**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, facility record review, hospital record review, and policy review the facility failed to protect residents' right to be free from physical, verbal, psychological, psychosocial and sexual abuse to one (Resident #1) of three residents reviewed, by failing to provide medication and supervision to an unsafe resident. On 1/20/2024 at approximately 3:35 AM Resident #1 was punched repeatedly in the face and sexually assaulted by Resident #2 in Resident #1's room. The facility failed to provide supervision of Resident #2, who was exhibiting poor impulse control, combativeness, erratic behavior, aggressive behavior and was difficult to redirect. Resident #2 required two psychiatric medication changes in the first five days of his stay in the facility and four days later he assaulted Resident #1. Resident #2's admission medication was not correctly transcribed and of the two medication changes made only one was administered, and that one, only once. This failure created a situation that resulted in serious injury to Resident #1 and resulted in the determination of Immediate Jeopardy on 1/17/2024. The findings of Immediate Jeopardy were determined to be removed on 1/29/2024 and the severity and scope was reduced to a D after verification of removal of immediacy of harm. Findings include: An interview was conducted with Staff C, Certified Nursing Assistant (CNA) on 2/5/2024 at 1:58 PM. Staff C, CNA stated, on the evening of 1/20/2024, she was sitting at nurse station, charting. Staff D, CNA was assigned to Resident #1's room. Staff D, CNA was on the split assignment (assigned to rooms on two separate halls). Staff C, CNA stated she passed Resident #1's room [ROOM NUMBER] minutes earlier and Resident #1 was in her bed asleep with the door open. Staff C, CNA stated [Resident #1 name]'s call light went on. [Staff D name, CNA] went to answer the call light. [Staff D name, CNA] yelled for me that the door was jammed and there was a man on top of [Resident #1 name]. I ran to the room. We pushed the door open. [Resident #2 name] was in the chair naked, putting his clothes on. I was yelling for nurses to come. When the nurses arrived, we tried to get him out of the room. [Resident #2 name] started punching me and one of the nurses. [Resident #2 name] left the room followed by a nurse. [Resident #1 name] wanted to go to bathroom, so we assisted. [Resident #1 name]'s eyes were swollen shut, her face was bloody, and she was crying. The nurse assisted [Resident #1 name] from there. Staff C, CNA stated she later spoke to Resident #1. Resident #1 told me He tried to rape me but couldn't get 'it' in, so he stuck his finger up me. Staff C, CNA stated after Resident #1 left her room for a cigarette with the nurse, we changed the linens on her bed and found her tooth. An interview was conducted with Staff A, Licensed Practical Nurse (LPN) on 2/5/2024 at 1:38 PM. Staff A, LPN stated on the evening of 1/20/2024 she was getting ready for her 30-minute break. She was walking toward the break room when she noticed people in Resident #1's room. She noticed Resident #1 had face trauma. Staff B, LPN, Staff C, CNA and Staff D, CNA were in the room and explained what they had witnessed. She called the supervisor. Staff A, LPN stated prior to leaving Resident #1's room to call the supervisor, she listened to what the other staff were asking Resident #1, to ensure she had the event accurate. Resident #2 was no longer in the room when she arrived. Resident #1 was her patient that night. The last time she saw Resident #1 was an hour prior, when the CNAs were providing care. An interview was conducted with Staff D, CNA on 2/5/2024 at 10:34 AM. Staff D, CNA stated Resident #1's call light was on, which was unusual because Resident #1 did not utilize the call light. When she arrived at Resident #1's room door, it was closed. She could hardly open the door. The door was jammed with a wheelchair behind it. She could see Resident #2 on top of Resident #1. She yelled for another CNA (Staff C, CNA); she and Staff C, CNA were able to push the door open. Resident #2 was pulling up his pants and sat down in the wheelchair. Staff D, CNA stated, she last provided care for Resident #1 at 2:35 AM on 1/20/2024 with Staff C, CNA. A follow up interview was conducted with Staff D, CNA on 2/13/2024 at 1:31 PM. Staff D, CNA stated the door to Resident #1's room was blocked by two wheelchairs, both wheelchairs had their wheels locked. This is why she couldn't get the door open by herself. She believes Resident #2 intentionally put the wheelchairs behind the door like that to prevent the door from opening. An interview was conducted with Staff B, Licensed Practical Nurse (LPN) on 2/5/2024 at 10:05 AM. Staff B, LPN stated she was the nurse for Resident #2 on 1/20/2024. She was sitting at the East Unit nurses station charting when Resident #2 rolled by in his wheelchair. Resident #2 was heading toward lower east and Lifestyle 1 Units. Staff B, LPN continued to state, this is the first-time meeting Resident #2. Resident #2 appeared calm and not confused. Staff B, LPN continued to state, about 20 minutes later she heard a CNA screaming down the hallway [Resident #2 name] is on top of [Resident #1 name]. When Staff B, LPN arrived Resident #2 was standing next to Resident #1's bed pulling his pants, up from the knees. Staff B, LPN stated we were trying to get Resident #2 out of the room. Resident #2 was hitting me and the CNA. We got him out. Staff B, LPN stated [Resident #1 name]'s incontinent brief was ripped open on the side and her whole belly was exposed. The resident was crying, which was unusual, she never cries. The CNA and I got Resident #2 out of the room. Resident #1 Review of Resident #1's progress notes showed an eINTERACT SBAR Summary for Providers dated 1/20/2024 at 4:00 AM, authored by: Director of Nursing (DON). The document revealed the change of condition being reported was Trauma, including vital signs from 1/7/2024 The section titled Outcomes of Physical Assessment revealed: Mental Status Evaluation: No changes observed Functional status evaluation: No changes observed Behavioral Status Evaluation: Not clinically applicable to the change in condition being reported Respiratory Status Evaluation: Not clinically applicable to the change in condition being reported Cardiovascular Status Evaluation: Not clinically applicable to the change in condition being reported Abdominal/GI Status Evaluation: Not clinically applicable to the change in condition being reported Skin Status Evaluation: Contusion Pain Status Evaluation: Does the resident/patient have pain? No Neurological Status Evaluation: Not clinically applicable to the change in condition being reported Nursing observations, evaluation, and recommendations are: resident was allegedly assaulted by another resident police risk manager and LNHA (Licensed Nursing Home Administrator) notified Primary care provider feedback: primary care provider responded with the following feedback: A. Recommendations: Send to ER . Review of Resident #1's facility progress note dated 1/20/2024 at 10:30 AM authored by the DON, revealed writer spoke with charge nurse at ER, resident is being admitted dx (diagnosis) alleged assault. CT (Computerized Tomography) scan done and all negative lab work done and wnl (within normal limits). Review of Resident #1's facility progress note dated 1/20/2024 at 10:34 AM authored by the DON, revealed Medical Director notified of alleged assault and resident being admitted to hospital, will have psych available to see resident upon return to the facility. Primary care physician is also aware of alleged incident and resident status. Review of Resident #1's facility NSG [Nursing] - Pain Evaluation - V2 dated 1/20/2024 at 4:00 AM authored by the DON revealed: The resident had pain in the past 5 days to the right eye and the resident is unable to describe. The remainder of the form is blank. Review of Resident #1's facility NSG - Weekly Skin Evaluation - V2 dated 1/20/2022 at 4:00 AM authored by the DON revealed: bruise to the right eye, and the resident refused further skin assessment noted discoloration and swelling to right eye per resident allegedly struck by another resident police risk and lnha notified Review of Resident #1's Patient Encounter Note from the resident's primary care provider dated 1/23/2024 revealed Resident #1 is being seen status post discharge from the hospital on 1/22/2024, after being admitted for observation on 1/20/2024 and admitted on [DATE] status post assault and possible sexual assault. Resident #1 was noted to have bilateral facial bruising and a missing front right tooth in the Emergency Department (ED). Computerized Tomography (CT) of the face shows right periorbital (tissue surround the opening in the skull for the eye) and prezygomatic (tissue surrounding the eye, temple, lower lid and cheek) soft tissue swelling, with partial desiccation (removal) of the right mastoid air cells (air cells protect the delicate structures of the ear and protect the temporal bone during trauma), and minimal mucoperiosteal thickening of the right maxillary sinus (inflammatory reaction of the mucous lining of the maxillary sinus. This condition may result from harmful actions caused by trauma). Patient seen in her room alert to self in no acute distress. Patient reports pain in her face. Pain is 7 out of 10. Patient is being followed by psychiatry, with medications changes as needed. Review of the Resident #1's hospital History and Physical record face dated 1/20/2024 at 6:20 AM revealed History of Present Illness [HPI]: Chief complaint: Traumatic injury HPI: [Resident #1] . brought to the hospital for facial injury . she had several bruises on the face. She also claims that she was sexually assaulted . a computerized tomography (CT) of the face showed, [Resident #1 name]'s impression of the CT: Right preorbital and prezygomatic soft tissue swelling. No acute fracture. Partial desiccation of the right mastoid air cells. Minimal mucoperiosteal thickening in the right maxillary sinus. Review of Resident #1's Psychiatric Advanced Practice Registered Nurse (APRN) note date 1/22/2024 showed, Resident #1 returned from the hospital last night. Staff reports that [Resident #1 name] was involved in a resident-to-resident altercation where [Resident #1 name] was physically and sexually assaulted. [Resident #1 name] is alert and oriented to person and time. [Resident #1 name] is tearful on interview describing the assault . [Resident #1 name] reports he beat me up . My face is ruined. It hurts me badly. [Resident #1 name] reports significant emotional distress. Patient is currently unstable but requires no medication changes: I feel the symptoms are occurring due to acute stress disorder. [Resident #1 name] has a complex mental health history. Today we completed a Post Traumatic Stress Disorder (PTSD) checklist (PCL), score of 20 represents a clinically significant change. After reviewing prior documentation, it appears to be directly linked to this stressor/event. Despite most answers not at all, it is very evident based on the behaviors this event has caused significant emotional and physical distress. [Resident #1 name] is hypervigilant on interview, requesting coffee to calm her down, tearful and withdrawn. [Resident #1 name]'s speech is disorganized and includes frequent derailment. Despite [Resident # 1 name]'s mental status examination, the initial shock may have contributed to an acute on chronic psychotic event. [Resident #1 name] has treatment refractory psychosis and a trial of Clozapine may be warranted. I discussed medication to help ease the anxiety, but patient opposed additional medication. At