**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents received adequate supervision to prevent accidents for 2 of 8 residents (Resident #1 and Resident #2) reviewed for supervision to prevent accidents. The facility failed to ensure Resident #2 was free from physical abuse when Resident #1 hit Resident #2 on 06/08/25 on the secure unit. The facility failed to provided training regarding 1-1 or notify management of 1-1 status. CNA A was the only staff assigned to the unit. After the altercation, CNA A was also assigned to provide 1-1 for 1.5 hours for Resident #1 but took Resident #2 with her as she cared for other residents and did not provide 1-1 for Resident #1. The facility failed to ensure Resident #1 and Resident #2 did not hit each other on 06/17/25 on the secure unit. CNA A did not request assistance when she was providing care to another resident. CNA A was assigned to the unit and assigned to provide 1:1 for Resident #1 from 9:30 a.m. to 12:45 p.m. She had to take Resident #1 with her while providing care for other residents. MA C was assigned 1:1 for Resident #2 from 9:30 a.m. - 1:00 p.m. There was no additional staff assigned to provide care and supervision for the remaining residents on the unit. The facility did not review, update, or implement interventions to include adequate supervision and continued to leave Resident #1 alone and unsupervised with Resident #2 and with other residents. There was no documentation of who discontinued the 1:1 monitoring of Resident #1 or Resident #2. A De-escalation Techniques training was provided following the second incident. It did not address staff 1:1, notifying management of escalation behaviors, or identifying escalating behaviors. The behavior management policy did not address 1:1 monitoring when residents had escalated/aggressive behaviors or if management would be notified. The facility did not have a system in place to ensure residents were supervised in the secured unit while the assigned staff was providing care for other residents. An Immediate Jeopardy (IJ) was identified on 07/10/25 at 2:25 p.m. The IJ template was provided to the facility on [DATE] at 2:48 p.m. While the IJ was removed on 07/11/25, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. These failures could place residents at risk for emotional distress, fear, decreased quality of life, and further abuse. Findings included: Record review of Resident #1's face sheet dated 07/08/25 indicated she was a [AGE] year-old female who was admitted on [DATE]. Her diagnoses included Alzheimer's (brain condition that progressively damages memory, thinking, and learning skills), severe dementia (loss of cognitive function) with agitation, and anxiety (feelings of dread and inner turmoil). Record review of Resident #1's quarterly MDS assessment dated [DATE] indicated she was usually able to make herself understood and usually understood others, had severe cognitive impairment (BIMS-4), and had behavioral symptoms not directed at others. Record review of Resident #1's care plan dated 06/09/25 indicated Resident #1 had potential to exhibit physical behaviors. Interventions included give resident as many choices as possible about care and activities, if Resident #1 had physical behavior towards 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, restarted Buspirone, Resident #1 was separated from other resident, and one-to-one monitoring until determined safe, and secure care consult referral, and when Resident #1 becomes agitated: intervene before agitation escalates. Record review of Resident #1's late entry progress note dated 06/08/25 at 10:15 p.m., completed by RN D, indicated she was notified by CNA A Resident #1 hit Resident #2 with an open hand. The physician and the RP were notified. Resident #1 was restarted on Buspar (Buspirone) (anti-anxiety medication). Record review of Resident #1's progress note dated 06/17/25 at 9:35 a.m., completed by LVN E indicated MA B reported she was outside the secure unit and Resident #1 and Resident #2 being physically combative with each other. There were no injuries noted. Residents were separated with no further events. The MD and the RP were notified. Record review of Resident #2's face sheet dated 07/08/25 indicated she was an [AGE] year old female, admitted on [DATE] and her diagnoses included Alzheimer's and severe dementia with anxiety. Record review of Resident #2's quarterly MDS dated [DATE] indicated she was rarely able to make herself understood, sometimes understood others, had severe cognitive impairment (BIMS-3), and had physical and verbal behaviors directed at others (behavior of this type occurred 1-3 days). Record review of Resident #2's care plan dated 06/18/25 indicated Resident #2 had potential to demonstrate physical behaviors due to dementia and poor impulse control. Interventions included give Resident #2 as many choices as possible about care and activities, if Resident #2 has physical behaviors toward another resident immediately intervene to protect the residents involved and call for assistance, if intervening is unsafe call out for staff assistance immediately, notify the charge nurse of any physically abusive behaviors, and when Resident #2 becomes agitated: intervene before agitation escalates guide away from source of distress, engage calmly in conversation. If response is aggressive, staff to walk away calmly away and approach later. Record review of Resident #2's progress note dated 06/17/25 at 9:34 a.m., completed by LVN E indicated MA B reported she was outside the secure unit and Resident #1 and Resident #2 being physically combative with each other. There were no injuries noted. Residents were separated with no further events. The MD and the RP were notified. Record review of facility investigation dated 06/13/25, completed and signed by the Administrator, indicated the allegation of abuse was confirmed. Resident #1 level of supervision was within eyesight. Resident #2's level of supervision was within eyesight. Resident #2 had a history of physical aggression. CNA A was getting a resident up for the day when she heard yelling. She went to investigate and noticed Resident #1 and Resident #2 yelling at each other with their fingers in each other's faces. CNA A stepped in between Resident #1 and Resident #2 to separate them and Resident #1 grabbed CNA A's wrist and twisted her arm behind her back. CNA A got loose and was able to separate them, then went back to finish with the other resident. CNA A tried to keep Resident #2 out of the dining area and redirect; however Resident #2 managed to get into the dining room. When Resident #2 tried to come out of the dining hall, Resident #1 would not let her pass, and then hit Resident #2 with an open hand on the left arm/shoulder area. There were no injuries. Residents were immediately separated, Medical Director, RP, ADON, Administrator, Corporate Compliance Nurse, and Area Director of Operations, were all