accepted on 01/27/23 at 12:58 PM and reflected the following: On January 8, 2023, Resident #1 [Resident #23] was observed with her family member near the nurse's station. The resident's family member was observed by facility staff raising her voice at the resident while the resident was on the phone with .[Family #2]. Daughter then rolled the resident to her room and closed the door. Facility staff heard yelling coming from the resident's room and clearly heard [Family #1] was yelling shut up! Shut! Just shut up! Days prior to the 1/8/23 , exact date unknown, staff reported Resident #1 [Resident #23] mentioned and gestured to them that her [Family #1] had grabbed her face an shook it. Staff did not report this allegation to anyone because they did not know if it was true since it had not been witnessed. The facility had not implemented any measures to ensure Resident #1 [Resident #23] was protected for potential abuse by the family and continued to allow the family to visit the resident after the incident on 1/8/23. A head-to-toe assessment completed to Resident on January 25, 2023 at 5:23 p.m.: tattoo to mid chest; 3 bruises faint green in color to right arm and hand. One bruise to left hand. One bruise to left upper arm green-purple in color. Faint yellow bruises to both lower legs-left side of knee; right inner thigh. Moisture redness to coccyx also noted. 98.5 (temperature) - 68 _(heart rate)-18 (pulse) 120/64 (blood pressure) 97% (oxygen saturations). Dr. aware of bruising. On January 26, 2023, at 8:58 a.m., the Social Worker visited the resident for a wellness visit. Resident was asked by the Social Worker if she felt safe and comfortable here, resident said yes, and she loves it here. On January 26, 2023, facility Administrator will notify resident' family that all future residents visit will be conducted in the facility's common areas, not in the resident's room, where staff presence is available, and staff were re-educated to intervene immediately as needed for any abusive situations from daughters towards the resident. On January 26, 2023, facility Administrator or designees will in-service all facility staff regarding resident's family future resident visits will be conducted in the facility's common area and not in the resident's room. This in-service will be completed on January 26, 2023, at 8 p.m Any staff member that has not been in-serviced will not be allowed to assume their duties until in-services are completed. Initiated today, January 26, 2023, the facility Administrator or designee will interview all facility employees to identify and address other possible abuse incidents. These interviews will be completed on January 26, 2023 at 8 p.m. Any staff member that has not been interviewed will not be allowed to assume their duties until interviews are completed. Completed staff interviews did not reveal additional allegations of abuse and neglect. On January 26, 2023, the facility Administrator or designee will interview all alert and oriented residents to identify and address other possible abuse incidents. Completed resident interview did not reveal additional allegations of abuse and neglect. On January 26, 2023, the Regional Compliance Nurse completed one to one in-service with the facility Administrator and Director of Nursing regarding company's Abuse and Neglect Policy and Procedure that included definition of abuse and neglect, abuse types, prevention components that include Screening, Training, Prevention, Identification, Reporting, Investigation and Protection. On January 26, 2023, the Regional Compliance Nurse completed one to one in-service with the facility Administrator and Director of Nursing regarding Long-Term Care Regulatory Provider Letter (guidance for reporting incidents to HHSC) that included Incidents that Nursing Facilities must report to HHSC and the Time Frames for Reporting. On January 26, 2023, the Administrator or designee will in-service all facility staff on Abuse and Neglect that included definition of abuse and neglect, types of abuse, abuse coordinator, timely reporting of allegations, allegations of abuse against family members, intervening immediately by removing resident away from visitors or families, prevention components that include Screening, Training, Prevention, Identification Reporting, Investigation and Protection. This in-service will be completed January 26, 2023 at 8 p.m. Any staff member that is not present or not in-serviced will not be allowed to assume their duties until in-service had been completed. The Medical Director was notified of the Immediate Jeopardy on January 26, 2023, at 1:11 p.m. The Medical Director was notified regarding the incident with [Family #1] putting their hand on the resident's cheek and verbal altercation involving resident's daughters that were not reported and interventions were not put in place. No new orders received. Ad HOC Quality Assurance Performance Improvement meeting will be held on January 26, 2023 to review and discuss Immediate Jeopardy. The Administrator or designee will monitor this corrective action daily x 6 weeks. Any identified issues will be immediately addressed by the Administrator or designee. The Administrator will report progress of this plan of the Quality Assurance Performance Improvement Committee meeting monthly x 3 months. The facility Administrator will monitor plan and make changes until issues are resolved. Monitoring of the facility's implementation of the Plan of Removal revealed the following: Review of the in-services dated 01/27/23 revealed facility staff from various shifts and departments were in-serviced on visitor instructions for Resident #23, Abuse and Neglect/Abuse and neglect family focus. Observation on 01/27/23 at 2:07 PM revealed Resident #23 and Family #1 were in the living area visiting with each other. Resident #23 was sitting in her wheelchair and Family #1 was on the couch. There were no concerns with the interaction between the two and neither one raised their voice. Interviews were conducted on 