this time, I recommend supportive care, coping strategies, and helping resident process the emotions given the little insight the resident has. [Resident #1 name] should continue self-care and getting adequate sleep. Review of Resident #1's Psychiatric Advanced Practice Registered Nurse (APRN) note date 1/19/2024 showed, . Patient report no signs of anxiety. Patient has no behavioral outburst. Patient is sleeping well with fair appetite. Patient has no signs of agitation. No other psychiatric symptoms observed. Patient is at baseline. No gradual dose reduction of medication is suggested. As per collected information and interview, it appears that the patient is doing well overall. The symptoms are causing no or at times only mild distress. An observation and interview were conducted with Resident #1 on 2/5/2024 at 12: 45 PM. Resident #1 was observed with yellow discoloration to the right side of her face from her eye to her chin. Resident #1 stated, I'm not good, my face hurts, I was attacked by a man . he hit me over and over again on my face. My face still hurts but ice and aspirin help. Resident #1 continued to state I did not know the man, I saw him in the smoke area. Resident #2 Review of Resident #2's Hospital Emergency Department Documents dated 12/23/2024 at 14:56 revealed: HPI: patient presenting with a complaint of agitation presenting from a nursing care facility where he escalated to hitting someone with a cane. Upon arrival he was initially calm he escalated again around 1630. Became instantaneously violent. ETO (Emergency Treatment Order) for medications given at 1630 secondary to aggressive behavior of patient in impending threat to staff and the patient. Review of Resident #2's hospital record titled History and Physical dated 12/24/2024 located in the facility medical record, revealed Resident #2 was admitted to the hospital on [DATE] from a (the previous) nursing home, for an unprovoked physical outburst leading to Resident #2 striking and injuring another resident causing a laceration that required closure. patient is psychotic, claiming that the resident told him she wanted to die, which she denied. An interview was conducted with the Assistant Director of Nursing (ADON) from the previous nursing home on 2/12/2024 at 10:15 AM. The ADON remembers Resident #2 and the incident at their facility which required Resident #2 and another resident to be transferred out to the hospital. The female resident was resting her head on the table, not making a noise. Out of nowhere, Resident #2 started hitting her on the head with his cane. The female resident received lacerations to the head that required her to be transferred to the hospital for treatment. Resident #2 was sent to the hospital for a psychiatric evaluation and stabilization. Review of Resident #2's hospital Discharge Instructions dated 1/11/2024 at 11:02 AM a 10-page document, located in the facility's medical record, page 4 revealed Medications the following are listed: . (listing here limited to psychiatric mediations) Depakote 250 mg (milligram) oral delayed release tablet, one tablet two times per day; fluphenazine 25 mg/mL (milliliter) injectable solution, give 75 mg intramuscularly every two weeks; trazodone 50 mg oral tablet, one tablet at bedtime. Review of Resident #2's hospital Medication List - All Active Medications printed 1/8/2024, found in the facility's medical record (listing here limited to psychiatric mediations) reveals: Haldol 10 mg, = 2 tab(s), PO (by mouth), 2 x daily, 1/5/24, 21:00 EST, Routine Divalproex sodium (divalproex sodium 250 mg oral delayed release tablet) 250mg=1 tab (s), PO, 2xdaily, 0 refill(s), 12/26/23 9:32 EST, 1 Trazodone 50 mg, = 1 tab(s), PO, 1 x daily hs (at bedtime) #30 tabs, no refills, 1 Divalproex sodium (Depakote) 500 mg, = 1 tab(s), PO, EC tab, 2 x daily, 1/2/24, 09:00 EST, routine Fluphenazine (Prolixin Decanoate) 75 mg, = 3 mL, IM-intramuscular, injection, every 2 weeks, 12/28/23 Review of Resident #2's hospital Psychiatric Progress Note *Final Report* dated 1/8/2024, located in the facility's medical record with the section titled Assessment/Plan: revealed: Patient is a [AGE] year old man with a history of schizophrenia . was admitted to the hospital after he attacked another resident at his ALF. Given patients psychotic and violent behavior in the community patient is felt to be at high risk of imminent harm towards himself where he to be discharged in his current condition without further evidence of improvement and stability. Patient was started on Prolixin and transition to Prolixin decanoate. However, Prolixin was subsequently discontinued as proxy reported that patient tends to refuse injections if they are occurring too often and would prefer, he be placed on something once a month as he has been more compliant with that in the past. -Patients continue to show stability. He is stabilizing well on current medications . Allow time for medications to gain efficacy, and for discharge planning to occur. -continue Haldol 10 milligrams PO twice daily with plans to titrate to Haldol decanoate -continue Depakote 500 milligrams PO bid for sub therapeutic VPA (Valproic Acid), a medication used to treat certain types of seizures. Steady state VPA 74.8 on 1/7 -Artane 2 milligrams nightly . Review of Resident #2 admission Record showed the resident was admitted on [DATE] with diagnoses that included: Schizophrenia- unspecified, Schizoaffective disorder - bipolar type, Major depressive disorder- recurrent- moderate, Other specified mood disorder , Type 2 Diabetes Mellitus without complications, Muscle Weakness, Unsteadiness on feet, Monoplegia Of upper limb, following cerebral infarction affecting left dominant side, Essential hypertension, Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris, Hyperlipidemia, Gastro-Esophageal Reflux Disease (GERD), Fracture of one rib left side- with routine healing. Review of Resident #2's Pre-admission Screen and Record Review (PASRR) Level II completed on 1/9/2024. Service recommendations indicated: Based on clinical of the submitted documentation and information, this individual is considered to have a Serious Mental Illness as defined in 42 CFR Part 483.102(b)(1) and F.A.C. 59G-1.040(2)(m) based on each of the categories of diagnosis, level of impairment and recent treatment. Specifically, this individual does have a major mental disorder with associated significant symptoms. Once psychiatrically cleared, given the information provided for the review, a nursing facility placement is determined to be appropriate due to the patient's medical needs, and the need for medication management. The patient does not appear independently capable of self- monitoring his health status, nutritional status, or self- administration and scheduling medical treatment. Specialized Services are deemed not necessary given the client does not appear to need acute inpatient psychiatric care at this time. It is recommended that the following rehabilitative services, of a lesser intensity than Specialized Services, are added to the patient's Comprehensive Person- Centered Nursing Care Plan: - Psychiatric medication management - Supportive counseling. Supportive services cannot be effectively provided in a less restrictive environment at this time are recommended to be provided at the nursing facility. If he is unable to return home, all efforts should be made to transition him to a less restrictive environment such as an Assisted Living Facility that can meet his mental health needs, if agreed upon by the treating physician. The patient should be encouraged to participate in socialization and enrichment activities appropriate for his level of function. Given his history, care staff should monitor for symptoms of psychosis, and report any problems to the treatment team. Should there be a significant change in his mental status, it is recommended that an additional Level II review should be conducted. Review of the care plan for Resident #2 initiated on 1/17/2024 with a revision date of 2/2/2024 with a focus of : (Resident #2) is/has potential to be physically and verbally aggressive along with alleged assault to other residents. Not easily redirected. Chooses not to take psychiatric medication. Interventions included: Administer medications as ordered. Monitor/document for side effects and effectiveness. Provide physical and verbal cues to alleviate anxiety; give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff member when agitated; mental health services as needed/as ordered; monitor (document observed behavior and attempted interventions in behavior log; monitor/ document/report PRN and sign/symptoms of resident posting danger to self and others; Psychiatric/Psychogeriatric consult as indicated; 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. Revisions to interventions were added 1/20/2024: One on One Intensive Supervision, BA 52 An interview was conducted with Staff R, LPN MDS (Minimum Data Set) Coordinator on 2/13/2024 at 10:23 AM. Staff R, LPN MDS confirmed responsibility for updating care plans, evaluating residents upon admission for the MDS and care plan needs. Staff R, LPN MDS continued to state when reviewing a resident who is a new admission she reviews the hospital paperwork, including nurses' notes, history and physicals, and discharge summaries. With the information gathered from the information she can develop care plans. This is how she developed the care plan for Resident #2 being physically aggressive and that Resident #2 had a history of being non-compliant in taking his medications. Review of Resident #2's Minimum Data Set (MDS) dated [DATE] showed a Brief Interview for Mental Status (BIMS) of 12 out of 15, meaning cognitively moderately impaired. Section E for Behavior indicated in the last 7 days from 1/17/2024 Resident #2 showed signs of hallucinations, delusions, wandering, physical and verbal behaviors directed towards other at least 1 to 3 days of the past 7. Review of the facility's progress notes for Resident #2 dated 1/11/2024 at 2:00 PM showed Resident #2 was admitted from the hospital. Admitting diagnosis schizophrenia patient is alert with some confusion. Able to make needs known. Patient is independent with ambulation and feeding. Continent of B&B (bowel and bladder). Denies any pain/discomfort at this time. No open areas noted. Appetite good, fluid intake adequate. Took medications without difficulty. Patient stated dentures were lost. Wears glasses, hearing adequate no hearing aids. Will continue to monitor. Review of Resident #2's facility Order Summary Report Active orders as of 1/11/2024 revealed the following physician orders: (listing psychiatric medications only) 1.Depakote 250 mg by mouth two times a day, order and start date 1/11/2024 2.Fluphenazine Decanoate Injection Solution 25mg/ml inject 1 dose intramuscularly one time a day every 14 days Order date 1/11/2024, start date 1/12/2024. The mg per dose was not listed. 