notified. The facility conducted staff training on Abuse/Neglect and Resident Rights. Staff were not in-serviced on deescalating behaviors with residents. There was no documentation of who implemented or discontinued the 1:1 monitoring of Resident #1. CNA A's statement dated 06/08/25 indicated I was getting a resident up for the day. I started to transfer that resident to her wheelchair when I heard yelling. When I got the resident in the wheelchair I went to see about the yelling I saw Resident #1 and Resident #2 yelling at each other and their fingers pointing in each other's faces. I got in between them so they will not make contact with each other. In the process of separating them, Resident #1 pushed me and grabbed my wrist and twisting it and then twisted my arm behind my back. I finally got loose and got them separated. Then I went back to finish attend to the other resident. Resident #1 was sitting at the dining room table. I tried to keep Resident #2 out of the dining room but she still managed to get in the dining room. As I was getting Resident #2 out of the dining room she went the other way. Resident #1 would not let her past. That's when Resident #1 hit Resident #2 open handed on the left arm shoulder area. I got Resident #2 out of the dining room I saw MA B coming to break me out for lunch. I let her know what happened and to keep them separated. Then I let my nurse know what happened. Before this incident I had to let my nurse know that Resident #1 might need a PRN because shortly after Resident #1 got up she started with her normal behavior of we are stealing her stuff and Resident #1 was rummaging way above her normal behavior the nurse did get come and give her something.[sic] Record review of the facility investigation dated 06/19/25, completed by the Administrator indicated the allegation of abuse was confirmed. Resident #1 level of supervision was within arms length. She had a history of similar allegations. Resident #2's level of supervision was within eyesight. Resident #2 had a history of physical aggression. MA B was passing medications just outside the secure unit. She looked up and saw both residents passing licks to one another. MA B hollered out for help and rushed into the secure unit to separate the residents due to CNA A was providing care to another resident. There were no injuries. Provide action taken Post-Investigation included staff training on abuse and neglect and resident rights. One-to-One provided for Resident #1 and Resident #2. Staff were not in-serviced on deescalating behaviors with residents. There was no documentation of who implemented or discontinued the 1:1 monitoring of Resident #1. Record review of MA B's statement dated 06/17/25 indicated I was passing pills on the outside of the unit. When gathering pills, I looked up and saw both residents passing licks to one another. I hollered out and rushed into the doors to separate due to the staff member was with another resident. Record review of Resident #1's monitoring sheet dated 06/17/25 and signed by CNA A indicated CNA A documented in 15 minute intervals from 9:30 a.m. through 12:45 p.m. There was no documentation of one-to-one assignment or what Resident #1 was doing at the time of the 15 minute monitoring. Record review of Resident #2's monitoring sheet dated 06/17/25 and signed by MA C indicated MA C documented in 15 minute intervals from 9:30 a.m. through 1:00 p.m. There was no documentation of one-to-one assignment or what Resident #2 was doing at the time of the 15 minute monitoring. During an interview on 07/08/25 at 9:15 a.m., the Administrator said the secure unit had 8 beds. She said the current census indicated there were 7 residents on the unit. She said the CNAs worked 12 hour shifts from 6:00 a.m. through 6:00 p.m. and 6:00 p.m. through 6:00 a.m. She said a nurse was not physically on the unit for any shift but would come on the unit, as necessary. During observation and interview on 07/08/25 at 9:25 a.m., CNA A said she was the only staff assigned to work in the secure unit from 6:00 a.m. through 6:00 p.m. She said she was in the process of cleaning the dining room after Resident #2 had an incontinent episode. She said she did not ask for staff assistance to clean the area or while she provided incontinent care for Resident #2. Resident #1 was off the secure unit and in therapy. Resident #2 smiled and said hello. During an interview on 07/08/25 at 11:10 a.m., the Administrator said one-to-one meant watching a resident all the time. She said CNA A was monitoring and 1-1 on 06/08/25. She said she was not aware another staff was assigned. She said resident supervision that required within eyesight was not possible with only one staff. During an interview on 07/08/25 at 11:15 a.m., the ADON said she spoke with the psych NP on 06/08/25 and Resident #1's Buspar was restarted that was previously discontinued on 06/06/25. She said she was not aware of who started or discontinued Resident #1's one-to-one staff on 06/08/25. During an interview on 07/08/25 at 11:53 a.m., the Administrator said the facility did not have a policy or a procedure/protocol for one-to-one staff. She said she was not aware of staff training related to one-to-one staff or expectations. During an interview on 07/09/25 at 9:25 a.m., CNA A said she was the only staff assigned to work on the unit for the shift 6:00 a.m. to 6:00 p.m. She said secure unit/memory care unit only had one staff assigned for each shift and each shift was 12 hours. She said another staff would supervise the unit if she was on her break or had to leave the unit. She said on 06/08/25 she was getting another resident ready for the day and was transferring the resident to a wheelchair when she heard a commotion. She said she opened the door of the resident's room and observed Resident #1 and Resident #2 in an argument with their fingers in each other's face. She said she separated the residents and Resident #1 was in the dining room and Resident #2 was in the TV room. She said she returned to the other resident's room to finish getting her dressed. She said she came back out of the room and observed Resident #2 walk into the dining room. She said Resident #2 refused to leave the dining room and when she walked to the other side of the dining room Resident #1 hit Resident #2. She said she was assigned to one-to-one supervision of Resident #1 but took Resident #2 around with her as she took care of other residents. She said Resident #2 was more compliant and would wait in another resident's room while she assisted other residents in the washroom with the door closed. She said she did not ask for assistance when she had to care for other residents while providing one-to one. She said she did not recall who assigned or discontinued Resident #1's one-to-one on 06/08/25. She said the second incident on 06/17/25 occurred when she was taking care of another resident. She said MA B intervened. She said