01/27/23 starting at 1:30 PM and continued through 6:13 PM with 25 staff members from various shifts regarding in-services which included Screening, Training, Prevention, Identification Reporting, Investigation and Protection of abuse/neglect. The staff members were able to identify the different types of abuse, what do if they saw abuse/neglect, identify their abuse coordinator, and to immediately intervene and report to the abuse coordinator if they observed or heard any type of abuse/neglect. The staff were all able to verbalize understanding that Resident #23's family were to visit only in common areas so they could be supervised to prevent incidents of abuse/neglect. The staff interviewed from various shifts were as follows: the Administrator, DON, BOM, LVN A, Weekend Supervisor, CNA B, ADON, MA C, LVN D, LVN E, RN F, MA G, LVN H, Housekeeper I, CNA J, CNA K, CNA L, RN M, Housekeeper N, Floor Technician O, CNA P, CNA Q, Transportation, LVN R, LVN S. The Administrator was notified on 01/27/23 at 7:04 PM, the Immediate Jeopardy was removed. While the immediacy was removed on 01/27/23, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not Immediate Jeopardy, due to the facility continuing in-servicing and monitoring 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 implement written policies and procedures that prohibited and prevented abuse for one (Resident #23) of 17 residents reviewed for abuse and neglect. The facility failed to immediately intervene when Resident #23 was overheard by staff to be in a verbal altercation with Family #1 on 01/08/23. The resident was found crying, shaking and visibly afraid. Staff failed to report when Resident #23 let them know through gestures that Family #1 had put their hands on her face and shook it, on an unknown date prior to the 01/08/23 incident. An Immediate Jeopardy was identified on 01/26/23. While the Immediate Jeopardy was removed on 01/27/23, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not Immediate Jeopardy, due to the facility's continuation of in-servicing and monitoring the plan of removal. The failure placed residents at risk for abuse and neglect. Findings included: Review of the facility's Abuse/Neglect policy revised March 2018 reflected the following: The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint no required to treat the resident's medical symptoms. Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants, or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. The facility will provide and ensure the promotion and protection of resident rights. It is each individual's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property abuse and situations that may constitute abuse or neglect to any resident in the facility C. Prevention .3. All reports of abuse or suspicion of abuse/neglect or potentially criminal behavior will be investigated as per facility protocol. 4. The facility will be responsible to identify, correct, and intervene in situations of possible abuse/neglect . .D. Identification The facility will identify and investigate events that may constitute abuse/neglect. The facility will determine the direction of the investigation based on a thorough examination of events Review of Resident #23's admission MDS dated [DATE] revealed the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included stroke, cancer, hypertension, dementia, and presence of cardiac pacemaker. The MDS further reflected Resident #23 had difficulty communicating some words or finishing thoughts and missed some part/intent of message but comprehended most conversations. Resident #23 required extensive assistance of one to two staff for ADLs and she used a wheelchair for mobility. Review of Resident #23's undated care plan revealed the resident's family was known to argue in the room, upsetting the resident. Approaches included family visits to occur in common areas where staff could monitor for abuse/neglect, remove resident from situations that were potentially upsetting and report any situations where abuse/neglect was suspected to the Administrator/Abuse Coordinator immediately. Interview on 01/25/22 at 3:49 PM with an APS Investigator revealed their agency had received an anonymous report on 01/13/23, regarding concerns of financial exploitation and abuse of Resident #23. The APS Investigator called the facility the same day they received the report and spoke with the BOM about the resident's finances, and then asked her if she (BOM) knew about an incident involving Resident #23 being grabbed by her face and yelled at by her family. The APS Investigator further stated the BOM was able to provide some of the same details that were in the anonymous report. The APS Investigator was not able to provide further details on the incident. Review of the APS report received on 01/13/23 revealed an anonymous caller reported an allegation of physical abuse the week prior (date not provided). The resident's (Resident #23) family grabbed her by the face and yelled at her and said, YOU WILL SIT DOWN AND LISTEN TO ME. The report reflected the resident was extremely upset and hysterically crying when she was trying to share the information. Interview on 01/25/23 at 4:12 PM with the BOM revealed she received a phone call, the exact date she could not recall, from an APS Investigator initially inquiring about Resident #23's finances. The BOM stated the APS Investigator then asked if she was aware of an incident that took place where Resident #23 was yelled at and grabbed by the face. The BOM stated she told the APS Investigator she was not aware of the incident, nor had she heard or witnessed Resident #23 being abused by her family. The BOM further stated she was aware she needed to report allegations of abuse/neglect, but she did not report the alleged abuse the APS Investigator mentioned to the Administrator/Abuse Coordinator or anyone because she did not believe it was true. The BOM stated she knew protocol was to report any concerns of abuse to the Admin. The BOM stated moving forward