3.Trazadone HCL Oral tablet 50 mg, give 50 my by mouth at bedtime order and start date 1/11/2024. Review of Resident #2's facility Order Summary Report Active Orders as of 1/20/2024 revealed the following physician orders: . (listing psychiatric mediations only) 1.Depakote 250 mg by mouth two times a day, order and start date 1/11/2024 2.Fluphenazine 25 mg/mL, inject 25 mg intramuscularly one time only order date 1/19/2024, start date 1/22/2024 (after discharge) 3.Fluphenazine Decanoate 25 mg/mL, inject 50 mg intramuscularly every 14 day(s) - order date 1/19/2024, start date 2/5/2024 (after discharge) 4.Haldol 5 mg/mL, inject 5 mg intramuscularly every 6 hours as needed for 14 days - order and start date 1/12/2024 5.Trazodone 50 mg, give 50 mg by mouth at bedtime, order and start date 1/11/2024 Review of progress note dated 1/12/2024 at 2:02 AM showed . Resident #2 was restless this shift. Resident constantly in and out of the room, opening and shutting the door, turning the TV and lights on and off, room mate (sic) yelling at him to stop going in and out and turning the TV and lights on and off because he is waking up the other room mates (sic) in the room. Resident able to make needs known, speech slurred, and observed talking to himself. Attempted to redirect resident but he seems very anxious and on edge. Will continue to monitor resident closely. Review of progress note dated 1/12/2024 at 4:10 AM showed Resident #2 sat at nurse's station willing stating I'm here because I helped kill a lady, because she wanted to kill herself. Resident then elaborated that he didn't feel like there was anything wrong with helping her because he felt like he was doing the right thing since she wanted to die. Writer attempted to redirect resident's attention multiple times. At approximately 3:45 AM, he went back to his room and is now asleep in bed. Resident appears to be A & O x 4 (alert and oriented to person, place, time and event) and is able to make his needs known though his speech is sometimes hard to understand. No S/S (signs and symptoms) of SOB (shortness of breath) or distress noted, Will continue to monitor closely. Review of Psychiatric Advanced Practice Registered Nurse (APRN) note for date of service 1/12/2024 showed Resident #2 endorses hallucinations. Patient reports he doesn't know what the 'voices' are saying 'they talk to each other'. Patient's speech is dysarthria (difficulty speaking because the muscles you use for speech are weak) of patient gets frustrated with interviewer and states 'stop asking me all the questions'. Interview was ended. Patient was visited on smoke patio where he was irritable and difficult to redirect. Patient is restless in and out of his room repeatedly, yelling at staff. Assessment and plan for Resident #2 shows patient is unstable requiring medication changes. I feel the symptoms are occurring due to exacerbation of underlying psychotic disorder. The symptoms are occurring almost daily and causing severe distress. I decided to start Haldol 5 mg (milligrams) intramuscularly (IM) every 6 hours PRN (as needed) for 14 days for schizophrenia. Review of Resident #2's progress note dated 1/16/2024 at 1:18 PM showed Unit manager (UM) was discussing patient care with this nurse. She was facing me while I was sitting at the nurse desk computer. This resident rolled up to the UM back and hit her very hard in the lower back. Staff removed the resident from his attack on the unit manager. He stated he wanted food. This nurse provided him with a PBJ (Peanut Butter and Jelly) sandwich, and he was satisfied with it. Admin arrived, assessed this patient PRN (as needed) IM was provided. Review of Resident #2's facility MAR revealed the order for Haldol 5 mg, IM every 6 hours as needed for mood disorder was administered one (1) time on 1/16/2024 at 12:13 AM. Review of Resident #2's Facility Medication Administration Record (MAR) revealed an order with a start date of 1/12/2024 at 1:45 PM for Haldol 5 mg, IM every 6 hours as needed for mood disorder. The MAR showed Resident #2 was not administered this medication on 1/12/2024, 1/13/2024, 1/14/2024, 1/15/2024, 1/17/2024, 1/18/2024, 1/19/2024 or 1/20/2024. An interview was conducted with Staff K, LPN, Unit Manager (UM) on 2/13/2024 at 1:00 PM. Staff K, LPN stated she was standing at the station (on 1/16/2024) and Resident #2 punched me in the back, it was shocking. The nurse she was speaking with administered an injection, he calmed right down, and no further events occurred that evening. An interview was conducted with Staff M, RN on 2/13/2024 at 10:50 AM. Staff M, RN confirmed she witnessed the event of 1/16/2024 with the UM. Staff M, RN stated I had him in the morning and was charting at nurses' station. The UM was at the nurse station opposite of me standing with her back to the hallway. Suddenly, the UM made a startling noise, Oh. Resident #2 had punched her in the lower back. Resident #2 stated he wanted a sandwich. Staff M, RN stated He would just explode big action and then be fine. Review of Psychiatric Advanced Practice Registered Nurse (APRN) note for date of service 1/16/2024 showed Resident #2 examined. Patient is aggressive when he wants something and does not get it immediately. Patient is difficult to redirect. Patient is combative and his behavior is erratic. Patient is sleeping and eating well. Patient is tolerating current medication. Assessment and Plan: Patient is unstable requiring medication changes: As per collected information due to exacerbation of an underlying schizoaffective disorder. The symptoms are occurring almost daily and causing severe distress. Therefore, I decided to make medication changes to stabilize the symptoms. Continue Haldol for schizophrenia, Trazodone for depression and Divalproex for mood disorder. Increase Fluphenazine to 50 mg/ml every 14 days. Review of the MAR showed the resident was not given this increased dose of medication. Review of Resident #2's progress notes dated 1/17/2024 at 4:00 AM showed Resident #2 purposely keeping other residents awake with TV. This writer asked resident to turn down TV to be respectful to other residents. Resident #2 then proceeded to slam door, slam nightstand and yell throughout the shift. An interview was conducted on 2/05/2024 at 3:15 PM with Staff J, CNA. Staff J, CNA stated Resident #2 had verbally threatened staff. On the evening of 1/17/2024 he had the volume on the TV very loud. Resident #2 became angry and very aggressive in his room, we just stood in the doorway and made sure he didn't attack his roommates. Resident #2 finally calmed down on his own. Every day was horrible with him. We would keep his door open for safe keeping of the other roommates. An interview was conducted with Staff C, CNA on 2/5/2024 at 1:58 PM. On 1/18/2024 Resident #2 was upset and combative on smoke patio, he wanted a cigarette. Resident #2 was chewing cigarette butts from the ground, saying he was going to beat the ladies up. Staff L, Registered Nurse (RN) came out and resident calmed down. Resident went to his room with Staff L, RN. An interview was conducted on 2/13/2024 at 12:52 PM with Staff F, CNA. Staff F, CNA recalled the event on 1/18/2024 on the smoking patio with Resident #2. Staff F, CNA explained, the smoking area closes for about 15-20 minutes to accommodate shift change. Residents are usually lined up waiting for the patio to resume. Resident #2 was there waiting, he already appeared agitated. Resident #2 was upset about not getting his cigarettes first, before everyone else. Resident #2 started yelling. I had heard he could be aggressive, so I did not want to turn my back on him. I wanted to get him a cigarette so he would calm down. He became more combative. I told the other staff member to call a Code Grey. I started to back up while facing him. Resident #2 continued to yell, 'I'm going to get you, etc', Resident #2 stood up out of his wheelchair and started to walk toward me. I was walking backwards and fell. Resident #2 fell to his knees at the same time. Staff F, CNA said Resident #2 immediately calmed down. Staff F, CNA was able to assist Resident #2 back into the wheelchair. Staff F, CNA stated the Director of Nursing (DON) arrived to the patio and took over from there. Resident #2 was in his wheelchair at this point and was given a cigarette. Staff F, CNA confirmed he had not[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, facility record review, hospital record review, and policy review the facility failed to ensure adequate supervision to prevent physical and psychosocial harm to one (Resident #1) of three residents reviewed. On 1/20/2024 at approximately 3:35 AM Resident #1 was punched repeatedly in the face and sexually assaulted by Resident #2 in Resident #1's room. The facility failed to provide supervision of Resident #2, who was exhibiting poor impulse control, combativeness, erratic behavior, aggressive behavior and was difficult to redirect. This failure created a situation that resulted in serious injury to Resident #1 and resulted in the determination of Immediate Jeopardy on 1/17/2024. The findings of Immediate Jeopardy were determined to be removed on 1/29/2024 and the severity and scope was reduced to a D after verification of removal of immediacy of harm. Findings include: An interview was conducted with Staff C, Certified Nursing Assistant (CNA) on 2/5/2024 at 1:58 PM. Staff C, CNA stated, on the evening of 1/20/2024, she was sitting at nurse station, charting. Staff D, CNA was assigned to Resident #1's room. Staff D, CNA was on the split assignment (assigned to rooms on two separate halls). Staff C, CNA stated she passed Resident #1's room [ROOM NUMBER] minutes earlier and Resident #1 was in her bed asleep with the door open. Staff C, CNA stated [Resident #1 name]'s call light went on. [Staff D name, CNA] went to answer the call light. [Staff D name, CNA] yelled for me that the door was jammed and there was a man on top of [Resident #1 name]. I ran to the room. We pushed the door open. [Resident #2 name] was in the chair naked, putting his clothes on. I was yelling for nurses to come. When the nurses arrived, we tried to get him out of the room. [Resident #2 name] started punching me and one of the nurses. [Resident #2 name] left the room followed by a nurse. [Resident #1 name] wanted to go to bathroom, so we assisted. [Resident #1 name]'s eyes were swollen shut, her face was bloody, and she was crying. The nurse assisted [Resident #1 name] from there. Staff C, CNA stated she later spoke to Resident #1. Resident #1 told me He tried to rape me but couldn't get 'it' in, so he stuck his finger up me. Staff C, CNA stated after Resident #1 left her room for a cigarette with the nurse, we changed the linens on her bed and found her tooth. An interview was conducted with Staff A, Licensed Practical Nurse (LPN) on 2/5/2024 at 1:38 PM. Staff A, LPN stated on the evening of 1/20/2024 she was getting ready for her 30-minute break. She was walking toward the break room when she noticed people in Resident #1's room. She noticed Resident #1 had face trauma. Staff B, LPN, Staff C, CNA and Staff D, CNA were in the room and explained what they had witnessed. She called the supervisor. Staff A, LPN stated prior to leaving Resident #1's room to call the supervisor, she listened to what the other staff were asking Resident #1, to ensure she had the event accurate. Resident #2 was no longer in the room when she arrived. Resident #1 was her patient that night. The last time she saw Resident #1 was an hour prior, when the CNAs were providing care. An interview was conducted with Staff D, CNA on 2/5/2024 at 10:34 AM. Staff D, CNA stated Resident #1's call light was on, which was unusual because Resident #1 did not utilize the call light. When she arrived at Resident #1's room door, it was closed. She could hardly open the door. The door was jammed with a wheelchair behind it. She could see Resident #2 on top of Resident #1. She yelled for another CNA (Staff C, CNA); she and Staff C, CNA were able to push the door open. Resident #2 was pulling up his pants and sat down in the wheelchair. Staff D, CNA stated, she last provided care for Resident #1 at 2:35 AM on 1/20/2024 with Staff C, CNA. A follow up interview was conducted with Staff D, CNA on 2/13/2024 at 1:31 PM. Staff D, CNA stated the door to Resident #1's room was blocked by two wheelchairs, both wheelchairs had their wheels locked. This is why she couldn't get the door open by herself. She believes Resident #2 intentionally put the wheelchairs