she was assigned one-to-one for Resident #1 and MA B was assigned one-to-one for Resident #2. She said there was no other staff to assist the other 5 residents on the unit. She said she did not recall who assigned or discontinued the one-to-one for Resident #1 or Resident #2. She said one-to-one meant staying with the resident all the time. During an interview on 07/09/25 at 9:40 a.m., the DON said MA B stayed on the unit until the one-to-one was discontinued. She said if CNA A needed help she would call out to the nurses' station for assistance. During an interview on 07/09/25 at 11:53 a.m., the Administrator said the facility did not have a policy for resident supervision or one-to-one resident supervision. During an interview on 07/09/25 at 1:57 p.m., the ADON said Resident #1's Buspar was restarted due to her increased behaviors after the GDR on 06/06/25. She said RN D completed an incident report and notified me because the DON was on PTO. She said one-to-one was stopped because we had de-escalated her behaviors. During an interview on 07/10/25 at 9:43 a.m. the DON said on 06/08/25 the corporate secure care nurse was notified of the incident and scheduled a TEAMS meeting to review the incident on 06/17/25. She said the second incident occurred right before the meeting started. The secure care nurse suggested the residents be evaluated for pain and routine pain medications be administered if appropriate. It was also suggested the staff receive training on de-escalation. She said the incident on 06/17/25 was discussed with the Administrator and the ADON. Resident #1 and Resident #2's behaviors had calmed and the one-to-one was discontinued. She said staff were trained on de-escalation on 06/23/25. She said the other resident that received care during the incident on 06/08/25 and 06/17/25 was moved off the unit. She said staff was directed to call for assistance if they need help. She said there was no additional issues identified with the one-to-one during both incidents. During an interview on 07/09/25 at 4:30 p.m., the Administrator said one-to-one was someone to sit with a resident, so another altercation did not happen. She said she would not want other residents endangered. She said a TEAMS call with a secure care nurse was completed after the incident on 06/08/25. She said the facility did not talk to the secure care nurse until the following week after the second incident on 06/17/25. She said one-to-one was not really one-to-one because we did not assign an additional staff to watch the other residents. She said the RN weekend supervisor was responsible for ensuring adequate staff on the weekend. She said the RN weekend supervisor should have separated residents 06/08/25 and gotten another staff to sit with the resident until the behaviors were under control and until we got direction from the doctor on how to proceed. She said residents were at risk of injury for accidents without adequate supervision. During an interview on 07/10/25 at 12:51 p.m., RN B said she did not recall the incident on 06/08/25. She said she did not remember assigning one-to-one to any staff. She said residents were at risk of accidents and injuries without adequate supervision. During an interview on 07/10/25 at 1:10 p.m., weekend supervisor RN BB said she recalled the incident on 06/08/25 but she was not involved. She said she did not know who assigned one-to-one or who discontinued one-to-one for Resident #1. She said RN B was involved with the incident. She said residents were at risk of accidents and injuries without adequate supervision. During an interview on 07/10/25 at 2:04 p.m., MA B said she was passing medications outside of the secure unit on 06/17/25. She said she observed Resident #1 and Resident #2 hitting each other. She said she immediately went on the unit and separated the residents. She said she was not aware of any one-to-one assignment. She said residents were at risk of accidents and injuries without adequate supervision. During an interview on 07/10/25 at 2:21 p.m., MA C said she was assigned one-to-one with Resident #2 on 06/17/25. She said CNA A was assigned one-to-one with Resident #1. She said there were no additional staff assigned to the unit while the one-to-one was in place. She said we managed to keep up with everything. She said CNA A took Resident #1 with her while she assisted other residents or she was in her (MA C's) eyesight. She said the DON directed her to stop on-to-one. She said residents were at risk of accidents and injuries without adequate supervision. An Immediate Jeopardy/Immediate Threat was identified on 07/10/25 at 2:25 p.m. The ADO and the DON were notified of the Immediate Jeopardy and provided the IJ template on 07/10/25 at 2:48 p.m. 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 07/10/25 at 8:26 p.m. and reflected the following: Plan of Removal: The facility failed to adequately supervise residents to implement interventions to prevent accidents and protect residents from potential injuries from resident to resident altercations.Interventions: All residents in template or put at risk for harm were assessed by charge nurse. No findings identified. All Residents are assessed weekly for behaviors on the weekly nursing summary. To include Wandering, verbal and physical behavior symptoms directed towards others. Last assessment completed on 7/10/25Resident were separated, placed on 1:1, social service consult, safe surveys, trauma informed PRN assessment completed, interviewed staff, skin assessments, secure care consult scheduled, Inservice regarding abuse/neglect to include resident to resident abuse and resident rights, medical director was notified, ADHOC initiated for incident date 6/8/25 & 6/17/25Monitored on the following for incident date 6/8/25 & 6/17/25Ask 10 staff members per week, if they have noticed any inappropriate behavior among residents, if so, verify what the staff member did and if it was reported properly. Document any corrective action as needed. If they have not observed any inappropriate behavior, ask what they would do if they did and who they would report it to. Document date/time, if they answered correctly, the staff member's name, and any corrective action if needed.Document 5 resident quality of life rounds every week, asking how things are going for them, etc. Document date/time, the resident's name, if there was any negative response, and any corrective action if needed.During incident/event review in standup, the DON and Admin will monitor for potential inappropriate resident behaviors in the event reports.During facility rounds, are there any signs of potential resident to resident inappropriate behavior.medication adjustments for Resident #1 on 6/8/25.The DON and ADON were in-serviced 1:1 by the ADO on following in-services on 7/10/25 at 4:30 pm.1:1 monitoring: Consistent observation involving assigning a dedicated staff member to continuously observe a single resident. Process