she would report all information she received about abuse to the Administrator whether she believed it or not. Review of Resident #23's progress notes dated 01/08/23 documented by LVN A revealed the following: Prior when [Family #1] entered the facility resident was on phone with other [Family #2] and she [Family #1] stated, 'get off the phone, Hang Up'. Resident became agitated and they wheeled her to room. 8:20 PM Resident's [Family #1 and spouse visiting resident inside her room. Few minutes later we heard loud voices and resident yelling, and shaking as they was discussing issue about money. Conversation continues and this nurse called weekend supervisor to assist. Resident was asking [Family #1] and spouse to leave facility, which complied to resident. Nurse assessed resident in distress VS WNL 159/89 [blood pressure, 18 [heart rate] , 116 pulse. Asked to close door so they wouldn't enter the room, was put to bed for night. Call light within reach. Resident felt safe and secure. Interview on 01/25/23 at 11:34 AM with Resident #23 revealed she was unable to complete a full interview due to her diagnosis of aphasia (loss of ability to understand or express speech). She was able to express feelings and needs but could not speak in full sentences and her thoughts appeared scattered. Resident #23 was asked if she had ever been mistreated, and she then grabbed her own face and demonstrated someone had grabbed her face and yelled at her to be quiet. The resident denied being afraid but said she was always fussing and was mean mean. Resident #23 was asked who she was referring to and she said half-sister, and she was not able to provide further details. Interview on 01/25/23 at 4:58 PM with LVN A revealed on 01/08/23, during the evening shift, Resident #23 was at the nurse's station talking to Family #2 on the phone. LVN A stated mid-conversation Family #1 entered the facility and very loudly told Resident #23 to hang the phone up and ordered the resident not to talk to her (Family #2). Resident #23 hung up the phone and Family #1 took the resident to the room and closed the door. After they were in the room, LVN A heard loud voices coming from the resident's room and she was able to hear Resident #23 say, It's my money, and I decide what to do. LVN A did not initially go into the room because she did not want to get in the middle of family drama. The yelling escalated and LVN A heard Family #1 tell the resident to Shut up! so LVN A went and reported the yelling to the Weekend Supervisor. LVN A said she and the Weekend Supervisor entered Resident #23's room and the resident was shaking and crying and stated she did not want Family #1 in there. They asked Family #1 to step out of the room so they could provide care and the resident was also assessed at that time and her blood pressure and pulse were elevated. Resident #23 was put to bed but the rest of the night the resident was worried and afraid and wanted to make sure Family #1 would not return. LVN A further stated she did not recall what day but days prior to the incident (01/08/23) Resident #23 made hand gestures showing LVN A her family had grabbed her face and shook it and the incident had occurred at the facility. LVN A was not able to fully understand what the resident was talking about due to the resident's communication deficit, so she told CNA B what Resident #23 had said. LVN A further stated she let the DON know about the verbal altercation, after it occurred, between the resident and the family only and not the physical incident because she was unsure if it had really occurred. LVN A also said the family continued to visit after the allegations of abuse were reported by Resident #23. Interview on 01/25/23 at 5:27 PM with CNA B revealed she was close to Resident #23's room when she heard yelling on 01/08/23. The door to the room was closed and LVN A was able to hear Family #1 yell at the resident to Shut up! Shut up! Just shut up!, but she was not able to make out what other things they were yelling about. CNA B said she did not feel comfortable entering the room when she heard the yelling because Family #1 was mean and crazy so she went to tell LVN A. LVN A then went and got the Weekend Supervisor so they could go in the room together. Once Family #1 had left the room, Resident #23 remained scared because she kept asking her (CNA B) not to leave her alone. The resident kept staring at the door and would jump at loud sounds and CNA B had to reassure the resident that Family #1 would not be entering her room that night. CNA B further stated days prior to that incident, the exact date she could not recall, Resident #23 told her Family #1 had grabbed her face with her hand and shook it. She said she had not witnessed the incident so she then reported what Resident #23 had said to LVN A. CNA B also said she did not report the allegation to the Administrator because it was the weekend so she let LVN A know. CNA B also said the family continued to visit after the allegations of abuse were reported by Resident #23. Interview on 01/26/23 at 3:48 PM with the Weekend Supervisor revealed Resident #23 was at the nurse's station on the phone with Family #2 when Family #1 arrived on 01/08/23, during the evening shift. The Weekend Supervisor said Family #1 and Family #2 began to argue over the phone and she heard them mention there was an APS case and Resident #23 was asking Family #1 to stop arguing with Family #2. Later LVN A told the Weekend Supervisor there was yelling coming from Resident #23's room but LVN A did not feel comfortable going into the room alone. When LVN A and the Weekend Supervisor entered Resident #23's room, Family #1 was leaving, and Family #1 was told they needed to visit another time. She further stated she did not recall seeing the resident upset and crying. The Weekend Supervisor further stated LVN A had documented the incident in Resident #23's progress notes and notified the DON. Interview on 01/25/23 at 5:18 PM with the DON revealed there appeared to be a lot of