Health inspection·August 22, 2025

F 0656 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for4 (Res#1, Res#2, Res#3 and Res#4) of 5 residents reviewed for updated care plans. The facility failed to provide Resident#1,2,3,4 with updated care plans to reflected concerns for health and safety when leaving the facility unsupervised. An IJ was identified on 08/21/25. The IJ template was provided to the facility on [DATE] at 5:53 pm While the IJ was removed on 08/22/25, the facility remained out of compliance at a scope of potential for more than minimal harm that is not Immediate Jeopardy and a severity level of pattern because all staff had not been trained on 08/22/25. This failure can affect residents health, safety and possible death.Findings included:Record review of Resident#1's face sheet dated 08/20/25 reflected, he was a [AGE] year old male who was originally admitted on [DATE] and readmitted on [DATE] and diagnosed with Paraplegia (symptom of paralysis that mainly affects your legs (though it can sometimes affect your lower body and some of your arm abilities, too), Anemia ( a problem of not having enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissues), Hyperlipidemia (have high lipid levels), Depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), Anxiety disorder (frequently have intense, excessive and persistent worry and fear about everyday situations), Cerebral infarction ( an ischemic stroke, it is the most common form of stroke) personal history of traumatic brain injury (a brain injury that is caused by an outside force), chronic pain( lasts months or years and can affect any part of your body), essential hypertension (abnormally high blood pressure), pressure ulcer (forms on an area of the skin with prolonged pressure due to immobility) of right buttock, stage 4 (Full-thickness tissue loss with exposed bone, tendon, ligament, fascia, cartilage, or muscle)-onset 07/23/25, and Sepsis (potentially life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs) -unspecified organism-08/08/25 onset. Record review of Resident#1's MDS, dated [DATE] reflected his BIMS score was 14 which indicated cognitive intact. Record review of Resident#1 care plan, dated 07/14/25 reflected, no documentation of resident health and safety being addressed when leaving the facility unsupervised. Record review of Resident#2's face sheet, dated 08/22/25 reflected, he was a [AGE] year-old male who or was originally admitted on [DATE] and readmitted on [DATE] and diagnosed with Epilepsy (neurological disorder characterized by recurrent, unprovoked seizures), depression, mid cognitive impairment of uncertain unknown etiology (cognitive issues like memory and thinking problems are present but the specific underlying cause hasn't been identified), depression, unspecified convulsions, hyperlipidemia (a condition characterized by high levels of lipids (fats) in the blood, including cholesterol and triglycerides), hypothyroidism (happens when your thyroid gland Page 1 of 8 455881 455881 08/22/2025 Dfw Nursing & Rehab 900 W Leuda St Fort Worth, TX 76104

F 0656 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some doesn't make enough thyroid hormones to meet your body's needs), and tracheostomy (a surgical procedure that creates an opening in the trachea (windpipe) to provide an airway and facilitate breathing.) Record review of Resident#2's MDS, dated [DATE] reflected his BIMS score was 14 which indicated cognitive intact. Record review of Resident#2 care plan, dated 08/18/25 reflected, no documentation of resident health and safety being addressed when leaving the facility unsupervised. Record review of Resident#3 s face sheet, 08/21/25 reflected, she was a [AGE] year-old female who was originally admitted on [DATE] and diagnosed with unspecified Dementia (a condition where cognitive decline is present, but the specific underlying cause cannot be identified), bipolar disorder, anxiety disorder and cerebral infraction (occurs when blood flow to the brain is interrupted, leading to cell death and brain damage), unspecified. Record review of Resident#3's MDS, date reflected her BIMS score was 13 which indicated cognitive intact. Record review of Resident#3 care plan, dated 07/14/25 reflected, no documentation of resident health and safety being addressed when leaving the facility unsupervised. Record review of Resident#4 face sheet, dated 08/22/25 reflected, he was a [AGE] year-old male who was originally admitted [DATE] and readmitted [DATE] and diagnosed with major depressive disorder, diffuse traumatic brain injury (a type of brain injury that occurs when the brain experiences rapid acceleration or deceleration forces, causing widespread damage to the white matter tracts) with loss of consciousness of unspecified, conversion disorders with