of determining when 1:1 is initiated and concluded: one on one will be determined by the DON or designee and concluded by consulting with psych services/secure care team/or IDT team. De escalating behaviors Abuse and neglect to include increased supervision for residents with aggressive behaviors.1:1 in service with the aides who completed the one on one on 6/8 & 6/17/25- the staff member doing one on one will have consistent observation involving assigning a dedicated staff member to continuously observe a single resident. All other staff we're also in-serviced over 1:1 monitoring. Starting 7/11/25 review all new incident and accidents and self-reports during clinical meeting & stand down to ensure the correct process was followed regarding one on one and reporting to be reviewed by IDT team. Review of staffing in memory care unit- In the event an incident occurs between residents additional staff will be pulled to assist with monitoring and resident care. The aide will notify the charge nurse immediately via phone located in memory care unit. When the aid is providing care to residents they will call additional staff to supervise residents in the memory care unit during that time. The Medical Director was notified of the Immediate Jeopardy on 7/10/25 by the [NAME] ADHOC QAPI meeting was completed by the interdisciplinary team to include the Medical Director 7/10/25.In-services: The following services were initiated on 7/10/25 for all staff members by the DON, ADON, and/or Regional Compliance Nurse. All staff not present for in-servicing will not be permitted to work their assignment until in-serviced. All new hires will be in-serviced during facility orientation. All agency staff will be in-serviced prior working their floor assignment. Abuse and Neglect: Failure to properly monitor residents with aggression towards others can lead to negative outcomes and not having proper 1:1 may result in additional behaviors and additional aggressive behaviors.Deescalating behaviors with resident- how staff can manage and deescalate residents when having altercations. In the event the resident becomes aggressive with staff or other residents, the staff or aide need to keep residents separated and notify the charge nurse immediately. Prevention of resident-to-resident abuse- staff to engage residents with activities, snack, redirection, and monitor for any new changes of condition.1:1 monitoring: Consistent observation involving assigning a dedicated staff member to continuously observe a single resident (not providing care to any other residents during this time). One on one will be determined by the DON or designee and concluded by consulting with psych services/secure care team/or IDT team. Documentation of one on one monitoring will be reflected on the monitoring sheets and show discontinuation. Any staff member can provide one on one monitoring. Monitoring: Monitor 5 days a week x 6 weeks any events that required 1:1, was there proper 1:1 completed.Monitor 5 days a week x 6 week any changes of condition or possible resident to residents.Monitoring of the facility's Plan of Removal included the following: Record review of Resident #1 and Resident #2 assessments dated 07/10/25 indicated no negative findings . Record review of Resident #1, Resident #2, Resident #3, Resident #4, Resident #6, Resident #7, and Resident #8's weekly nursing summaries dated 07/10/25 included wandering, verbal and physical behavior symptoms directed towards others. There were no concerns noted.Record review of staff training dated 07/10/25 at 4:40 p.m. indicated the DON and ADON were in-serviced 1:1 by the ADO on 1:1 monitoring: Consistent observation involving assigning a dedicated staff member to continuously observe a single resident. Process of determining when 1:1 is initiated and concluded: one on one will be determined by the DON or designee and concluded by consulting with psych services/secure care team/or IDT team, de-escalating behaviors, abuse and neglect to include increased supervision for residents with aggressive behaviors.Record review of 1:1 in service dated 07/10/25 with CNA A and MA C who completed the one on one on 6/8/25 & 6/17/25 indicated the staff member doing one on one will have consistent observation involving assigning a dedicated staff member to continuously observe a single resident. All other staff we're also in-serviced over 1:1 monitoring. Record review of incident and accident reports and self reports from 07/08/25 though 07/11/25 indicated there was no concerns noted during clinical meeting & stand down on 07/11/25 regarding one on one and reporting to be reviewed by IDT team. Record review of staffing in memory care unit- In the event an incident occurs between residents additional staff will be pulled to assist with monitoring and resident care. The aide will notify the charge nurse immediately via phone located in memory care unit. When the aid is providing care to residents they will call additional staff to supervise residents in the memory care unit during that time. Record review of staff training dated 07/10/25 and 07/11/25 conducted by the DON, ADON, and/or Regional Compliance Nurse indicated Abuse and Neglect: Failure to properly monitor residents with aggression towards others could lead to negative outcomes and not having proper 1:1 may result in additional behaviors and additional aggressive behaviors. De-escalating behaviors with resident- how staff can manage and deescalate residents when having altercations. In the event the resident becomes aggressive with staff or other residents, the staff or aide need to keep residents separated and notify the charge nurse immediately. Prevention of resident-to-resident abuse- staff to engage residents with activities, snack, redirection, and monitor for any new changes of condition. 1:1 monitoring: Consistent observation involving assigning a dedicated staff member to continuously observe a single resident (not providing care to any other residents during this time). One on one would be determined by the DON or designee and concluded by consulting with psych services/secure care team/or IDT team. Documentation of one on one monitoring would be reflected on the monitoring sheets and show discontinuation. Any staff member can provide one on one monitoring. Observation and interview on the secure unit on 07/11/25 at 10:46 a.m. Resident #1 and Resident #2 were sitting in the TV room. They were calm and there were no signs of agitation. Resident #1 and Resident #2's 1-1 was previously discontinued. MA C was assigned to watch the 7 residents of the secure unit while CNA F was on her lunch break. MA C indicated she received training related abuse/neglect/reporting, behaviors and de-escalating behaviors, and one-to-one resident supervision. She indicated for one-to-one she would remain within close proximity, engage the resident and monitor for any changes. She would notify the nurse in charge, DON, and Administrator of any changes. During an interview on the secure unit on 07/11/25 at 10:50 a.m., MA B indicated she received training related abuse/neglect/reporting, behaviors and de-escalating behaviors, and one-to-one resident supervision. She indicated for one-to-one she would remain within close proximity, engage the resident and monitor for any changes. She would notify the nurse in charge, DON, and Administrator of any changes. There was no resident assigned one-to-one monitoring as of 07/11/25. Interviews conducted on 07/11/25 from 10:46 a.m. through 2:00 p.m. representing staff from all shifts and departments (6a.m.