behind the door like that to prevent the door from opening. An interview was conducted with Staff B, Licensed Practical Nurse (LPN) on 2/5/2024 at 10:05 AM. Staff B, LPN stated she was the nurse for Resident #2 on 1/20/2024. She was sitting at the East Unit nurses station charting when Resident #2 rolled by in his wheelchair. Resident #2 was heading toward lower East and Lifestyle 1 Units. Staff B, LPN continued to state, this is the first-time meeting Resident #2. Resident #2 appeared calm and not confused. Staff B, LPN continued to state, about 20 minutes later she heard a CNA screaming down the hallway [Resident #2 name] is on top of [Resident #1 name]. When Staff B, LPN arrived Resident #2 was standing next to Resident #1's bed pulling his pants, up from the knees. Staff B, LPN stated we were trying to get Resident #2 out of the room. Resident #2 was hitting me and the CNA. We got him out. Staff B, LPN stated [Resident #1 name]'s incontinent brief was ripped open on the side and her whole belly was exposed. The resident was crying, which was unusual, she never cries. The CNA and I got Resident #2 out of the room. Resident #1 Review of Resident #1's progress notes showed an eINTERACT SBAR [Situation, Background, Assessment, Recommendation] Summary for Providers dated 1/20/2024 at 4:00 AM, authored by: Director of Nursing (DON). The document revealed the change of condition being reported was Trauma, including vital signs from 1/7/2024 The section titled Outcomes of Physical Assessment revealed: Mental Status Evaluation: No changes observed Functional status evaluation: No changes observed Behavioral Status Evaluation: Not clinically applicable to the change in condition being reported Respiratory Status Evaluation: Not clinically applicable to the change in condition being reported Cardiovascular Status Evaluation: Not clinically applicable to the change in condition being reported Abdominal/GI Status Evaluation: Not clinically applicable to the change in condition being reported Skin Status Evaluation: Contusion Pain Status Evaluation: Does the resident/patient have pain? No calmyNeurological Status Evaluation: Not clinically applicable to the change in condition being reported Nursing observations, evaluation, and recommendations are: resident was allegedly assaulted by another resident police risk manager and LNHA (Licensed Nursing Home Administrator) notified Primary care provider feedback: primary care provider responded with the following feedback: A. Recommendations: Send to ER . Review of Resident #1's facility progress note dated 1/20/2024 at 10:30 AM authored by the DON, revealed writer spoke with charge nurse at ER, resident is being admitted dx (diagnosis) alleged assault. CT (Computerized Tomography) scan done and all negative lab work done and wnl (within normal limits). Review of Resident #1's facility progress note dated 1/20/2024 at 10:34 AM authored by the DON, revealed Medical Director notified of alleged assault and resident being admitted to hospital, will have psych available to see resident upon return to the facility. Primary care physician is also aware of alleged incident and resident status. Review of Resident #1's facility NSG [Nursing] - Pain Evaluation - V2 dated 1/20/2024 at 4:00 AM authored by the DON revealed: The resident had pain in the past 5 days to the right eye and the resident is unable to describe. The remainder of the form is blank. Review of Resident #1's facility NSG - Weekly Skin Evaluation - V2 dated 1/20/2022 at 4:00 AM authored by the DON revealed: bruise to the right eye, and the resident refused further skin assessment noted discoloration and swelling to right eye per resident allegedly struck by another resident police risk and lnha notified Review of Resident #1's Patient Encounter Note from the resident's primary care provider dated 1/23/2024 revealed Resident #1 is being seen status post discharge from the hospital on 1/22/2024, after being admitted for observation on 1/20/2024 and admitted on [DATE] status post assault and possible sexual assault. Resident #1 was noted to have bilateral facial bruising and a missing front right tooth in the Emergency Department (ED). Computerized Tomography (CT) of the face shows right periorbital (tissue surround the opening in the skull for the eye) and prezygomatic (tissue surrounding the eye, temple, lower lid and cheek) soft tissue swelling, with partial desiccation (removal) of the right mastoid air cells (air cells protect the delicate structures of the ear and protect the temporal bone during trauma), and minimal mucoperiosteal thickening of the right maxillary sinus (inflammatory reaction of the mucous lining of the maxillary sinus. This condition may result from harmful actions caused by trauma). Patient seen in her room alert to self in no acute distress. Patient reports pain in her face. Pain is 7 out of 10. Patient is being followed by psychiatry, with medications changes as needed. Review of the Resident #1's hospital History and Physical record face dated 1/20/2024 at 6:20 AM revealed History of Present Illness [HPI]: Chief complaint: Traumatic injury HPI: Resident #1 . brought to the hospital for facial injury . she had several bruises on the face. She also claims that she was sexually assaulted . a computerized tomography (CT) of the face showed, Resident #1's impression of the CT: Right preorbital and prezygomatic soft tissue swelling. No acute fracture. Partial desiccation of the right mastoid air cells. Minimal mucoperiosteal thickening in the right maxillary sinus. Review of Resident #1's Psychiatric Advanced Practice Registered Nurse (APRN) note date 1/22/2024 showed, Resident #1 returned from the hospital last night. Staff reports that Resident #1 was involved in a resident-to-resident altercation where Resident #1 was physically and sexually assaulted. Resident #1 is alert and oriented to person and time. Resident #1 is tearful on interview describing the assault . Resident #1 reports he beat me up . My face is ruined. It hurts me badly. Resident #1 reports significant emotional distress. Patient is currently unstable but requires no medication changes: I feel the symptoms are occurring due to acute stress disorder. Resident #1 has a complex mental health history. Today we completed a Post Traumatic Stress Disorder (PTSD) checklist (PCL), score of 20 represents a clinically significant change. After reviewing prior documentation, it appears to be directly linked to this stressor/event. Despite most answers not at all, it is very evident based on the behaviors this event has caused significant emotional and physical distress. Resident #1 is hypervigilant on interview, requesting coffee to calm her down, tearful and withdrawn. Resident #1's speech is disorganized and includes frequent derailment. Despite Resident # 1's mental status examination, the initial shock may have contributed to an acute on chronic psychotic event. Resident #1 has treatment refractory psychosis and a trial of Clozapine may be warranted. I discussed medication to help ease the anxiety, but patient opposed additional medication. At this time, I recommend supportive care, coping strategies, and helping resident process the emotions given the little insight the resident has. Resident #1 should continue self-care and getting adequate sleep. Review of Resident #1's Psychiatric Advanced Practice Registered Nurse (APRN) note date 1/19/2024 showed, . Patient report no signs of anxiety. Patient has no behavioral outburst. Patient is sleeping well with fair appetite. Patient has no signs of agitation. No other psychiatric symptoms observed. Patient is at baseline. No gradual dose reduction of medication is suggested. As per collected information and interview, it appears that the patient is doing well overall. The symptoms are causing no or at times only mild distress. An observation and interview were conducted with Resident #1 on 2/5/2024 at 12: 45 PM. Resident #1 was observed with yellow discoloration to the right side of her face from her eye to her chin. Resident #1 stated, I'm not good, my face hurts, I was attacked by a man . he hit me over and over again on my face. My face still hurts but ice and aspirin help. Resident #1 continued to state I did not know the man, I saw him in the smoke area. Resident #2 Review of Resident #2's Hospital Emergency Department Documents dated 12/23/2024 at 14:56 revealed: HPI: patient presenting with a complaint of agitation presenting from a nursing care facility where he escalated to hitting someone with a cane. Upon arrival he was initially calm he escalated again around 1630. Became instantaneously violent. ETO (Emergency Treatment Order) for medications given at 1630 secondary to aggressive behavior of patient in impending threat to staff and the patient. Review of Resident #2's hospital record titled History and Physical dated 12/24/2024 located in the facility medical record, revealed Resident #2 was admitted to the hospital on [DATE] from a (the previous) nursing home, for an unprovoked physical outburst leading to Resident #2 striking and injuring another resident causing a laceration that required closure. patient is psychotic, claiming that the resident told him she wanted to die, which she denied. An interview was conducted with the Assistant Director of Nursing (ADON) from the previous nursing home on 2/12/2024 at 10:15 AM. The ADON remembers Resident #2 and the incident at their facility which required Resident #2 and another resident to be transferred out to the hospital. The female resident was resting her head on the table, not making a noise. Out of nowhere, Resident #2 started hitting her on the head with his cane. The female resident received lacerations to the head that required her to be transferred to the hospital for treatment. Resident #2 was sent to the hospital for a psychiatric evaluation and stabilization. Review of Resident #2 admission Record showed the resident was admitted on [DATE] with diagnoses that included: Schizophrenia- unspecified, Schizoaffective disorder - bipolar type, Major depressive disorder- recurrent- moderate, Other specified mood disorder, Type 2 Diabetes Mellitus without complications, Muscle Weakness, Unsteadiness on feet, Monoplegia Of upper limb, following cerebral infarction affecting left dominant side, Essential hypertension, Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris, Hyperlipidemia, Gastro-Esophageal Reflux Disease (GERD), Fracture of one rib left side-with routine healing. Review of Resident #2's Pre-admission Screen and Record Review (PASRR) Level II completed on 1/9/2024. Service recommendations indicated: Based on clinical of the submitted documentation and information, this individual is considered to have a Serious Mental Illness as defined in 42 CFR Part 483.102(b)(1) and F.A.C. 59G-1.040(2)(m) based on each of the categories of diagnosis, level of impairment and recent treatment. Specifically, this individual does have a major mental disorder with associated significant symptoms. Once psychiatrically cleared, given the information provided for the review, a nursing facility placement is determined to be appropriate due to the patient's medical needs, and the need for medication management. The patient does not appear independently capable of self- monitoring his health status, nutritional status, or self- administration and scheduling medical treatment. Specialized Services are deemed not necessary given the client does not appear to need acute inpatient psychiatric care at this time. It is recommended that the following rehabilitative services, of a lesser intensity than Specialized Services, are added to the patient's Comprehensive Person-Centered Nursing Care Plan: - Psychiatric