seizures or convulsions (involves real physical symptoms that resemble epileptic seizures but result from psychological factors),Epileptic seizures related to external causes not intractable (seizures triggered by an external factor that are not the chronic, difficult-to-manage form of epilepsy). Record review of Resident#4's MDS, date reflected his BIMS score was 14 which indicated cognitive intact. Record review of Resident#4 care plan, dated 08/01/25 reflected, no documentation of resident health and safety being addressed when leaving the facility unsupervised. In an interview on 08/20/25 at 10:45 am Resident#1 stated he did not want to talk about why he left the facility, where he went, who he was with and about his hospital stay. Resident#1 stated he was ok and did not have any concerns. Resident#1 stated that he signs himself in and out when he left the facility. In an interview on 08/20/25 at 10:52 am Resident# 4 stated he signed himself in and out. Resident#4 stated that he comes back to the facility every day. Resident#4 stated he did not have any concerns. In an interview on 08/21/24 at 12:48 pm resident#3 stated he signed himself in and out. Resident#3 stated he came back the same day that he left. Resident#3 stated he did not have any concerns. In an interview on 08/22/25 at 11:30 am the DON stated she was responsible for updating the care plans. The DON stated she was not sure why those residents care plans were not updated to reflect that they did not follow the facility policy on signing in and out. Those residents care plans do not mention they can leave unsupervised. The DON stated she has been working the floor a lot. The DON stated not updating the care plan could leave residents needs not being met. Record review od facility policy dated, revised 12/2016, titled Care plans, comprehensive person centered reflected in part: C. Describe services that would otherwise be provided for the above, but are not provided due to residents exercising his or her right, including the right to refuse treatment.G, incorporate identified problem areas.13. Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents condition changes. On 08/21/25 at 5:53 PM the IJ was called. The template was provided to the Admin and DON, POR was approved on 08/22/25. 1. Identification of Residents Affected or Likely to be Affected:The facility took the following actions to address the citation and prevent any additional residents from suffering [Resident#1] care plan was updated by don/designee on 8/21/2025 2. Actions to Prevent 455881 Page 2 of 8 455881 08/22/2025 Dfw Nursing & Rehab 900 W Leuda St Fort Worth, TX 76104

F 0656 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Occurrence/Recurrence:The facility took the following actions to prevent an adverse outcome from out. The IDT team will be in-serviced on revising the care plans for each resident that signs out by the corporate nurse/DON by 8/22/2025. The administrator/director of nursing were in-serviced by corporate team on 8/21/2025 at 6:54 on updating care plans A Quality Assurance Performance Improvement (QAPI) Performance Improvement Project (PIP) was implemented to review and interpret all audit findings. All findings will be discussed at the monthly QAA meeting for a minimum of three months or until the pattern of compliance is maintained. QAPI will be completed by corporate nurse by 8/21/25. New staff will be educated and trained on resident signing in and out, with timely returning Agency staff will be educated and trained on residents signing in and out, with timely returning prior to starting shift. Care plan, drugs, and signing out policies always made available for review.Record review of Resident#1 revised 08/22/25, care plan initiated on 08/21/25 reflected Potential for disrupting continuity of care due to the resident will sign himself out of the facility and sits outside with a group of other residents and socializes . Goal reflected, The resident will understand the risk associated with signing out of the facility.The resident was educated to provide an expected time of return upon signing out of the facility. If the resident does not return within 2 hours of the expected timeframe, Attempt to contact the resident, the family members, the police, the MD, the DON and Administrator. The resident was educated on the risk of being outside during extreme heat and heat related illnesses and the potential for harm. The resident was educated on the risk of using illegal substances while out on pass The resident will be encouraged to sign out each time they leave the facility and to give the expected time of return. Record review of Resident#2 revised care plan initiated on 08/21/25 reflected, Potential for disrupting continuity of care due to the resident will sign himself out of the facility