-6p.m., 6p.m.-6a.m., 6a.m.-2p.m., 2p.m.-10p.m., and 10p.m.-6a.m.) included the DON, CNA A, MA B, MA C, LVN G, CNA H, HR/CNA I, CNA J, BOM K, CNA L, LVN M, CNA N, PT/DOR O, Medical Records P, MDS LVN Q, Dietary [NAME] R, LVN S, ADON/LVN T, Dietary [NAME] U, Dietary [NAME] V, HSK W, SW X, Dietary Manager Y, and HSK Z. All staff were able to identify the different types of abuse, what to do if they witnessed resident to resident abuse, what signs to watch for in residents to prevent resident to resident abuse, who to report any incidents of abuse. Staff were able to identify ways to prevent residents with high-risk behaviors such as wandering and agitation from abuse and neglect (remove from reach of others, increase supervision of wandering by monitoring while they are wandering, and/or engaging in activity). Staff indicated they were to be aware of resident behaviors, monitor for behaviors, and how to de-escalate behaviors. Staff knew they were to separate residents immediately and ensure residents were safe. All staff were able to identify the responsibilities of assigned 1:1 supervision. All staff were able to identify the responsibilities of caring for a resident with aggressive behaviors. All staff were able to identify the responsibilities for supervision and monitoring residents. All staff were able to identify 1:1 monitoring/supervision meant always staying with resident -keep eyes on the residents and they had to be relieved by another trained staff before going on break/meal. All staff aware of supervising and monitoring was a preventive or proactive intervention. The process of determining when 1:1 was initiated and discontinued would be determined by the DON or designee. Nursing staff indicated they would be notified of CNA/MAs breaks and were responsible for monitoring residents until the aide returned. All staff indicated resident behaviors and triggers including resident specific triggers to provide optimal monitoring and prevention on falls/injuries. All staff identified redirection techniques of walking with residents and/or engage in diversional activities if a resident was agitated or wandering. CNA staff identified responsibilities of checking Kardex for resident specific care plan and triggers. During an interview on 07/11/25 at 10:46 a.m., MA C indicated1:1 monitoring included consistent observation involving a dedicated staff member to continuously observe a single resident. The process of determining when 1:1 is initiated and concluded would determined by the DON or designee and, was able to give examples of de-escalating behaviors, and prevention of abuse and neglect included increased supervision for residents with aggressive behaviors. During an interview on 07/11/25 at 11:00 a.m., CNA A said indicated1:1 monitoring included consistent observation involved a dedicated staff member to continuously observe a single resident. The process of determining when 1:1 was initiated and concluded would be determined by the DON or designee and was able to give examples of de-escalating behaviors, and prevention of abuse and neglect included increased supervision for residents with aggressive behaviors. During an interview on 07/10/25 at 1:15 p.m., the DON said. Monday through Friday she and the ADON would review all incidents and the 24-hour report and make needed changes to care plans with any change of condition including behaviors or resident-to-resident altercations. She indicated 1:1 monitoring included [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for 1 of 10 residents (Resident #1) reviewed for accidents and supervision. 1. The facility failed to ensure Resident #1 did not sustain injuries of unknown origin. On 03/10/24 Resident #1 was diagnosed with a comminuted (broken in two places) intertrochanteric left femur (thigh bone) fracture with varus angulation, comminuted intertrochanteric right femur fracture with varus (inwards) angulation, and anteriorly displaced distal fracture fragment of the right femoral fracture, and an acute angulated displaced fracture of the left proximal humeral diaphysis (shaft). 2. The facility failed to ensure CNA A transferred Resident #1 with a gait belt on 03/09/24 per facility protocol. An Immediate Jeopardy (IJ) situation was identified on 04/03/24. While the IJ was removed on 04/04/24, the facility remained out of compliance at a scope of isolated with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk for falls resulting in injury, pain, and hospitalization. Findings include: Record review of Resident #1's face sheet, dated 03/22/24, reflected a [AGE] year old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), cognitive communication deficit (difficulty with thinking and how someone uses language), need for assistance with personal care, muscle wasting and atrophy (decrease in size and wasting of muscle tissue), rhabdomyolysis (rare muscle injury where muscles break down), abnormalities of gait and mobility (weakness of the hip and lower extremity muscles commonly cause gait disturbances), lack of coordination, reduced mobility and a history of falling. Record review of Resident #1's assessment, dated 01/05/24, reflected she was sometimes able to make herself understood, understood others, had severe cognitive impairment (BIMS score of 7), had impaired range of motion on one upper side extremity and impaired ROM of both lower extremities, utilized a wheelchair for mobility, and required assistance to transfer to and from a bed or wheelchair. Record review of Resident #1's care plan, dated 10/16/21, reflected she was at risk for falls related to confusion, gait/balance problems, incontinence, poor communication/comprehension, unaware of safety needs and vision problems. Interventions included one staff to assist with transfers. Record review of Resident #1's care plan, dated 10/16/21, reflected Resident #1 had an ADL self-care performance deficit related to activity intolerance, confusion, dementia, fatigue, impaired balance and limited mobility. Interventions included one staff for transfer assistance. Record review of Resident #1's [NAME] (electronic care record), provided by the facility on 04/04/24, reflected Resident #1 required one staff assist with transfers. Record review of progress note, dated 03/09/24 at 5:00 p.m., completed by LVN