medication management - Supportive counseling. Supportive services cannot be effectively provided in a less restrictive environment at this time are recommended to be provided at the nursing facility. If he is unable to return home, all efforts should be made to transition him to a less restrictive environment such as an Assisted Living Facility that can meet his mental health needs, if agreed upon by the treating physician. The patient should be encouraged to participate in socialization and enrichment activities appropriate for his level of function. Given his history, care staff should monitor for symptoms of psychosis, and report any problems to the treatment team. Should there be a significant change in his mental status, it is recommended that an additional Level II review should be conducted. Review of the care plan for Resident #2 initiated on 1/17/2024 with a revision date of 2/2/2024 with a focus of : (Resident #2) is/has potential to be physically and verbally aggressive along with alleged assault to other residents. Not easily redirected. Chooses not to take psychiatric medication. Interventions included: Administer medications as ordered. Monitor/document for side effects and effectiveness. Provide physical and verbal cues to alleviate anxiety; give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff member when agitated; mental health services as needed/as ordered; monitor (document observed behavior and attempted interventions in behavior log; monitor/ document/report PRN and sign/symptoms of resident posting danger to self and others; Psychiatric/Psychogeriatric consult as indicated; 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. Revisions to interventions were added 1/20/2024: One on One Intensive Supervision, BA 52 An interview was conducted with Staff R, LPN MDS (Minimum Data Set) Coordinator on 2/13/2024 at 10:23 AM. Staff R, LPN MDS confirmed responsibility for updating care plans, evaluating residents upon admission for the MDS and care plan needs. Staff R, LPN MDS continued to state when reviewing a resident who is a new admission she reviews the hospital paperwork, including nurses' notes, history and physicals, and discharge summaries. With the information gathered from the information she can develop care plans. This is how she developed the care plan for Resident #2 being physically aggressive and that Resident #2 had a history of being non-compliant in taking his medications. Review of Resident #2's Minimum Data Set (MDS) dated [DATE] showed a Brief Interview for Mental Status (BIMS) of 12 out of 15, meaning cognitively moderately impaired. Section E for Behavior indicated in the last 7 days from 1/17/2024 Resident #2 showed signs of hallucinations, delusions, wandering, physical and verbal behaviors directed towards other at least 1 to 3 days of the past 7. Review of the facility's progress notes for Resident #2 dated 1/11/2024 at 2:00 PM showed Resident #2 was admitted from the hospital. Admitting diagnosis schizophrenia patient is alert with some confusion. Able to make needs known. Patient is independent with ambulation and feeding. Continent of B&B (bowel and bladder). Denies any pain/discomfort at this time. No open areas noted. Appetite good, fluid intake adequate. Took medications without difficulty. Patient stated dentures were lost. Wears glasses, hearing adequate no hearing aids. Will continue to monitor. Review of Resident #2's facility Order Summary Report Active orders as of 1/11/2024 revealed the following physician orders: (listing psychiatric medications only) 1. Depakote 250 mg (milligrams) by mouth two times a day, order and start date 1/11/2024 2. Fluphenazine Decanoate Injection Solution 25mg/ml (milliliter) inject 1 dose intramuscularly one time a day every 14 days Order date 1/11/2024, start date 1/12/2024. The mg per dose was not listed. 3. Trazadone HCL Oral tablet 50 mg, give 50 my by mouth at bedtime order and start date 1/11/2024. Review of Resident #2's facility Order Summary Report Active Orders as of 1/20/2024 revealed the following physician orders: (listing psychiatric mediations only) 1. Depakote 250 mg by mouth two times a day, order and start date 1/11/2024 2. Fluphenazine 25 mg/mL, inject 25 mg intramuscularly one time only order date 1/19/2024, start date 1/22/2024 (after discharge) 3. Fluphenazine Decanoate 25 mg/mL, inject 50 mg intramuscularly every 14 day(s) - order date 1/19/2024, start date 2/5/2024 (after discharge) 4. Haldol 5 mg/mL, inject 5 mg intramuscularly every 6 hours as needed for 14 days - order and start date 1/12/2024 5. Trazodone 50 mg, give 50 mg by mouth at bedtime, order and start date 1/11/2024 Review of progress note dated 1/12/2024 at 2:02 AM showed . [Resident #2 name] was restless this shift. Resident constantly in and out of the room, opening and shutting the door, turning the TV and lights on and off, room mate (sic) yelling at him to stop going in and out and turning the TV and lights on and off because he is waking up the other room mates (sic) in the room. Resident able to make needs known, speech slurred, and observed talking to himself. Attempted to redirect resident but he seems very anxious and on edge. Will continue to monitor resident closely. Review of progress note dated 1/12/2024 at 4:10 AM showed [Resident #2 name] sat at nurse's station willing stating I'm here because I helped kill a lady, because she wanted to kill herself. Resident then elaborated that he didn't feel like there was anything wrong with helping her because he felt like he was doing the right thing since she wanted to die. Writer attempted to redirect resident's attention multiple times. At approximately 3:45 AM, he went back to his room and is now asleep in bed. Resident appears to be A & O x 4 (alert and oriented to person, place, time and event) and is able to make his needs known though his speech is sometimes hard to understand. No S/S (signs and symptoms) of SOB (shortness of breath) or distress noted, Will continue to monitor closely. Review of Psychiatric Advanced Practice Registered Nurse (APRN) note for date of service 1/12/2024 showed [Resident #2 name] endorses hallucinations. Patient reports he doesn't know what the 'voices' are saying 'they talk to each other'. Patient's speech is dysarthria (difficulty speaking because the muscles you use for speech are weak) of patient gets frustrated with interviewer and states 'stop asking me all the questions'. Interview was ended. Patient was visited on smoke patio where he was irritable and difficult to redirect. Patient is restless in and out of his room repeatedly, yelling at staff. Assessment and plan for [Resident #2 name] shows patient is unstable requiring medication changes. I feel the symptoms are occurring due to exacerbation of underlying psychotic disorder. The symptoms are occurring almost daily and causing severe distress. I decided to start Haldol 5 mg (milligrams) intramuscularly (IM) every 6 hours PRN (as needed) for 14 days for schizophrenia. Review of Resident #2's progress note dated 1/16/2024 at 1:18 PM showed Unit manager (UM) was discussing patient care with this nurse. She was facing me while I was sitting at the nurse desk computer. This resident rolled up to the UM back and hit her very hard in the lower back. Staff removed the resident from his attack on the unit manager. He stated he wanted food. This nurse provided him with a PBJ (Peanut Butter and Jelly) sandwich, and he was satisfied with it. Admin arrived, assessed this patient PRN (as needed) IM was provided. Review of Resident #2's facility MAR revealed the order for Haldol 5 mg, IM every 6 hours as needed for mood disorder was administered one (1) time on 1/16/2024 at 12:13 AM. Review of Resident #2's Facility Medication Administration Record (MAR) revealed an order with a start date of 1/12/2024 at 1:45 PM for Haldol 5 mg, IM every 6 hours as needed for mood disorder. The MAR showed Resident #2 was not administered this medication on 1/12/2024, 1/13/2024, 1/14/2024, 1/15/2024, 1/17/2024, 1/18/2024, 1/19/2024 or 1/20/2024. An interview was conducted with Staff K, LPN, Unit Manager (UM) on 2/13/2024 at 1:00 PM. Staff K, LPN stated she was standing at the station (on 1/16/2024) and Resident #2 punched me in the back, it was shocking. The nurse she was speaking with administered an injection, he calmed right down, and no further events occurred that evening. An interview was conducted with Staff M, RN on 2/13/2024 at 10:50 AM. Staff M, RN confirmed she witnessed the event of 1/16/2024 with the UM. Staff M, RN stated I had him in the morning and was charting at nurses' station. The UM was at the nurse station opposite of me standing with her back to the hallway. Suddenly, the UM made a startling noise, Oh. Resident #2 had punched her in the lower back. Resident #2 stated he wanted a sandwich. Staff M, RN stated He would just explode big action and then be fine. Review of Psychiatric Advanced Practice Registered Nurse (APRN) note for date of service 1/16/2024 showed [Resident #2 name] examined. Patient is aggressive when he wants something and does not get it immediately. Patient is difficult to redirect. Patient is combative and his behavior is erratic. Patient is sleeping and eating well. Patient is tolerating current medication. Assessment and Plan: Patient is unstable requiring medication changes: As per collected information due to exacerbation of an underlying schizoaffective disorder. The symptoms are occurring almost daily and causing severe distress. Therefore, I decided to make medication changes to stabilize the symptoms. Continue Haldol for schizophrenia, Trazodone for depression and Divalproex for mood disorder. Increase Fluphenazine to 50 mg/ml every 14 days. Review of the MAR showed the resident was not given this increased dose of Fluphenazine. Review of Resident #2's progress notes dated 1/17/2024 at 4:00 AM showed [Resident #2 name] purposely keeping other residents awake with TV. This writer asked resident to turn down TV to be respectful to other residents. [Resident #2 name] then proceeded to slam door, slam nightstand and yell throughout the shift. An interview was conducted on 2/05/2024 at 3:15 PM with Staff J, CNA. Staff J, CNA stated Resident #2 had verbally threatened staff. On the evening of 1/17/2024 he had the volume on the TV very loud. [Resident #2 name] became angry and very aggressive in his room, we just stood in the doorway and made sure he didn't attack his roommates. [Resident #2 name] finally calmed down on his own. Every day was horrible with him. We would keep his door open for safe keeping of the other roommates. An interview was conducted with Staff C, CNA on 2/5/2024 at 1:58 PM. On 1/18/2024 Resident #2 was upset and combative on smoke patio, he wanted a cigarette. Resident #2 was chewing cigarette butts from the ground, saying he was going to beat the ladies up. Staff L, Registered Nurse (RN) came out and resident calmed down. Resident went to his room with Staff L, RN. An interview was conducted on 2/13/2024 at 12:52 PM with Staff F, CNA. Staff F, CNA recalled the event on 1/18/2024 on the smoking patio with Resident #2. Staff F, CNA explained, the smoking area closes for about 15-20 minutes to accommodate shift change. Residents are usually lined up waiting for the patio to resume. Resident #2 was there waiting, he already appeared agitated. Resident #2 was upset about not getting his cigarettes first, before everyone else. [Resident #2 name] started yelling. I had heard he could be aggressive, so I did not want to turn my back on him. I wanted to get him a cigarette so he would calm down. He became more combative. I told the other staff member to call a Code Grey. I started to back up while facing him. [Resident #2 name] continued to yell, 'I'm going to get you, etc', [Resident #2 name] stood up out of his wheelchair and started to walk toward me. I was walking backwards and fell. [Resident #2 name] fell to his knees at the same time. Staff F, CNA said Resident #2 immediately calmed down. Staff F, CNA was able to assist Resident #2 back into the wheelchair. Staff F, CNA stated the Director of Nursing (DON) arrived to the patio and took over from there. Resident #2 was in his wheelchair at this point and was given a cigarette. Staff F, CNA confirmed he had not informed anyone of the falls (his or the Resident's). Review of Resident #2's progress note dated 1/20/2024 at 7:47 AM revealed, [Resident #2 name] went by nurses' station (East Unit) in his wheelchair around 3:15 AM about 20 minutes later the Certified Nursing Assistant (CNA) from Lifestyle 1 unit came running down the hall way (sic) telling me to come the other nurse and I ran down the hallway to the CNA . she was stating [Resident #2 name] was naked laying on top of the female resident in her room on her bed . when I got to room [Resident #2 name] was pulling up his pants . female resident whos (sic) room it was was (sic) laying on bed on her back . her pull up was tore off she was covering her face and crying . the other nurse, CNA and I were questioning [Resident #2 name] and trying to remove this resident from the room . [Resident #2 name] began cursing at staff and hit both me (in the chest) and the CNA . this resident then proceeded to go back to his room . I followed this resident to insure (sic) the safety of the other resident . Police called . call placed to DR (doctor) and after and update order to call psychiatric practitioner to have resident (sic) admitted to an acute psychiatric unit. Review of the Hospital History and Physical dated 1/20/2024 revealed Resident #2 presents under BA (Baker Act) at his facility .[Resident #2] has been with increased agitation, irritability, and combativeness. Review of Resident #2's Facility MAR dated 1/1/2024 to 1/31/2024 revealed the following psychiatric medications: Fluphenazine 25 mg/mL inject one dose intramuscularly one time a day every 14 days, order start date of 1/15/2024 at 0900 and a discharge date of 1/19/2024 at 1544. Resident #2 was administered this medication once on 1/15/2024. The mg per dose was not specified. Haldol 5 mg, IM every 6 hours as needed for mood disorder. Start date of 1/12/2024 at 1:45 PM. Resident #2 was administered this medication once on 1/16/2024 at 12:13 AM. Trazodone HCl oral tablet 50 mg by mouth at bedtime Start date of 1/11/2024 at 2100 and a discharge date of 1/20/2024 at 1142. Resident #2 was administered this medication on 1/11/2024, 1/12/2024, 1/13/2024, 1/14/2024, 1/15/2024, 1/16/2024, 1/17/2024, 1/18/2024, and 1/19/2024. Divalproex Sodium Oral Table Delayed Release 250 mg, give 250 mg by mouth two times a day, order start date of 1/11/2024 at 1700 and a discharge date of 1/20/2024 at 1142. Resident was administered this medication at 0900, 1/12/2024, 1/13/2024, 1/14/2024, 1/15/2024, 1/16/2024, 1/17/2024, 1/18[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, facility policies and procedures review, interviews with facility staff, Nursing Home Administrator (NHA), Assistant Nursing Home Administrator (ANHA), Assistant Director of Nursing (ADON), Nurse Practitioner (NP), and Medical Director (MD), the facility failed to provide supervision during meal service to prevent choking for a vulnerable resident (#1), who was on a puree diet and had previously attempted to gain access to foods not on his prescribed diet, out of 12 sampled residents for dietary needs. On 08/13/2023 Resident #1, who was on a puree diet for a diagnosis of dysphagia, accessed a roommate's food tray. On 08/13/2023 during the dinner meal service, Resident #1 was observed attempting to access food trays from the tray cart when the cart was delivered to the floor and was redirected by staff. Resident #1 was witnessed by staff attempting to access trays from the tray cart again after the meal and was redirected back to his room. In his room, Resident #1 accessed a roommate's uneaten food tray. Resident #1 was found unresponsive with food in his mouth. EMS (Emergency Medical Services) were activated, CPR (Cardiopulmonary Resuscitation) was started, and the resident was transferred to the hospital. The resident was pronounced brain dead and expired on 08/15/2023. This failure created a situation that resulted in a serious injury and death to Resident #1 and resulted in the determination of Immediate Jeopardy on 08/13/2023. The findings of Immediate Jeopardy were determined to be removed on 08/23/2023 and the severity and scope was reduced to a D after verification of removal of Immediate Jeopardy. Findings included: A review of the admission Record revealed Resident #1 was admitted to the facility on [DATE], with diagnoses that included but not limited to, Parkinson's Disease, Mood Disorder, Atrial Fibrillation, Schizophrenia, Anxiety Disorder, Dysphagia, Dementia, Psychosis, Bipolar Disorder, COVID-19, and Sepsis with Septic Shock. A review of the Order Summary Report, dated 08/01/2023, revealed the following physician orders: Regular diet, Puree texture, Honey consistency, ordered on 4/10/2023. Full Code, ordered on 4/10/2023. Depakote sprinkles oral capsule delayed release sprinkle 125 MG (milligrams) Give 750 MG by mouth one time a day for Mood Disorder, ordered on 4/12/2023. Quetiapine Fumarate oral tablet 200 MG Give one tablet by mouth two times a day related to Schizophrenia, ordered on 6/08/2023. Estradiol oral tablet 1 MG Give one by mouth one time a day for inappropriate sexual behavior, ordered on 6/23/2023. A review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed in Section C: Cognitive Patterns, a Brief Interview for Mental Status (BIMS) score of 09, indicating severe cognitive impairment. In Section G: Functional Status the assessment revealed Resident #1 required extensive assistance by one person for locomotion on the unit, supervision by one person for eating, no impairment with range of motion for upper or lower extremities and utilized a wheelchair for mobility. A review of the Comprehensive Care Plan, last review date 5/18/2023, revealed Resident #1 had the following focus areas in place: Focus--Resident #1 is at risk for alteration in nutrition and hydration related to: Dx (diagnosis) Dementia, dysphagia and need for mech altered diet. Will take food from peers that may not always be appropriate for diet consistency due to Dx, may not understand that the food he takes is not his or that it is not safe for him .(Initiated 11/01/2020). Goal-- .Will not choke or aspirate through next 90 days . Interventions included but not limited to: Assist and encourage as needed with meals; Monitor and provide preferences as available; Monitor meal intake and offer alternate items as needed; Redirect as needed, offer alternate items as needed that are appropriate for his diet; Review in risk meetings as needed; Thickened liquids as ordered. Focus-Resident #1 has the following behavior problems: verbally and physically aggressive, easily agitated, entering other residents' rooms without permission, sexually inappropriate ., resident to resident altercations, takes food off other residents' trays (Initiated 7/28/2023). Goal-Resident #1 will have fewer episodes of disruptive behavior by next review date. Interventions included but not limited to: Anticipate and meet the resident's needs; Intervene as necessary to protect the rights and safety of others; Redirect the resident as necessary. A review of a Modified Barium Swallow Study Final Report, dated 3/09/2020, revealed a diagnosis after the study of moderate-severe oral with moderate pharyngeal phase dysphagia. The recommended oral diet was puree/honey. A review of Progress Notes for Resident #1 revealed the following: 8/13/2023 11:34 p.m. Resident was found unresponsive in room at 5:55 pm. Code was called Heimlich maneuver was provided while assisted to remove food out resident's mouth. Resident was brought to the floor and CPR was provided. Suction was provided to resident's mouth to remove and obstructions. EMT [Emergency Medical Technician] arrived and took over at 6:15pm. EMT took over CPR. Started an IV [Intravenous] bag via shin. Resident was intubated at 6:20pm EMT got at pulse at 6:28 pm and resident was taken to hospital at 6:30pm. 8/14/2023 2:12 a.m. res [resident] was admitted to ICU [Intensive Care] at [hospital name] with a diagnosis cardiac arrest. A review of the EMS patient care report, DOS (date of service) 8/13/2023, revealed the following narrative: Dispatched to [facility name] for the [AGE] year-old male cardiac arrest/ Staff states that she saw the patient 30 minutes prior and when she next saw the patient, he was sitting in his scooter unresponsive with food on his lap. Staff states that the patient is on a puree diet but had a sandwich next to him. Staff states that they moved the patient to the floor and started CPR. FD [Fire Department] states that they found the patient on the ground with chest compressions being performed by staff. FD states that the patient's airway had soft food in his airway that was suctioned as much as possible before placing a king airway. Patient was found to be in asystole. Patient has a history of dementia and Parkinson's. Patient was found supine on the floor with staff/FD, unresponsive with chest compressions and assisted ventilations being performed. Cardiac arrest post asphyxiation with ROSC [Return of Spontaneous Circulation]. Patient was carried to the stretcher via back board, secured X5 seat belts, and transported to the closest appropriate facility as documented without incident. All interventions as listed were performed with positive patient outcomes. Transfer of care was completed at patient's bedside with a verbal report given to ED [Emergency Department] nursing staff. A review of the hospital record Intensive Care Consultation report, dated 8/14/23 at 6:57 a.m., revealed the following: Reason for consult: Cardiac Arrest HPI (History and Physical Information): (Resident #1) is a [AGE] year-old male with a previous history of Parkinson's Disease who presents from nursing home after a cardiac arrest. Patient is currently intubated and sedated .Patient has had dysphagia for years and is on a soft/puree diet at his nursing facility. Around 5:00 p.m. the previous evening he was given his assigned dinner. Around 5:40 p.m. he was placed back into his room. When staff checked on him around 5:55 p.m. they found him unresponsive. They noticed he had gotten food from his roommate's plate and suspected he chocked .Upon arrival to the ED, patient was minimally responsive but otherwise hemodynamically stable. Hypothermia protocol as initiated, and patient was transferred to ICU for further management. Diagnosis, Assessment & Plan: Cardiac arrest secondary to Hypoxia Acute Hypoxic Respiratory Failure Aspiration secondary to Dysphagia . Death Event Note: Pronouncement of Death Date: 8/15/2023 Time: 1810 (6:10 p.m.) Clinical assessment: blood pressure absent, cerebral unresponsiveness, pulse absent, pupils dilated/unreactive, respirations absent. During an interview on 8/22/23 at 10:25 a.m. Staff A, Licensed Practical Nurse (LPN) stated she had worked at the facility for a long time. She stated the diet trays are checked by the nurse first to make sure the trays are accurate for each resident. She stated the aides are responsible for monitoring the residents on puree foods during their meals and they should keep them close so they can make sure the resident does not choke. She stated if the resident is able to eat on their own the staff have to go in