and sits outside with a group of other residents and socializes . Goal reflected, Referral to psyche services as needed. The resident will understand the risk associated with signing out of the facility.The resident was educated to provide an expected time of return upon signing out of the facility. If the resident does not return within 2 hours of the expected timeframe, attempt to contact the resident, the family members, the police, the MD, the DON and Administrator. The resident was educated on the risk of being outside during extreme heat and heat related illnesses and the potential for harm. The resident was educated on the risk of using illegal substances while out on pass The resident will be encouraged to sign out each time they leave the facility and to give the expected time of return. Record review of Resident#3 revised care plan initiated on 08/21/25 reflected, Potential for disrupting continuity of care due to the resident will sign herself out of the facility and sits outside with a group of other s . Goal reflected, The resident will understand the risk associated with signing out of the facility.The resident was educated to provide an expected time of return upon signing out of the facility. If the resident does not return within 2 hours of the expected timeframe, attempt to contact the resident, the family members, the police, the MD, the DON and Administrator. The resident was educated on the risk of being outside during extreme heat and heat related illnesses and the potential for harm. The resident was educated on the risk of using illegal substances while out on pass The resident will be encouraged to sign out each time they leave the facility and to give the expected time of return. In an interview on 08/22/25 at 2:53 pm with the corporate consulting nurse at 11:00 am she was able to verbalize everything that the facility had implemented. In an interview on 08/23/25 between 1:00 pm to 3:30 pm, the ADON, DON, RN J, LVN G, LVN H, LVN I stated the care plans needed to be updated as needed and acute changes . The DON stated after QAPI meetings and morning minutes Residents care plans needed to be updated 455881 Page 3 of 8 455881 08/22/2025 Dfw Nursing & Rehab 900 W Leuda St Fort Worth, TX 76104

F 0656 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some so that concerns or issues that need to have interventions could be addressed. RN J stated the care plans needed to reflect the Residents current conditions and concerns. RN J stated measurable interventions and goals need to be put in place to address corns for residents' health and safety. All residents care plans were audit who signed themselves out. The DON was responsible for updating care plans daily after IDT meetings if needed and monthly after QAA meetings and as needed. In an interview on 08/22/25 at 3:30 pm the DON and Admin verbalized everything the facility had implemented. An IJ was identified on 08/21/25. The IJ template was provided to the facility on [DATE] at 5:53 pm While the IJ was removed on 08/22/25, the facility remained out of compliance at a scope of potential for more than minimal harm that is not Immediate Jeopardy and a severity level of pattern because all staff had not been trained on 08/22/25. 455881 Page 4 of 8 455881 08/22/2025 Dfw Nursing & Rehab 900 W Leuda St Fort Worth, TX 76104

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observations and record review, the facility failed to ensure 1 (Resident#1) out of 4 received adequate supervision when reviewed for accidents. The facility failed to provide Resident#1 with adequate supervision on 08/01/25 when Resident#1 left the unsupervised for 3 day's The facility was not made aware until 08/04/25 that Resident#1 had been admitted the hospital. An IJ was identified on 08/21/15. The IJ template was provided to the facility on [DATE] at 4:45 pm. While the IJ was removed on 08/22/25, the facility remained out of compliance at a scope of potential for more than minimal harm that is not Immediate Jeopardy and a severity level of isolated because all staff had not been trained on 08/22/25. Thia failure could affect all resident's health, safety and possible death. Findings included:Record review of Resident#1's face sheet, dated 08/30/25 reflected, he was a [AGE] year old male who was originally admitted on [DATE] and readmitted on [DATE] and diagnosed with Paraplegia (symptom of paralysis that mainly affects your legs (though it can sometimes affect your lower body and some of your arm abilities, too), Anemia ( a problem of not having enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissues), Hyperlipidemia (have high lipid levels), Depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), Anxiety disorder (frequently have intense, excessive and persistent worry and fear