B, indicated CNA A notified LVN B that when she transferred Resident #1 to the bed from the wheelchair, Resident #1 complained of pain to RLE. ROM WNL to all extremities and no signs of symptoms of pain or discomfort. Resident #1 refused Tylenol. Record review of progress note, dated 03/09/24 at 11:45 p.m., completed by LVN C, reflected a can A reported Resident #1 does not look right and something was wrong with her. Resident #1's skin was pale, warm and dry. Neuros WNL. Resident denied pain. Lungs were clear to CTA. Will continue to monitor. Record review of progress note, dated 03/10/24 at 1:20 a.m., completed by LVN C, reflected when LVN C applied the BP cuff to Resident #1's wrist , Resident #1 said ow. LVN C looked at Resident #1's hand and wrist and asked if she as in pain. Resident #1 giggled and replied no. LVN C asked Resident #1 to raise her arms and Resident #1 was able to raise both arms with no sign or symptom of pain and no complaint of plain. Asked Resident #1 to smile and no facial drooping noted. DON notified. Will continue to monitor. Record review of progress note, dated 03/10/24 at 6:00 a.m., completed by LVN C, reflected Resident #1 was resting in bed. No sign or symptoms of SOB, pain or discomfort. Resident continues to deny SOB and pain. Record review of progress note, dated 03/10/24 at 1:34 p.m., by LVN D reflected CNA E reported Resident did not urinate for the entire shift but did have a BM. CNA E reported Resident #1 complained of pain to her left hip when she was rolled on to her left side during incontinent care. Left hip was assessed and swelling noted. Resident #1 was able to move her left leg. And when asked where she was hurting she replied my arm STAT x-ray that had been ordered at 8:00 a.m. had not arrived at facility. Resident transferred to ER for evaluation. Record review of progress note, dated 03/10/24 at 2:04 p.m., completed by LVN D, reflected Resident #1 was transferred to the hospital at 2:00 p.m. related to pain and discoloration to left upper arm, swelling and pain to left hip and decreased urine output. Record review of hospital records, dated 03/10/24, reflected Comminuted intertrochanteric left femur (thigh bone) fracture with varus angulation, comminuted intertrochanteric right femur fracture with varus angulation, anteriorly displaced distal fracture fragment of the right femoral fracture, and acute angulated displace fracture of the proximal humeral diaphysis (shaft) . Bruising noted to left collar bone, left neck, left inner upper arm, left elbow, right outer mid-calf, right hand, and left hand. Patient responsive to pain only. Dried blood noted to fingernails and gown with no source of active bleeding . 4:15 p.m. incon(tinent) care performed . crepitus (a popping, clicking or crackling sound in a joint) felt to right hip-patient alert-yelling 'I want to go home' . 4:40 p.m. patient yelling out-'I want to go home .what are you doping to me . Please don't hurt me' denied pain at this time. During an interview on 03/22/24 at 10:52 a.m., LVN D said she worked on Saturday, 03/09/24, until 2:30 p.m. She said Resident #1 was up in her wheelchair for the most part and had no complaints of pain on that day. She said Resident #1 was her normal self. Resident #1 would usually be up in her wheelchair. She said Resident #1 required assist of one staff for transfers from her wheelchair to bed and bed to wheelchair. She said Resident #1 could not stand on her own. She said she was not aware of any recent falls for Resident #1. She said if Resident #1 had fallen she would not be able to get herself up and in her bed without assistance. She said Resident #1 stayed in bed on 03/10/24 due to waiting for STAT x-ray for the pain in her arm. She said Resident #1 complained of pain to her left arm. She said Resident #1 complained of pain when she was rolled on to her left side during incontinent care. She said CNA G reported the complaint of pain. She said STAT x-ray had not shown since the morning request and due to the new complaint of pain, Resident #1 was transferred to the hospital for evaluation. She said the information for resident care was in the [NAME] system. She said if staff did not follow the [NAME] for care needs then residents could get seriously injured. She said she was not aware of how Resident #1 could have sustained a fracture to her left arm or two bilateral femur fractures. During an interview on 03/22/24 at 12:53 p.m., the DON said she went to the hospital on [DATE] and did not see any bruises on Resident #1's face, neck, color bones or limbs. She said she trained staff on dementia and pain. She said Resident #1 would not have been able to get up from a fall without assist and she was not aware of any recent falls for Resident #1. She said Resident #1 required the assist of 1 staff for transfer from her wheelchair to the bed or the bed to wheelchair. She said if staff did not follow the [NAME] for care needs then residents could get seriously injured. She said she was not aware of how Resident #1 could have sustained a fracture to her left arm or two bilateral femur fractures. During an interview on 03/22/22 at 2:32 p.m., LVN B said CNA A came and got her from the nurse station at approximately 7:00 p.m. on 03/09/24. She said CNA A said she transferred Resident #1 and Resident #1 winced. She said she assessed Resident #1 and asked Resident #1 if she was hurting. She said Resident #1 said she was not hurting. She said there was no redness or bruising. She said she moved all of Resident #1's limbs as she was in a lying position on her bed and Resident #1 said she had no pain. She said she offered Resident #1 a pain medication and Resident #1 declined the pain medication. She said she came back to work at 2:00 p.m. on 03/10/24 and Resident #1 was in the process of being transferred to the hospital. She said if staff did not follow the [NAME] for care needs then residents could get seriously injured. She said she was not aware of how Resident #1 could have sustained a fracture to her left arm or two bilateral femur fractures. She said she was not aware of any falls. During an interview on 03/28/24 at 10:13 a.m., CNA I said he started his shift at 10:00 p.m. on 03/09/24. He said Resident #1 was in bed. He said he got report from CNA A that Resident #1 was hurting too bad to change and she was screaming and crying. He said he checked on Resident #1 and Resident #1 said she was hurting. He said Resident #1's color was off. He said LVN C brought her some pain medication. He said then it seem like Resident #1 was having dry-heaving and choking, then gasping for air followed by more heaving. He said LVN C looked Resident #1 over and he looked her over too as they were looking for mottling. He said LVN C and he checked on Resident #1 throughout the shift. She said her left arm hurt. He said Resident #1 assisted with rolling over during care, but her hip seemed loose and it had less control than her right