family dynamics between Resident #23 and her family. The DON was made aware by nursing staff that Resident #23 had been in a yelling match about money with her family (01/08/23). The DON was also told the resident appeared to be a little disheveled after the family left and the staff had to calm the resident down. The DON said no one mentioned the resident had been told to shut up by the family and he thought the commotion was between Family #1 and Family #2. He further stated he did not feel like the incident was considered abuse because Resident #23 appeared to be fine, did not complain, and thought the incident did not directly involve the resident. The DON said he was never made aware the resident's family had put their hands on the resident until today (01/25/23). The DON further stated he did not report the incident to the Administrator because he did not feel the incident was abusive as the resident did not complain and appeared to be fine. He said the family also continued to visit often. Interview on 01/25/23 at 6:14 PM with the Administrator revealed she was not aware of the family dynamics between Resident #23 and Family #1 and #2. The Administrator was not told of any abuse allegations until the surveyor was inquiring with the BOM and she then read the progress notes for Resident #23 of the incident on 01/08/23. The Administrator said as the Abuse Prevention Coordinator, she would have expected to be contacted about the incidents and expected the BOM to have told her about the allegation the APS Investigator made. The Administrator also expected the staff to have intervened immediately when they heard the verbal altercation between Resident #23 and her family so they could have put measures in place to protect the resident from abuse. The Administrator revealed staff had recently been in-serviced on abuse and neglect not that long ago. Review of an in-service dated 11/30/22 revealed the BOM, LVN A and CNA B had been in-serviced on Abuse, Neglect, and Exploitation. An Immediate Jeopardy was identified on 01/26/23. The Administrator, Regional RN, and DON were notified of the Immediate Jeopardy on 01/26/23 at 01:05 PM and were provided with the Immediate Jeopardy Template. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The Facility's Plan of Removal for Immediate Jeopardy was accepted on 01/27/23 at 12:58 PM and reflected the following: On January 8, 2023, Resident #1 [Resident #23] was observed with her family member near the nurse's station. The resident's family member was observed by facility staff raising her voice at the resident while the resident was on the phone with .[Family #2]. Daughter then rolled the resident to her room and closed the door. Facility staff heard yelling coming from the resident's room and clearly heard [Family #1] was yelling shut up! Shut! Just shut up! Days prior to the 1/8/23 , exact date unknown, staff reported Resident #1 [Resident #23] mentioned and gestured to them that her Family #1 had grabbed her face an shook it. Staff did not report this allegation to anyone because they did not know if it was true since it had not been witnessed. The facility had not implemented any measures to ensure Resident #1 [Resident #23] was protected for potential abuse by the family and continued to allow the family to visit the resident after the incident on 1/8/23. A head-to-toe assessment completed to Resident on January 25, 2023 at 5:23 p.m.: tattoo to mid chest; 3 bruises faint green in color to right arm and hand. One bruise to left hand. One bruise to left upper arm green-purple in color. Faint yellow bruises to both lower legs-left side of knee; right inner thigh. Moisture redness to coccyx also noted. 98.5 (temperature) - 68 _(heart rate)-18 (pulse) 120/64 (blood pressure) 97% (oxygen saturations). Dr. aware of bruising. On January 26, 2023, at 8:58 a.m., the Social Worker visited the resident for a wellness visit. Resident was asked by the Social Worker if she felt safe and comfortable here, resident said yes, and she loves it here. On January 26, 2023, facility Administrator will notify resident' family that all future residents visit will be conducted in the facility's common areas, not in the resident's room, where staff presence is available, and staff were re-educated to intervene immediately as needed for any abusive situations from daughters towards the resident. On January 26, 2023, facility Administrator or designees will in-service all facility staff regarding resident's family future resident visits will be conducted in the facility's common area and not in the resident's room. This in-service will be completed on January 26, 2023, at 8 p.m Any staff member that has not been in-serviced will not be allowed to assume their duties until in-services are completed. Initiated today, January 26, 2023, the facility Administrator or designee will interview all facility employees to identify and address other possible abuse incidents. These interviews will be completed on January 26, 2023 at 8 p.m. Any staff member that has not been interviewed will not be allowed to assume their duties until interviews are completed. Completed staff interviews did not reveal additional allegations of abuse and neglect. On January 26, 2023, the facility Administrator or designee will interview all alert and oriented residents to identify and address other possible abuse incidents. Completed resident interview did not reveal additional allegations of abuse and neglect. On January 26, 2023, the Regional Compliance Nurse completed one to one in-service with the facility Administrator and Director of Nursing regarding company's Abuse and Neglect Policy and Procedure that included definition of abuse and neglect, abuse types, prevention components that include Screening, Training, Prevention, Identification, Reporting, Investigation and Protection. On January 26, 2023, the Regional Compliance Nurse completed one to one in-service with the facility Administrator and Director of Nursing regarding Long-Term Care Regulatory