about everyday situations), Cerebral infarction ( an ischemic stroke, it is the most common form of stroke) personal history of traumatic brain injury (a brain injury that is caused by an outside force), chronic pain( lasts months or years and can affect any part of your body), essential hypertension (abnormally high blood pressure), pressure ulcer (forms on an area of the skin with prolonged pressure due to immobility) of right buttock, stage 4 (Full-thickness tissue loss with exposed bone, tendon, ligament, fascia, cartilage, or muscle)-onset 07/23/25, and Sepsis (potentially life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs) -unspecified organism-08/08/25 onset. Record review of Resident#1's MDS, dated [DATE] reflected his BIMS score was 14 which indicated cognitive intact. Record review reflected no behaviors noted on the MDS. Record review of Resident#1 care plan, dated 07/14/25 reflected, no documentation of resident leaving the facility unsupervised. Record review of Resident#1's progress notes dated, 07/25/25 to 08/20/25 reflected in part:On 08/01/25 Nurse noted reflected. Resident signed out on pass at 2145. Still out of the facility. Completed by LVN A. On 08/02/25 Nurse notes reflected, Resident still out on pass. Completed by LVN G On 08/03/25 Nurse note reflected, out on pass. Completed by LVN I On 08/04/25 Administration notes reflected, Resident on leave. Completed by LVN G On 08/07/25 communication with physician noted reflected, Spoke with nurse he is doing fine. Vitals are fine he is still on IV antibiotics for an infection once he has completed his antibiotics, he should be ready to discharge. Completed by nursing. Record review on 08/20/25 of sign out/in sheet from sign out/in booklet from the receptionist desk reflected, Resident#1 did not sign out on 08/01/25.Record review of hospital records dated 08/21/25 reflected Resident#1 arrived at the hospital on [DATE] at 12:35 pm. Resident#1 chief complaint reflected Resident#1 checked himself out, been sitting out in the rain and heat for 3 days. Record review of hospital record did not detail how Resident#1 arrived at the hospital.Diagnosed reflected:*Sepsis (serious condition in which the body responds improperly to an infection) due to Pseudomonas aeruginosa (severe infections, particularly in immunocompromised individuals) and Beta hemolytic streptococci group C infected decubitus ulcer (Bedsores are injuries to the skin and the tissue below the skin that are due to pressure on the skin for a long time)* Fever 101.2 (fever is defined as a temperature above 100.4 F )*Tachycardia (heart rate over 100 beats a 455881 Page 5 of 8 455881 08/22/2025 Dfw Nursing & Rehab 900 W Leuda St Fort Worth, TX 76104

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few minute)*Leukocytosis (high white blood cell count, can indicate a range of conditions, including infections, inflammation, injury and immune system disorders.)*Foul drainage from woundPolysubstance use disorder reflected, a history of methamphetamine ( a potent central nervous system (CNS) stimulant that is mainly used as a recreational), cannabis (which can also be called marijuana, weed, pot, or bud, refers to the dried flowers, leaves, stems, and seeds of the cannabis plant) and opiate (are natural or synthetic chemicals that bind to receptors in your brain or body to reduce the intensity of pain signals reaching the brain) abuse.*Repeated drug toxic screened positive for amphetamines, benzodiazepines (benzos, are a class of central nervous system (CNS) depressant drugs), cannabinoids and cocaine (Central nervous system stimulant and tropane alkaloid derived primarily from the leaves of two coca species.Requested EMS report online from city on 08/22/25 and have not received at this time. Record review of progress notes dated 08/01/25 to 08/04/25 reflected no documentation of emergency contact was called before 08/04/25. No documentation of active search for Resident#1 before 08/04/25. Record review of Resident#1 sign out and in sheet reflected, sign out and sign in sheet not completed. Review reflected dates, times, signatures and destination information missing. In an interview on 08/20/25 at 10:00 am the Admin and the DON stated the incident with Resident#1 would not be considered an elopement because Resident#1 signed out before he left the facility. The Admin stated the Representative adds a new sheet to the sign out sheet when the page was full and he kept the completed sign in/out sheets in his office in a separate binder. Admin stated Resident#1 signed out on his own and would sign himself back in. In an interview on 08/20/25 at 10:45 am Resident#1 stated he did not want to talk about why he left the facility, where he went, who he was with and about his hospital stay. Resident#1 stated he was ok and did