hip. He said he never saw Resident #1 in that physical condition before. He said she was complaint with care and was not aggressive. He said she required assist of one staff for transfers from her wheelchair and bed. He said the gait belt was required for all transfers. He said if staff did not follow the [NAME] for care needs then residents could get seriously injured. He said he was not aware of how Resident #1 could have sustained a fracture to her left arm or two bilateral femur fractures. He said she was not aware of any falls. During an interview on 03/28/24 at 10:58 a.m., LVN C said Resident #1 said ow when she was taking her BP. She said she asked Resident #1 if she was in pain and Resident #1 giggled. She said the aide said she did not look right. She said Resident #1's neuro's were within normal limits, she lifted both of her hands equally and wiggled her toes and feet. She said she did not do full ROM and lift her legs or wiggle her hips because it was not usually done for someone who was in a wheelchair. She said if staff did not follow the [NAME] for care needs then residents could get seriously injured. She said she was not aware of how Resident #1 could have sustained a fracture to her left arm or two bilateral femur fractures. She said she was not aware of any falls. During an interview on 03/28/24 at 3:41 p.m., CNA A said on 03/09/24, Resident #1 was at the nurse's station after her supper meal. She said Resident #1 wanted to go to her bed after the supper meal. She said she changed Resident #1's shirt while she was seated in her wheelchair. She said she transferred Resident #1 from her wheelchair to her bed. She said Resident #1 put her arms around her (CNA A) neck and shoulder area and she (CNA A) put her arms under Resident #1's arms around her upper back area and lifted her and put her on the bed. She said she transferred Resident #1 how she normally transferred her. She said she did not need the gait belt because Resident #1 was not heavy. She said she sat Resident #1 on the bed and then lifted her feet and legs and turned her so she was fully on the bed. She said Resident #1 laid down and she (CNA A) took off Resident #1's pants. She said Resident #1 was groaning. She said she asked Resident #1 if she was hurting and she said Resident #1 said she was hurting all over. She said Resident #1 never complained of hurting before with previous transfers. She said she told LVN B about Resident #1's complaint of pain. She said LVN B came and moved all of Resident #1's limbs. She said Resident #1 declined any pain medication. She said Resident #1 said she could not move her arm but lifted her right arm and not her left arm. She said she was not aware of any bruises. She said she did not usually work with Resident #1. She said she was trained to use a gait belt for transfers. She said if staff did not follow the [NAME] for care needs then residents could get seriously injured. She said she was not aware of how Resident #1 could have sustained a fracture to her left arm or two bilateral femur fractures. During an interview on 04/01/24 at 10:13 a.m., MD F said Resident #1's fractured arm and bilateral femurs could have occurred due to a fall and being picked up or transferred. He said there was no way to determine how the fractures occurred. During an interview on 04/01/24 at 11:27 a.m., CNA G said Resident #1 required extensive assist of one staff for transfers. She said all transfers were done with a gait belt. She said she transferred Resident #1 from her bed to the wheelchair for breakfast, then back to her bed after breakfast for incontinent care then back to her wheelchair. She said Resident #1 ate lunch then she transferred her to her to bed for incontinent care and afternoon reset. She said she transferred Resident #1 to her wheelchair for the supper meal. She said after the supper meal, CNA A transferred Resident #1 to bed. She said CNA A mentioned Resident #1 was in pain and the nurse was informed. She said when she returned to work on 03/10/24, Resident #1 said she was in pain all over. She said Resident #1 complained of pain during care. She said she completed the care, and she reported Resident #1's pain to the nurse. She said she asked Resident #1 if she wanted to get up for breakfast and Resident #1 said she did but Resident #1 complained of pain and stayed in bed. She said she and CNA H completed peri-care after breakfast and Resident #1 complained of pain. She said she completed the care and reported Resident #1's pain to the nurses. She said the nurse came to the room and Resident #1 was later sent out to the hospital. She said Resident #1's left hip looked like there was something wrong, a little swollen and loose. She said Resident #1 was always compliant with care and not aggressive. She said she was not aware of any falls. She said Resident #1 would not be able to lift herself up from the floor after a fall. During an interview on 04/01/24 at 11:55 a.m., CNA H said she assisted CNA G to complete peri-care on Resident #1. She said Resident #1 complained of pain when being turned onto her hips during care. She said the nurse was informed of the pain. She said Resident #1 was usually complaint with care and not aggressive. She said she was not aware of any falls for Resident #1. She said Resident #1 required transfer assist of one staff. She said staff was required to use a gait belt with all transfers. During an interview on 04/03/24 at 1:24 p.m., PTA J said she started re-training staff on transfers and gait belts on 03/11/24. She said she trained CNA A on 04/02/24. She said she still had some staff to retrain. PTA J said staff were supposed to use gait belts for all pivot transfers. Record review of CNA A's competency check off for Assisting Residents to Transfer to Chair or Wheelchair, dated 11/07/23 and completed by PTA A, reflected .show the resident the gait belt and explain its use as a safety device. Apply the gait belt over the resident's clothing around the waist and check the fit by inserting your fingers under it, stand in front of the resident with your knees bent, feet apart, and back straight. Grasp the gait belt with an under-hand grip and move the resident forward so his or her feet are flat on the floor. Lean forward and instruct the resident to place his or her hands on your shoulders. Do not let the resident put his or her arms around your neck. Place your hands on either side of the gait belt, and on prearranged signal, gradually assist the resident up into a standing position, supporting the knees and feet with your legs and feet as appropriate. This was determined to be an Immediate Jeopardy (IJ) on 04/03/24 at 12:23 p.m. The Administrator was provided with the IJ template on 04/03/24 at 12:23 p.m. The following Plan of Removal submitted by the facility was accepted on 04/04/24 at 9:35 a.m.: As of 4/3/24, CNA A was in-serviced 1:1 by the DON on the following: All other nursing staff were