Provider Letter (guidance for reporting incidents to HHSC) that included Incidents that Nursing Facilities must report to HHSC and the Time Frames for Reporting. On January 26, 2023, the Administrator or designee will in-service all facility staff on Abuse and Neglect that included definition of abuse and neglect, types of abuse, abuse coordinator, timely reporting of allegations, allegations of abuse against family members, intervening immediately by removing resident away from visitors or families, prevention components that include Screening, Training, Prevention, Identification Reporting, Investigation and Protection. This in-service will be completed January 26, 2023 at 8 p.m. Any staff member that is not present or not in-serviced will not be allowed to assume their duties until in-service had been completed. The Medical Director was notified of the Immediate Jeopardy on January 26, 2023, at 1:11 p.m. The Medical Director was notified regarding the incident with family putting their hand on the resident's cheek and verbal altercation involving resident's family that were not reported and interventions were not put in place. No new orders received. Ad HOC Quality Assurance Performance Improvement meeting will be held on January 26, 2023 to review and discuss Immediate Jeopardy. The Administrator or designee will monitor this corrective action daily x 6 weeks. Any identified issues will be immediately addressed by the Administrator or designee. The Administrator will report progress of this plan of the Quality Assurance Performance Improvement Committee meeting monthly x 3 months. The facility Administrator will monitor plan and make changes until issues are resolved. Monitoring implementation of the Plan of Removal revealed the following: Review of the in-services dated 01/27/23 revealed facility staff from various shifts and departments were in-serviced on visitor instructions for Resident #23, Abuse and Neglect/Abuse and neglect family focus. Observation on 01/27/23 at 2:07 PM revealed Resident #23 and Family #1 were in the living area visiting with each other. Resident #23 was sitting in her wheelchair and Family #1 was on the couch. There were no concerns with the interaction between the two and neither one raised their voice. Interviews were conducted on 01/27/23 starting at 1:30 PM and continued through 6:13 PM with 25 staff members from various shifts regarding in-services which included Screening, Training, Prevention, Identification Reporting, Investigation and Protection of abuse/neglect. The staff members were able to identify the different types of abuse, what do if they saw abuse/neglect, identify their abuse coordinator, and to immediately intervene and report to the abuse coordinator if they observed or heard any type of abuse/neglect. The staff were all able to verbalize understanding that Resident #23's family were to visit only in common areas so they could be supervised to prevent incidents of abuse/neglect. The staff interviewed from various shifts were as follows: the Administrator, DON, BOM, LVN A, Weekend Supervisor, CNA B, ADON, MA C, LVN D, LVN E, RN F, MA G, LVN H, Housekeeper I, CNA J, CNA K, CNA L, RN M, Housekeeper N, Floor Technician O, CNA P, CNA Q, Transportation, LVN R, LVN S. The Administrator was notified on 01/27/23 at 7:04 PM, the Immediate Jeopardy was removed. While the immediacy was removed on 01/27/23, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not Immediate Jeopardy, due to the facility continuing in-servicing and monitoring 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 that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury to the administrator of the facility and to other officials (including to the State Survey Agency in accordance with State law through established procedures for one, (Resident #23) of 17 residents reviewed for abuse. Staff failed to immediately report an allegation of abuse involving Resident #23, to the Administrator, when she was found crying, shaking and afraid after a verbal altercation with Family #1 on 01/18/23 and failed to report to the Administrator when Resident #23 reported that Family #1 had previously grabbed her face and shook it. The failure to report to the Administrator resulted in a lack of investigation and interventions to prevent further abuse. An Immediate Jeopardy was identified on 01/26/23. While the Immediate Jeopardy was removed on 01/27/23, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not Immediate Jeopardy, due to the facility's continuation of in-servicing and monitoring the plan of removal. The failure placed residents at risk of possible on-going abuse. Findings included: Review of Resident #23's admission MDS dated [DATE] revealed the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included stroke, cancer, hypertension, dementia, and presence of cardiac pacemaker. The MDS further reflected Resident #23 had difficulty communicating some words or finishing thoughts and missed some part/intent of message but comprehended most conversations . Resident #23 required extensive assistance of one to two staff for ADLs and she used a wheelchair for mobility. Review of Resident #23's undated care plan revealed the resident's family was known to argue in the room, upsetting the resident. Approaches included family visits to occur in common areas where staff could monitor for abuse/neglect, remove resident from situations that were potentially upsetting and report any situations where abuse/neglect was suspected to the Administrator/Abuse Coordinator immediately. Interview on 01/25/22 at 3:49 PM with the APS Investigator revealed their agency had received an anonymous report on 01/13/23, regarding concerns of financial exploitation and abuse of Resident #23. The APS Investigator called the facility the same day they received the report and spoke with the BOM about the resident's finances and then asked her if she (BOM) knew about an incident involving Resident #23 being grabbed by her face and yelled at by her family The APS