not have any concerns. Resident#1 stated that he signs himself in and out when he left the facility. In an interview on 08/20/25 at 11:00 am the Front desk Representative stated she was told to encourage the residents to sign in/ sign out but do not complete the sign out sheet for them. Front desk Representative stated Resident#1 was one of the residents did not sign out every time he left and would get upset when staff asked him to sign out. In an interview on 08/20/25 at 11:45 am the admission Director stated Resident#1 called her on 08/02 cussing her out and saying he saw her having sex with another man and that she stole his money. The admission Director stated she knew he had to be on an unknown substance because he was not acting that way the day before. The admission Director stated Resident#1 was found down [name of street] Street and transported to the hospital. In an interview on 08/21/25 at 4:30 am over the phone with LVN A who stated Resident#1 was already gone when he arrived at the facility at 10pm. LVN A stated he was told that Resident#1 had signed out and went to [NAME] and the box. LVN A did not recall who told him about Resident# 1 leaving. In an interview on 08/21/25 at 12:30 pm with the Marketer stated he started calling around to the local hospitals for Resident#1 after he was gone for 24 hours. The marketer stated he was not able to find Resident#1. The Marketer stated a discharge planner informed him that Resident#1 was in the hospital. The Marketer stated the discharge planner stated Resident #1 was denied admission to other facilities. The Marketer stated the facility did not want to get in trouble for dumping Resident#1 and he returned to the facility on [DATE]. In an interview on 08/21/25 at 1:50 pm LVN G stated she was Resident#1 day nurse, and the resident leaves the facility throughout the day. Resident#1 knows that he needs to sign in and out in the front before he leaves. In an interview on 08/21/25 at 2:20 pm LVN H stated she was Resident#1's night nurse and he left the facility often out on pass and returns the same day. LVN H stated he goes out by the tree with the other residents for 30 minutes or so and returned. In an interview on 08/22/25 at 8:00am with Resident#1 emergency contact stated she was notified on Monday 08/04/25 that Resident#1 had signed himself out 455881 Page 6 of 8 455881 08/22/2025 Dfw Nursing & Rehab 900 W Leuda St Fort Worth, TX 76104

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few and was in the hospital. Resident#1 emergency contact stated he was not able to stay with her and the facility had asked her about Resident#1 being discharged to her home and she said no. Resident#1 emergency contact stated she could not remember who called her. On 08/21/25 at 4:45PM the IJ was called. The template was provided to the Admin and DON, POR was approved on 08/22/25. Identification of Residents Affected or Likely to be Affected:The facility took the following actions to address the citation and ____8/22/2025__________) The Administrator and DON were in-serviced at 6:45pm on 8/22/25 by the Corporate Consulting Nurse on residents signing out and what to do if they do not return within the expected timeframe. The Administrator/DON provided education to staff on resident's signing out of facility on 8/21/2025. Resident # 1 returned to facility on 8/8/2025. Nurse assessed head to toe. Medical director and family notified of resident return on 8/8/25 Census checks to be completed on 8/21/2025 by DON/designee The Care Plan Coordinator/designee ensured all residents who sign out of facility have their care plan updated to reflect the education provided on returning to the facility, the dangers of using illegal substances, and providing an estimated return time. The DON/designee checked for any residents that have signed out at the current time to determine if any have been out on pass for over 24 hours, no other residents were identified as being out of the facility without the staff aware. 1. The facility took the following will conduct census checks twice a shift for two weeks and then they system will be re-evaluated. A resident council meeting was held on 8/22/25 to discuss drug usage, signing in and out of facility. Each resident was notified they will be provided to give an anticipated return time. The residents will be notified that if they do not return within the anticipated return timeframe the police will be notified, and the facility will start an investigation of their whereabouts. The DON or designee educated all staff that any resident that does not return within 2 hours of time frame we will notify MD and family and start to look for residents, The Corporate Nurse/Consultant Nurse In-serviced the administrator/don on the updated policy for residents signing out on 8/21/2025. All