and check on them often to make sure they are swallowing their food properly. During an interview on 8/22/23 at 11:15 a.m. Staff B, LPN stated residents who are on a puree diet have to be set up and assisted or monitored during their meals. She stated the staff have to keep a close eye out to watch for swallowing and choking when a resident is on a puree diet. During an interview on 8/22/23 at 11:55 a.m. Staff C, LPN stated she was the unit manager for the 2E and 2W nursing units. She said residents who receive altered diets are care planned, noted on the Kardex for staff information, and the food ticket will identify the consistency of the food and liquids for each resident. She stated she also keeps a list in the nourishment room of residents on honey and nectar thick liquids. She stated she updates the list if any diet changes occur for each resident. She stated she makes rounds during meals to observe staff assisting residents. She stated residents who can feed themselves may be out at the nurse's station during meals for closer observation. Staff C, LPN stated any changes in residents or concerns are discussed at morning team meeting and for residents with concerns about meals will be followed up with evaluation by speech therapy. During an interview on 8/22/23 at 12:25 p.m. with Staff D, Certified Nursing Aide (CNA) and Staff E, CNA they stated they had recent education and training related to assistance with meals for residents. They stated the education included: set up, checking liquids, oversight of residents during meals, elevating the head of the bed and not putting it down for 30 minutes after the meal, proper utensils, close monitoring to assure residents do not get the wrong food and risk choking, and monitoring of other residents to assure they do not give other food to residents at risk for choking. An interview was conducted with the Nursing Home Administrator (NHA), the Assistant Nursing Home Administrator (ANHA), and the Assistant Director of Nursing (ADON) on 8/22/23 at 1:56 p.m. They stated they were all are aware of the incident with Resident #1 and had conducted a full investigation and had reported the incident to all required agencies. The NHA stated the Director of Nursing (DON) was involved in the investigation at the time, but she is currently on leave. The ANHA stated she received notification from nursing Resident #1 was transferred to the hospital after the incident. She stated the incident occurred on a Sunday during the dinner meal. She stated the DON notified her at 6:19 p.m. The ANHA stated Staff E, LPN notified the DON after the incident because she was the nurse responsible for the care of Resident #1 on that evening. The NHA stated the incident was discussed over the phone with the ANHA and the DON right away and it was reported, and an investigation was begun. The ANHA stated Resident #1 was found in his wheelchair, unresponsive with food in his mouth, but they were unable to determine how much food he had consumed. She stated he had access to his roommate's dinner tray which was on the overbed table. She stated the roommate was not in the room. The ANHA stated Resident #1 liked to eat at the nurses' station, was able to eat on his own, and was on a puree diet. She stated the resident finished eating and could locomote on his own but slowly. She stated Resident #1 went back to his room on his own after the meal. She stated this was his routine. The ANHA stated Resident #1 had a history of taking other resident's food, but there had been no reports of this happening recently that she was aware of. She stated when the resident was discovered unresponsive, CPR was started, the Heimlich maneuver was done, EMS was called, and suction to remove the food was done by the nursing staff. When EMS arrived, they took over and the resident was taken to the hospital. The ANHA stated a complete investigation was conducted with interviews and record review with all of the staff involved in the incident. She stated they developed a timeline and confirmed the roommate was not in the room at the time of the incident. The ANHA stated during the interviews with staff it was determined the roommate would often eat some of his food and then leave it and return later to finish it. She stated the staff on the unit were very consistent and knowledgeable about the residents and their patterns. The ADON stated education was immediately started with verbal educations related to aspiration, choking, and coughing during meals. She stated they also have an electronic learning center that has been assigned to all staff related to aphasia and aspiration. The NHA stated the facility has initiated a manager doing rounds during dinner times, and they are currently getting ready to open the dining room so residents can be monitored by staff easier during meal times. The NHA said it was everyone's job to monitor for eating, dietary, feeding and aspiration. He stated meal times are 'all hands-on deck.' The ADON stated the reason Resident #1 was eating in the hallway by the nursing station was because it was his social element and he preferred hanging out at the nursing station. She stated the staff liked to see him there due to his risk for falls. She stated staff would monitor his eating at the nursing station also. She stated Resident #1 rarely ate in his room. The NHA stated the staff should have verified the roommate's food tray was left in the room unattended and should have removed it and placed it back in the cart until the roommate returned. During an interview on 8/22/23 at 2:53 p.m. Staff F, LPN stated she was the nurse assigned to Resident #1 on the day of the incident. She stated the resident received his puree diet around 5:00 p.m. and he ate it at the nurses station in the hallway. Staff E, LPN stated she was giving medications at the cart when she saw Resident #1 messing with the meal trays on the cart. She stated he was pulling the trays off the cart and attempting to get food off the used trays. Staff E, LPN told Resident #1 to stop, and he was redirected back to his room. She stated she continued to pass medications and she did see him once and he was sitting in the room with the other residents in his wheelchair. She stated the second time she checked on Resident #1 he was slumped in chair and blue, she called a code. She stated she saw bread in his mouth and tried to get it out. She stated an aide came in to help lower the resident to the ground. She stated the crash cart arrived and other staff came in to assist. She stated Resident #1 was not breathing and had no pulse. She stated she suctioned stuff out of his mouth and they began CPR. She stated when EMS arrived, they took over care. Staff F, LPN stated Resident #1 had eaten his puree diet without any problems. She stated she was a float nurse and had not had Resident #1 in about two weeks. She stated she was aware the resident was care planned for taking other residents' food. She stated there was one tray in room that she thought was from the B bed, but she was not sure. She stated the tray was untouched. She stated the trays were passed around 5:00 p.m. and she found Resident #1 around 5:55 p.m. She stated EMS intubated the resident at facility and had used suction while they were there to clear the food. She stated she told paramedics the resident was choking on food from another resident's tray. During an interview on 8/23/23 at 9:29 a.m. with the Advanced Registered Nurse Practitioner (ARNP) She stated she was familiar with Resident #1 and had cared for him for about two years. She stated the resident was wheelchair bound and could move around the facility in his chair on his own. She stated he was a pleasant man but did have some behavioral issues. She stated she was not sure if he was being seen by psychiatry. She stated he had dysphagia and was on a puree diet for a long time. The ARNP said she was not aware of any issues related to Resident #1 taking food from other trays. She stated she was made aware of the incident when she came in on the Monday morning following the incident. The ARNP stated she was not informed of the reason why Resident #1 coded, but she read the note in the record and was aware the resident expired. She stated her expectation would be the staff watch and check on residents who are on puree diets to make sure they are safe during the meals. During an interview on 8/23/23 at 9:43 a.m. Staff G, Speech Therapist (ST) stated Resident #1 was at the facility for a long time and she had known him for several years. She stated the resident was able to get around in his wheelchair. She stated she would do a quarterly screening on the resident to make sure his diet was appropriate. She stated he was on a puree honey thick liquids diet. She stated he had been on the diet for a long time because he was not able to masticate or swallow differing textures without problems. She stated her instructions to staff was to monitor Resident #1 during meals, but he could feed himself. The ST said she was unaware the resident was food seeking and she was not aware the resident was care planned for taking other resident's food but became aware after the incident occurred. The ST stated staff should be watching for any type of coughing, etc. while a resident on a puree diet is eating. During an interview on 8/23/23 at 9:53 a.m. Staff H, CNA stated she was working the floor during the evening of the event but was not assigned to care for Resident #1. She stated she started to pass trays and Resident #1 was trying to grab trays and food before she passed the trays. She stated she was assisting another resident and watching Resident #1 at same time. She stated Resident #1 eats 100% of the meal every time and eats well by himself. She stated after the meal she was picking up trays and saw the nurse redirecting Resident #1 to go to his room. She stated the nurse, and the resident were by the tray cart at the time. She stated about 10 minutes later she heard the nurse shout call a code. She said she went to the room and saw the nurse performing the Heimlich maneuver. She stated Resident #1 had food in his mouth and the nurse was trying to get it out. Staff H, CNA stated there was a tray in the room and she thought it belonged to B bed. She stated she gave a statement about the incident to the DON and ANHA and told the same story that she just relayed to surveyors. She stated she was aware Resident #1 was food seeking. She stated Resident #1 had sought food on a regular basis. She said she had seen the resident do this at least three times a week on the shifts she worked. She stated she had seen the resident food seeking in his room, in the hall, anywhere he was close to any food or drinks. She stated she was not aware he had dysphagia but was told Resident #1 ate his food too fast. She stated Resident #1 had to be watched to make sure he was safe. She stated Resident #1 was always seated in the hallway by the nurses station so he could be watched while eating. She said she would not leave a tray unattended in one of her rooms and if a resident was not in the room, she would store the tray in clean utility until resident was located. A telephone interview was conducted on 8/23/23 at 10:11 a.m. with the Medical Director (MD). The MD stated he was aware of Resident #1 and had discussed the resident in the psychotropic medical management meetings. He stated the resident was having increased behavioral issues. He stated he reviewed the resident's record and did not make any changes to his medications. He stated he was informed about the incident and what had occurred. He stated the resident had a choking incident as a result of accessing food that was not on his prescribed puree diet. The MD stated the incident