Investigator further stated the BOM was able to provide some of the same details that were in the anonymous report. The APS Investigator was not able to provide further details on the incident. Review of the APS report received on 01/13/23 revealed an anonymous caller reported an allegation of physical abuse the week prior (date not provided). The resident's (Resident #23) family grabbed her by the face and yelled at her and said, YOU WILL SIT DOWN AND LISTEN TO ME. The report reflected the resident was extremely upset and hysterically crying when she was trying to share the information. Interview on 01/25/23 at 4:12 PM with the BOM revealed she received a phone call, the exact date she could not recall, from an APS Investigator initially inquiring about Resident #23's finances. The BOM stated the APS Investigator then asked if she was aware of an incident that took place where Resident #23 was yelled at and grabbed by the face. The BOM stated she told the APS Investigator she was not aware of the incident, nor had she heard or witnessed Resident #23 being abused by her family. The BOM further stated she was aware she needed to report allegations of abuse/neglect but she did not report the alleged abuse the APS Investigator mentioned to the Administrator/Abuse Coordinator or anyone because she did not believe it was true. The BOM stated she knew protocol was to report any concerns of abuse to the Admin. The BOM stated moving forward she would report all information she receives about abuse to the Admin whether she believed it or not. Review of Resident #23's progress notes dated 01/08/23 documented by LVN A revealed the following: Prior when [Family #1] entered the facility resident was on phone with other [Family #2] and she [Family #1] stated, 'get off the phone, Hang Up'. Resident became agitated and they wheeled her to room. 8:20 PM Resident's [Family #1] and spouse visiting resident inside her room. Few minutes later we heard loud voices and resident yelling, and shaking as they was discussing issue about money. Conversation continues and this nurse called weekend supervisor to assist. Resident was asking [Family #1] and spouse to leave facility, which complied to resident. Nurse assessed resident in distress VS WNL 159/89 [blood pressure, 18 [heart rate] , 116 pulse. Asked to close door so they wouldn't enter the room, was put to bed for night. Call light within reach. Resident felt safe and secure. Interview on 01/25/23 at 11:34 AM with Resident #23 revealed she was unable to complete a full interview due to her diagnosis of aphasia (loss of ability to understand or express speech). She was able to express feelings and needs but could not speak in full sentences and her thoughts appeared scattered. Resident #23 was asked if she had ever been mistreated and she then grabbed her own face and demonstrated someone had grabbed her face and yelled at her to be quiet. The resident denied being afraid but said she was always fussing and was mean mean. Resident #23 was asked who she was referring to, and she said half-sister but she was not able to provide further details. Interview on 01/25/23 at 4:58 PM with LVN A revealed on 01/08/23, during the evening shift, Resident #23 was at the nurse's station talking to Family #2 on the phone. LVN A stated mid-conversation Family #1 entered the facility and very loudly told Resident #23 to hang the phone up and ordered the resident not to talk to her (Family #2). Resident #23 hung up the phone and Family #1 took the resident to the room and closed the door. After they were in the room, LVN A heard loud voices coming from the resident's room and she was able to hear Resident #23 say, It's my money and I decide what to do. LVN A did not initially go into the room because she did not want to get in the middle of family drama. The yelling escalated and LVN A heard Family #1 tell the resident to Shut up! so LVN A went and reported the yelling to the Weekend Supervisor. LVN A said she and the Weekend Supervisor entered Resident #23's room and the resident was shaking and crying and stated she did not want Family #1 in there. They asked Family #1 to step out of the room so they could provide care and the resident was also assessed at that time and her blood pressure and pulse were elevated. Resident #23 was put to bed but the rest of the night the resident was worried and afraid and wanted to make sure Family #1 would not return. LVN A further stated she did not recall what day but days prior to the incident (01/08/23) Resident #23 made hand gestures showing LVN A her family had grabbed her face and shook it and the incident had occurred at the facility. LVN A was not able to fully understand what the resident was talking about due to the resident's communication deficit, so she told CNA B what Resident #23 had said. LVN A further stated she let the DON know about the verbal altercation, after it occurred, between the resident and the family only and not the physical incident because she was unsure if it had really occurred. LVN A also said the family continued to visit after the allegations of abuse were reported by Resident #23. Interview on 01/25/23 at 5:27 PM with CNA B revealed she was close to Resident #23's room when she heard yelling on 01/08/23. The door to the room was closed and LVN A was able to hear Family #1 yell at the resident to Shut up! Shut up! Just shut up!, but she was not able to make out what other things they were yelling about. CNA B said she did not feel comfortable entering the room when she heard the yelling because Family #1 was mean and crazy so she went to tell LVN A. LVN A then went and got the Weekend Supervisor so they could go in the room together. Once Family #1 had left the room, Resident #23 remained scared because she kept asking her (CNA B) not to leave her alone. The resident kept staring at the door and would jump at loud sounds and CNA B had to reassure the resident that Family #1 would not be entering her room that night. CNA B further stated, days prior to that incident (unable to recall which day), Resident #23 told her Family #1 had grabbed her face with her hand and shook it. She said she had not witnessed the incident so she then reported what Resident #23 had said to LVN A. CNA B also said she did not report the allegation to the Administrator because it was the weekend so she let LVN A know. CNA B also said the family continued to visit after the allegations of abuse were reported by Resident #23. Interview on 01/26/23 at 3:48 PM with the Weekend Supervisor revealed Resident #23 was at the nurse's station on the phone with Family #2 when Family #1 arrived on 01/08/23, during the evening shift. The Weekend Supervisor said Family #1 and Family #2 began to argue over the phone and she heard them mention there was an APS case and Resident #23 was asking Family #1 to stop arguing with Family #2. Later LVN A told the Weekend Supervisor there was yelling coming from Resident #23's room but LVN A did not feel comfortable going into the room alone. When LVN A and the Weekend Supervisor entered Resident #23's room, Family #1 was leaving, and Family #1 was told they needed to visit another time. She further stated she did not recall seeing the resident upset and crying. The Weekend Supervisor further stated LVN A had documented the incident in Resident #23's progress notes and notified the DON. Interview on 01/25/23 at 5:18 PM with the DON revealed there appeared to be a lot of family dynamics between Resident #23 and her family. The DON was made aware by nursing staff that Resident #23 had been in a yelling match about money with her family (01/08/23). The DON was also told the resident appeared to be a little disheveled after the family left and the staff had to calm the resident down. The DON said no one mentioned the resident had been told to shut up by the family and he thought the commotion was between Family #1 and Family #2. He further stated he did not feel like the incident was considered abuse because Resident #23 appeared to be fine, did not complain, and thought the incident did not directly involve the resident. The DON said he was never made aware the resident's family had put their hands on the resident until today (01/25/23). The DON further stated he did not report the incident to the Administrator because he did not feel the incident was abusive as the resident did not complain and appeared to be fine. He said the family also continued to visit often. Interview on 01/25/23 at 6:14 PM with the Administrator revealed she was not aware of the family dynamics between Resident #23 and Family #1 and #2. The Administrator was not told of any abuse allegations until the surveyor was inquiring with the BOM, and she then read the progress notes for Resident #23 for the incident on 01/08/23. The Administrator said as the Abuse Prevention Coordinator, she would have expected to be contacted about the incidents and expected the BOM to have told her about the allegation the APS Investigator made. The Administrator also expected the staff to have intervened immediately when they heard the verbal altercation between Resident #23 and her family so they could have put measures in place to protect the resident from abuse. The Administrator revealed staff had recently been in-serviced on abuse and neglect not that long ago. Review of an in-service dated 11/30/22 revealed the BOM, LVN A and CNA B had been in-serviced on Abuse, Neglect, and Exploitation. Review of the facility's Abuse/Neglect policy revised on 03/2018 reflected the following: The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint no required to treat the resident's medical symptoms. Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants, or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. The facility will provide and ensure the promotion and protection of resident rights. It is each individual's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property abuse and situations that may constitute abuse or neglect to any resident in the facility .C. Prevention .3. All reports of abuse or suspicion of abuse/neglect or potentially criminal behavior will be investigated as per facility protocol. 4. The facility will be responsible to identify, correct, and intervene in situations of possible abuse/neglect . .D. Identification The facility will identify and investigate events that may constitute abuse/neglect. The facility will determine the direction of the investigation based on a thorough examination of events An Immediate Jeopardy was identified on 01/26/23. The Administrator, Regional RN, and DON were notified of the Immediate Jeopardy on 01/26/23 at 01:05 PM and were provided with the Immediate Jeopardy Template. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The Facility's Plan of Removal for Immediate Jeopardy was accepted on 01/27/23 at 12:58 PM and reflected the following: On January 8, 2023, Resident #1 [Resident #23] was observed with her family member near the nurse's station. The resident's family member was observed by facility staff raising her voice at the resident while the resident was on the phone with .[Family #2]. Daughter then rolled the resident to her room and closed the door. Facility staff heard yelling coming from the resident's room and clearly heard [Family #1] was yelling shut up! Shut! Just shut up! Days prior to the 1/8/23, exact date unknown, staff reported Resident #1 [Resident #23] mentioned and gestured to them that her [Family #1] had grabbed her face an shook it. Staff did not report this allegation to anyone because they did not know if it was true since it had not been witnessed. The facility had not implemented any measures to ensure Resident #1 [Resident #23] was protected for potential abuse by the family and continued to allow the family to visit the resident after the incident on 1/8/23. A head-to-toe assessment completed to Resident on January 25, 2023 at 5:23 p.m.: tattoo to mid chest; 3 bruises faint green in color to right arm and hand. One bruise to left hand. One bruise to left upper arm green-purple in color. Faint yellow bruises to both lower legs-left side of knee; right inner thigh. Moisture redness to coccyx also noted. 