in-serviced on the same topics by the DON/ADON/Director of Rehab. Completion date will 4/4/24. -Following the [NAME] in Point Click Care for all transfer status and assistance required with return demonstration from staff. -Gait belt transfers with return demonstration. -Abuse and Neglect (Improper transfers) -Fall Prevention Policy will be completed 1:1 with CNA A as of 4/4/24 by the Regional Compliance Nurse. This in-service will include reporting to the charge nurse immediately if a resident suffers a fall, has an accident, or is found on the floor. If the charge nurse is not available, staff will report to the DON immediately. Staff will not assist a resident off the floor until a charge nurse has been notified and assessed the resident. -As of 4/3/24 all residents in the facility received head to toe assessment by the DON/ADON/Tx Nurse for any injuries and/or fractures. No additional issues were found. -On 4/3/24, all residents in the facility were assessed and evaluated for transfer assistance by the DON/ADON and Director of Rehab. -On 4/3/24, all resident care plans were reviewed for accuracy of transfer status and assistance by DON and ADON. No issues were identified. -On 4/3/24 the Facility initiated our second round of gait belt training and check offs with return demonstration. All nursing staff will be checked off again prior to the start of their next shift. Training and checks will be completed by DON/ADON/and Director of Rehab. -The medical director was notified of the immediate jeopardy by the administrator on 4/3/24. -Ad hoc QAPI was held with the Medical Director and facility interdisciplinary team on 4/3/24 to discuss the immediate jeopardy and subsequent plan of removal. In-services: The Administrator, DON, and ADON were in-serviced 1:1 on the following topics below on 4/3/24 by the ADO/Regional Compliance Nurse. The DON and ADON then in-serviced all nursing staff on the following topics below as of 4/3/24. All staff not present will not be allowed to assume their duties until in-serviced. All new hires will be in-service on their date of hire, during facility orientation. All agency staff will be in-serviced prior to start of their assignment. -Abuse and neglect policy to include (Improper transfers) -Gait belt transfers with return demonstration. -How to use the [NAME] in PCC to determine the transfer status of a resident with return demonstration. -Fall Prevention Policy will all nursing staff as of 4/4/24 by the Regional Compliance Nurse/ADON. This in-service will include reporting to the charge nurse immediately if a resident suffers a fall, has an accident, or is found on the floor. If the charge nurse is not available, staff will report to the DON immediately. Staff will not assist a resident off the floor until a charge nurse has been notified and assessed the resident. Monitoring of the plan of removal included the following: Observations, interviews and record reviews were conducted on 04/04/23 from 1:00 p.m. through 2:55 p.m. and included 5 alert residents, nurses which included 1 RN (RN R weekend supervisor), 7 LVNs (LVN D 6:00 a.m. - 2:00 p.m., LVN M and LVN O 2:00 p.m. - 10:00 p.m. and prn all shifts, LVN L and LVN N 6:00 a.m.- 2:00 p.m. and prn shifts, LVN O 10:00 p.m.-6:00 a.m. and prn shifts LVN S 2:00 p.m. -10:00 p.m., and 6 CNAs (CNA G, H, I, P, Q, S - who work all shifts), the ADON and the Administrator. Observations on 04/04/24 of gait belt transfers completed by CNA P and CNA Q. They were able to transfer Resident #7 and #10 per the facility check off list. Staff were able to demonstrate the use of a gait belt and transfer for 2 residents. Staff provided appropriate resident supervision and redirection. There were no observed concerns. During interviews staff were able to identify the Abuse Coordinator as the administrator. Staff indicated they were to report allegations of abuse and neglect immediately to the charge nurse or administrator and were able to give example of physical, verbal, sexual abuse and immediate intervention procedures. They were to report all falls and residents found on the floor to the charge nurse. During interviews staff were able to identify residents' the care plans, the [NAME] system and how to find level of resident care, fall risks and prevention strategies, and who the abuse coordinator was. During an interview on 04/04/24 at 2:38 p.m., the Administrator said the audit of all residents' care plans and [NAME] revealed no issues or concerns. She said all staff were trained upon hire and provided a gait belt for use with transfers. Interviews with five residents on 04/04/24 from 1:00 p.m. through 2:55 p.m. (Resident #s 5,6,7, 8, and 10) indicated they were not afraid during care or had complaints of their care. Interviews with staff revealed staff were able to discuss the required level of staff assistance for ADLs per resident. Staff were able to demonstrate the use of the [NAME] system for resident care needs. Record review of the [NAME] for 9 residents (Resident #s 2,3,4,5,6,7,8,9, and 10) to ensure they matched with the resident's level of assistance required. The resident care plans matched the [NAME]. Record review of a facility audit for all residents indicated no issues or concerns and all care plans matched levels of care in the [NAME]. Record review of facility in-service indicated facility staff were in-serviced on abuse and neglect by the DON and ADON. The training was completed on 03/29/24 and 04/03/24. Record review of facility in-service indicated facility staff were in-serviced 04/03/24 and 04/04/24 on Preventative Strategies to Reduce Fall Risk and reporting to charge nurse immediately if a resident is found on the floor. The training was completed by the ADON and RN K. Record review of facility in-service indicated the Administrator, the DON, and the ADON were retrained on abuse and neglect and improper transfers, gait belt transfers, and the [NAME] (how to use with return demonstration), on 04/03/24 by PTA J. Record review of facility in-service indicated all nursing staff (LVNs and CNAs) were retrained by PTA J on 04/03/24 related to transfers/Hoyer lifts, and gait belts with return demonstration. Record review of facility in-service indicated CNA A was retrained on how to use the Abuse and Neglect (Improper Transfers), [NAME] and transfers with gait belt with return demonstration on 4/3/24 by the DON. Record review of facility in-service indicated CNA A was retrained by PTA J and completed transfer proficiency check off on 04/03/24. Record review of facility in-service indicated CNA A was re-trained on fall prevention strategies on 04/04/24 by RN K. Record review of facility in-service indicated staff who were unavailable and not in-serviced were on a list to receive training prior to their next scheduled shift. The Administrator was informed the Immediate Jeopardy was removed on 04/04/24 at 2:59 p.m. The facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.