was discussed with the NHA, the ANHA and the DON. He stated the findings were Resident #1 had access to another resident's tray and we could have been more careful to ensure he and other residents did not have access to other foods. The MD said Resident #1 was highly cognitively impaired and did not understand the dangers of eating others food. The MD stated the plan was to reopen the dining room so better supervision can be provided. He stated he was not personally aware of the food seeking concerns with Resident #1. The MD stated the expectation was residents were not given food in room where it was difficult to observe/supervise the residents. During a telephone interview on 8/23/23 at 10:30 a.m. with the Power of Attorney (POA) he stated Resident #1 had a Traumatic Brain Injury (TBI) and several strokes and had been in the facility since 2019. The POA stated he visited with the resident once a quarter and was working with social services on getting some dental work done for Resident #1. The POA stated the first two phases had been completed. He stated the facility called him and the call went to voicemail on the date of the incident. He stated before he could call the facility back, the hospital called him and updated him. He stated he called facility back and the nurse talked with him and told him the resident got a hold of his roommate's food and he choked and went into cardiac arrest. The POA stated the hospital told him Resident #1 was in critical condition, and in the Cardiovascular Intensive Care Unit (CVICU). He stated the hospital was doing cooling therapy to try to limit damage to Resident #1's brain. He said when he was at the hospital with the resident, 'I just knew, there was no reaction.' He stated the doctors came in and told him they were assessing to see if the resident's was brain dead. The POA made Resident #1 a Do Not Resuscitate (DNR) at the hospital. He stated the Neurologist saw Resident #1 and confirmed the resident was brain dead. The POA stated the ventilator was removed and the resident expired shortly after on Tuesday 8/15/23 at 6:10 p.m. The POA stated Resident #1 was on a puree diet for years because he would choke with regular food. The POA stated he had asked at several care plan meetings if the resident would ever be able to eat normal food, and he understood the answer was no. The POA stated Resident #1 was in the care of the funeral home and he had not received any death certificates at the time. During an interview on 8/23/23 at 10:48 a.m. Staff I, CNA stated she was the CNA assigned to Resident #1. She stated she was assisting residents with their meals at the time of the incident. She stated Resident #1 had already been served by another staff member and had eaten his food at the nursing station. She said she was aware Resident #1 was on a puree diet and was a risk for choking. She said she was aware the resident was food seeking. She stated she did not leave resident trays unattended in a resident's room. She stated she heard the code blue called and went to the room and helped the nurse get him onto the floor. She stated the nurse was getting food out of his mouth and was also suctioning. Staff I, CNA said it was about ½ sandwich that was in his mouth and she though it was a Philly Steak sandwich. During a telephone interview on 8/23/23 at 11:14 a.m. Staff J, CNA stated she was present on the date of the incident, and she was very familiar with Resident #1. She said she worked doubles on the weekend and was normally assigned to care for Resident #1 but on that date, he was assigned to a different CNA. She stated she was turning a resident and heard the code called and ran to the room. She said the nurse was trying get him resident to 'cough it up'. She stated Resident #1 was not alert and they got him unbuckled from his chair and tried the Heimlich maneuver and then got him on the floor. She stated it was evident he was choking on food. She stated there was bread in his mouth, and it belonged to his roommate. Staff J, CNA said Resident #1 attempted to get food off the carts and from other residents' trays all the time. The CNA stated Resident #1 would try to get food not on his diet every day. She stated she gave a statement and told the same story she conveyed to surveyors. She stated supervising a resident at meal time means she has to make sure they are swallowing correctly and not coughing or choking on their food. A review of the facility policy entitled Meal Supervision and Assistance, implemented on 1/2022 and revised on 4/2023, revealed the following: Policy: The resident will be prepared for a well-balanced meal in a calm environment, location of his/her preference and with adequate supervision and assistance to prevent accidents, provide adequate nutrition, and assure an enjoyable event. This includes: -Identifying hazards and risks -Evaluating and analyzing hazards and risks -Implementing interventions to reduce hazards and risks -Monitoring for effectiveness and modifying interventions when necessary Compliance Guidelines: 1 The facility will utilize a systemic approach to ensure safety throughout the resident's environment and among all staff. 2 The facility will develop and implement an individualized care plan based on the Resident Assessment Instrument (RAI) to address the resident's needs and goals, and to monitor the results of the planned interventions such as adequate supervision during meal time . Facility immediate actions to remove the Immediate Jeopardy included: --On 8/14/23 to 8-23-23 RN/ADON and/or designee, initiated education for meal supervision and aiding residents who have been prescribed a modified diet. These educations included verbal and online education courses 100% completion between in person, online and telephone education obtained on 8-23-2023. --On 8/23/23 the IDT (Interdisciplinary Team) reviewed MDS section K05102 for mechanically altered diet for all residents requiring assistance and or supervision with meals. ADON / designee reviewed care plans to identify current residents who have been prescribed a modified diet and require assistance with meals. Results of these audits were forwarded to the ad-hoc QAPI meeting held on 8/23/2023. For residents identified in the audit, care plans were revised, and ADL task list were updated to include aiding and supervision with meals. --On 8/14/23 an Ad Hoc QAPI (Quality Assurance Performance Improvement) meeting was conducted with the facility leadership team as well as the Medical Director to review the incident involving Resident #1. --On 8/23/23 an Ad Hoc QAPI meeting was conducted with the facility leadership team as well as the Medical Director to review IJ F 689 Abatement plan. Root Cause Analysis was completed. PIPs (Performance Improvement Plans) were developed based on audits completed to ensure adequate compliance with F689. Root caused determined to be lack of supervision. --On 8/23/2023 Additional staff members are now assigned to round throughout the building on both floors to provide additional supervision to ensure all residents get the appropriate meal and they are supervised until all trays are returned to kitchen. Staff educated to remove trays from patients' rooms after meal is completed and/or if the patient is not eating the dinner tray or not in the room. The tray would be placed back in the food cart until the patient is ready to eat. New dietary orders to also to be reviewed daily to assure all diet change orders are documented and reviewed. All audits will be reviewed after each meal by the Administrator/Designee to ensure compliance daily for 30 days. --Facility removed immediacy as of 8-23-23. Verification of the facility's removal plan was conducted by the survey team on 08/24/2023. Beginning on 8/24/23 at 11:50 A.M. Interviews were conducted with 59 staff members including: 20 licensed nurses, 26 CNAs, a receptionist, an activities aide, 2 business office staff, the Physical Therapy Director, and 7 housekeeping staff. The staff members were able to state they had been trained and were knowledgeable about the new policies. On 8/24/23 starting at 11:50 a.m. dining observations were conducted on the second-floor units. The nurse was observed to check all carts for accuracy of the trays for each resident. During the tray pass, staff were observed checking trays for accuracy. The manager and nurses were visible on the unit. Staff from administration were observing and supervising tray pass and resident dining. Staff were observed assisting residents with their meals. No trays were left unattended during the observations. On 8/24/23 starting at 12:30 p.m. Dining observations were conducted on the first-floor units. On the secured unit, all trays were observed to be checked by the nurses on the unit prior to passing them out. Trays were distributed to residents in rooms first and all residents were observed to be in the room at the time of the tray delivery. Trays were then brought to the dining room area and were checked again and placed in front of residents in the dining area. There were 21 residents in the dining room for the lunch meal and there were 4 staff members present in the dining room to monitor the meal in the secured unit. On 8/24/23 at 12:46 p.m. the dining room on the first floor was observed to be locked and not in use. An interview was conducted with Staff K, LPN. She stated the dining room was being cleaned and renovations were being done in preparation to open it up and begin serving residents once again in the dining room. On 8/24/23 at 12:49 p.m. the dining trays for the lunch meal were served on the Lifestyle 1 unit. Trays were checked by the nurses to assure correct meals for each resident and then the meal tray pass began. Trays were verified by staff as they were delivered into the resident rooms. All trays delivered to the rooms were placed in front of a resident and set up. No trays were observed to be delivered to any resident not in the room. Trays for residents needing assistance with meals were delivered last so staff could assist with the meal. The Unit Managers/Nurses/Activities staff/Business office personnel were all present in the hallways to assist with monitoring during the meal service. A review of a IJ removal plan book, supplied by the facility, was conducted on 8/24/23 at 1:45 p.m. during an interview with the ANHA and NHA. They stated they were able to educate all the staff on duty and 100% were completed as of 8/23/24. On 8/23/2023 an electronic medical record message was put in to notify all staff of mandatory education. They stated they also sent out a text message to all staff and 100% of staff received this message. They stated all staff receive the texting and clinical staff get both messages. The message will appear every time the staff sign in to the computer. They stated there were no changes to the policy. They stated there were five trainings for the dietary concerns related to the supervision, policy, aspiration, dysphasia, and choking with interventions for the staff to complete online. They stated the education had been ongoing since 14th of August. They stated they had made sure 100% had completed the supervision education and no staff will be allowed to work until the education is completed in the future. The NHA stated during the work week the extra person will be the managers on days and evenings for the meal service. The night shift is to be mindful of any food source. On the weekend it will be the staffing coordinators who are nursing assistants that will be the extra set of eyes at meal service. The NHA stated a Quality meeting was completed on 8/14, 8/23, and regularly done today on 8/24. He stated they did a Performance Improvement Plan (PIP) on the inc[TRUNCATED]