new staff and agency staff will be in-serviced upon hire or before working the shift. All findings from the PIP will be presented at the monthly QAA meeting. Monitoring/auditing and reporting will continue for a minimum of three months. Record review of the facility's policy titled Wandering and Elopements revised 03/2019 reflected: 3. If a resident is missing, initiate the elopement/missing resident emergency procedure:b. If the resident was not authorized to leave, initiate a search of the building(s) and premises.c. If the resident is not located, notify the Administrator and the Director of Nursing, the resident's legal representative, the attending physician, law enforcement officials.4. When the resident returns to the facility, the Director of Nursing services or charge Nurse shall:A. Examine the resident for injuries.E. Complete and file an incident reportF. Document relevant information in the resident's medical records. Record review of the facility policy titled signing Residents out revised 08/2006 reflected: Policy statement: All residents leaving the premises must be signed out.1. Each resident leaving the premises (excluding transfers/discharges) must be signed out 9. Resident must be signed in upon return to the facility. Record review of sign in and sign out sheet provided by the admin after the IJ was identified reflected, different handwriting, printed signature, missing dates, times and no destination information. Review of the sign out and in sheet reflected, Resident#1 signed out at 9:45pm on 08/01/25 and showed Resident#1 signed back in on 08/08/25 at 3:55 pm. Review of dates from 07/24 to 08/01/25 reflected Resident#1 did not stay gone more then then 3 hours at a time on the slots that were filled out. Review of sign out sheet reflected cted the sheet was not completely full. In an interview on 08/22/25 at 2:53 455881 Page 7 of 8 455881 08/22/2025 Dfw Nursing & Rehab 900 W Leuda St Fort Worth, TX 76104

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few pm with the corporate consulting nurse at 11:00 am she was able to verbalize everything that the facility had implemented. In an interview on 08/22/25 between 1:00 pm to 3:30 pm, the ADON, DON, Admin, LVN B, CNA C, CNA D, CNA E, CNA F, LVN G, LVN H, LVN I, RN J, Front desk representative, over the phone interviews RN A, stated they had been in-serviced on when a resident refused to sign out let the charge nurse know, and residents need to document the approximate time they plan on being back. If a resident stays out longer than 2 hours of the approximate time they will be back the facility will start calling around for the resident and then report to the police. If a resident returns to the facility and they appear to be under a substance the police will be called. The facility will complete census check twice a shift to ensure residents are accounted for. In an interview on 08/22/25 at 3:30 pm the DON and Admin verbalized everything the facility had implemented. Record review of Resident#1 revised, care plan initiated on 08/21/25 reflected, Potential for disrupting continuity of care due to the resident will sign himself out of the facility and sits outside with a group of other residents and socializes . Goal reflected, The resident will understand the risk associated with signing out of the facility.The resident was educated to provide an expected time of return upon signing out of the facility. If the resident does not return within 2 hours of the expected timeframe,Attempt to contact the resident, the family members, the police, the MD, the DON and Administrator. The resident was educated on the risk of being outside during extreme heat and heat related illnesses and the potential for harm. The resident was educated on the risk of using illegal substances while out on pass. The resident will be encouraged to sign out each time they leave the facility and to give the expected time of return. During an observation on 08/22/25 at 3:45pm, residents were gathered for a special resident council meeting. The DON talking to residents about signing in and out of the facility log. The DON stated residents must put an approximate time they will return to the facility and if they did not return in 2 hours, the facility would start a search for them. Record review of revised sign in/out sheet reflected, a return time was added to the sign out section and the destination/phone number information was deleted. An IJ was identified on 08/21/15. The IT template was provided to the facility on [DATE] at 4:45 pm. While the IT was removed on 08/22/25, the facility remained out of compliance at a scope of potential for more than minimal harm that is not Immediate Threat and a severity level of isolated because all staff had not been trained on 08/22/25. 455881 Page 8 of 8