98.5 (temperature) - 68 _(heart rate)-18 (pulse) 120/64 (blood pressure) 97% (oxygen saturations). Dr. aware of bruising. On January 26, 2023, at 8:58 a.m., the Social Worker visited the resident for a wellness visit. Resident was asked by the Social Worker if she felt safe and comfortable here, resident said yes, and she loves it here. On January 26, 2023, facility Administrator will notify resident' family that all future residents visit will be conducted in the facility's common areas, not in the resident's room, where staff presence is available, and staff were re-educated to intervene immediately as needed for any abusive situations from daughters towards the resident. On January 26, 2023, facility Administrator or designees will in-service all facility staff regarding resident's family future resident visits will be conducted in the facility's common area and not in the resident's room. This in-service will be completed on January 26, 2023, at 8 p.m Any staff member that has not been in-serviced will not be allowed to assume their duties until in-services are completed. Initiated today, January 26, 2023, the facility Administrator or designee will interview all facility employees to identify and address other possible abuse incidents. These interviews will be completed on January 26, 2023 at 8 p.m. Any staff member that has not been interviewed will not be allowed to assume their duties until interviews are completed. Completed staff interviews did not reveal additional allegations of abuse and neglect. On January 26, 2023, the facility Administrator or designee will interview all alert and oriented residents to identify and address other possible abuse incidents. Completed resident interview did not reveal additional allegations of abuse and neglect. On January 26, 2023, the Regional Compliance Nurse completed one to one in-service with the facility Administrator and Director of Nursing regarding company's Abuse and Neglect Policy and Procedure that included definition of abuse and neglect, abuse types, prevention components that include Screening, Training, Prevention, Identification, Reporting, Investigation and Protection. On January 26, 2023, the Regional Compliance Nurse completed one to one in-service with the facility Administrator and Director of Nursing regarding Long-Term Care Regulatory Provider Letter (guidance for reporting incidents to HHSC) that included Incidents that Nursing Facilities must report to HHSC and the Time Frames for Reporting. On January 26, 2023, the Administrator or designee will in-service all facility staff on Abuse and Neglect that included definition of abuse and neglect, types of abuse, abuse coordinator, timely reporting of allegations, allegations of abuse against family members, intervening immediately by removing resident away from visitors or families, prevention components that include Screening, Training, Prevention, Identification Reporting, Investigation and Protection. This in-service will be completed January 26, 2023 at 8 p.m. Any staff member that is not present or not in-serviced will not be allowed to assume their duties until in-service had been completed. The Medical Director was notified of the Immediate Jeopardy on January 26, 2023, at 1:11 p.m. The Medical Director was notified regarding the incident with family putting their hand on the resident's cheek and verbal altercation involving resident's family that were not reported and interventions were not put in place. No new orders received. Ad HOC Quality Assurance Performance Improvement meeting will be held on January 26, 2023 to review and discuss Immediate Jeopardy. The Administrator or designee will monitor this corrective action daily x 6 weeks. Any identified issues will be immediately addressed by the Administrator or designee. The Administrator will report progress of this plan of the Quality Assurance Performance Improvement Committee meeting monthly x 3 months. The facility Administrator will monitor plan and make changes until issues are resolved. Monitoring of the facility's implementation of the Plan of Removal revealed: Review of the in-services dated 01/27/23 revealed facility staff from various shifts and departments were in-serviced on visitor instructions for Resident #23, Abuse and Neglect/Abuse and neglect family focus. Observation on 01/27/23 at 2:07 PM revealed Resident #23 and Family #1 were in the living area visiting with each other. Resident #23 was sitting in her wheelchair and Family #1 was on the couch. There were no concerns with the interaction between the two and neither one raised their voice. Interviews were conducted on 01/27/23 starting at 1:30 PM and continued through 6:13 PM with 25 staff members from various shifts regarding in-services which included Screening, Training, Prevention, Identification Reporting, Investigation and Protection of abuse/neglect. The staff members were able to identify the different types of abuse, what do if they saw abuse/neglect, identify their abuse coordinator, and to immediately intervene and report to the abuse coordinator if they observed or heard any type of abuse/neglect. The staff were all able to verbalize understanding that Resident #23's family were to visit only in common areas so they could be supervised to prevent incidents of abuse/neglect. The staff interviewed from various shifts were as follows: the Administrator, DON, BOM, LVN A, Weekend Supervisor, CNA B, ADON, MA C, LVN D, LVN E, RN F, MA G, LVN H, Housekeeper I, CNA J, CNA K, CNA L, RN M, Housekeeper N, Floor Technician O, CNA P, CNA Q, Transportation, LVN R, LVN S. The Administrator was notified on 01/27/23 at 7:04 PM, the Immediate Jeopardy was removed. While the immediacy was removed on 01/27/23, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not Immediate Jeopardy, due to the facility continuing in-servicing and monitoring the Plan of Removal.